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

Autism diagnosis six years longer for girls, research finds

"I knew I always felt different, but I didn't know I was autistic."
For Rhiannon Lloyd-Williams, it would take until she was 35 to learn just why she felt different.
Now research by Swansea University has found it takes on average six years longer to diagnose autism in women and girls than in males.
A study of 400 participants found that 75% of boys received a diagnosis before the age of 10 - but only 50% of girls.
It also found the average age of diagnosis in girls was between 10 and 12 - but between four and six for boys.
Now charities in Wales are calling for greater investment into services to help better understand autism in females and speed up a diagnosis.
"The parents responding to the study said there was a marked impact on the girls mental health while waiting for a diagnosis," said Steffan Davies, who carried out the research.
"Girls represented in the study had a lot more pre-existing diagnosis, which suggests they are being misdiagnosed with anxiety disorders, eating disorders, and that tends to defer from the root diagnosis which tends to be autism."
Autism UK said this gender gap has long been an issue and is the down to the diagnosis criteria and research used, which has been focused around young boys.
"Many girls end up missing out on education, because the environment they're expected to learn in is just too overwhelming, while accessing healthcare can be difficult. Women are often not believed," said executive director Willow Holloway.
Read full story
Source: BBC News, 23 May 2022
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Ambulance service will collapse by August, predicts its nursing director

A struggling ambulance trust could face a ‘Titanic moment’ and collapse entirely this summer if the region’s worsening problems with hospital handover delays are not taken more seriously, its nursing director has told HSJ.
Mark Docherty, of West Midlands Ambulance Service (WMAS), said patients were “dying every day” from avoidable causes created by ambulance delays and that he could not understand why NHS England and the Care Quality Commission were “not all over” the issue.
He revealed that handover delays at the region’s hospitals were the worst ever recorded, that rising numbers of people were waiting in the back of ambulances for 24 hours, and that serious incidents have quadrupled in the past year, largely due to severe delays.
More than 100 serious incidents recorded at WMAS relate to patient deaths where the service has been unable to respond because its ambulances are held outside hospitals, according to the minutes of the trust’s March quality and safety committee.
"Around 17 August is the day I think it will all fail,” he said. “I’ve been asked how I can be so specific, but that date is when a third of our resource [will be] lost to delays, and that will mean we just can’t respond. Mathematically it will be a bit like a Titanic moment.
”It will be a mathematical certain that this thing is sinking, and it will be pretty much beyond the tipping point by then.”
Read full story (paywalled)
Source: HSJ, 25 May 2022
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NHS 111: Parents anger over four child deaths

The parents of a girl who died after failings by NHS 111 said they were horrified to learn coroners had already warned about similar shortcomings.
Hannah Royle, 16, died in 2020 after the NHS phone service failed to realise she was seriously ill.
BBC News found concerns had been raised about the call centre triage software in 2019 after three children died.
The NHS said it had learnt lessons from each case, but said it had not established a link between the deaths.
Hannah, who was autistic, had a cardiac arrest as she was driven to East Surrey Hospital by her parents. She had suffered a twisted stomach, but call handlers believed she had gastroenteritis.
A coroner's report said NHS 111 staff failed to consider her "disabilities and inability to verbalise" when using the triage software.
Known as NHS Pathways, the algorithm relies on answers being given over the phone to a set series of questions. The system guides call handlers, who are not medically qualified, to direct patients to other parts of the NHS for further assessment and treatment.
In 2019, three coroners issued reports "to prevent future deaths" after serious abdominal illness in Myla Deviren, Sebastian Hibberd, Alexander Davidson and were missed by NHS 111.
In all cases, coroners raised concerns about the ability of children to understand call handlers' questions or articulate their symptoms.
Read full story
Source: BBC News, 24 May 2022
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Covid can cause ongoing damage to heart, lungs and kidneys, study finds

Damage to the body’s organs including the lungs and kidneys is common in people who were admitted to hospital with Covid, with one in eight found to have heart inflammation, researchers have revealed.
As the pandemic evolved, it became clear that some people who had Covid were being left with ongoing symptoms – a condition that has been called Long Covid.
Previous studies have revealed that fewer than a third of patients who have ongoing Covid symptoms after being hospitalised with the disease feel fully recovered a year later, while some experts have warned Long Covid could result in a generation affected by disability.
Now researchers tracking the progress of patients who were treated in hospital for Covid say they have found evidence the disease can take a toll on a range of organs.
What’s more, they say the severity of ongoing symptoms appears to be linked to the severity of the Covid infection itself.
“Even fit, healthy individuals can suffer severe Covid-19 illness and to avoid this, members of the public should take up the offer of vaccination,” said Prof Colin Berry, of the University of Glasgow, which led the CISCO-19 (Cardiac imaging in Sars coronavirus disease-19) study.
“Our study provides objective evidence of abnormalities at one to two months post-Covid and these findings tie in with persisting symptoms at that time and the likelihood of ongoing health needs one year later,” Berry added.
Read full story
Source: The Guardian, 23 May 2022
 
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Breast cancer screening process in Scotland to change after recent errors

NHS Scotland is to change the way women are called to breast cancer detection appointments after major recent errors in the screening programme.
Some eligible for screening were not invited because they had moved between GP practices or were aged over 71 by the time their practice was called.
Women aged 50 to 70 are invited for appointments once every three years, based on their GP practice.
It emerged hundreds of women in NHS Lothian may have missed screenings.
The health board said in January that 369 women considered to have a higher risk of developing the disease may not have received appointments at the right time.
A major review of the programme in Scotland has made 17 recommendations to strengthen and improve services.
They include:
A more "person-centred" approach based on calling individual women - rather than the GP practice where they are registered - to set their next test date. Greater flexibility of appointments to provide better access and uptake, with more contact such as texts or phone calls to keep appointments on patients' radar. An online appointment cancellation and rebooking system to provide greater individual convenience. Evening and weekend appointments and more availability in rural and semi-urban locations. Read full story
Source: BBC News, 24 May 2022
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'I will never be the same': RaDonda Vaught speaks out after sentencing

RaDonda Vaught has spoken out about her criminal case for the first time last week in an exclusive interview with ABC News.
Ms. Vaught, 38, was sentenced to three years of supervised probation on 13 May. She was convicted of criminally negligent homicide and abuse of an impaired adult for a fatal medication error she made in December 2017 after overriding an electronic medical cabinet as a nurse at Vanderbilt University Medical Center in Nashville, Tenn. The error, in which vecuronium, a powerful paralyser, was administered instead of the sedative Versed, led to the death of 75-year-old Charlene Murphey. 
"I will never be the same person," Ms. Vaught told ABC News, "It's really hard to be happy about something without immediately feeling guilty. She could still be alive, with her family. Even with all the system errors, the nurse is the last to check."
Ms. Vaught immediately took responsibility for the medication error after it occurred but contends that her actions alone did not cause the error. Her case has spurred an outcry from nurses across the country, many of whom have expressed concerns about the likelihood of similar mistakes under increasingly difficult working conditions. 
"So many things had to line up incorrectly for this error to have happened, and my actions were not alone in that," Ms. Vaught said. 
When Ms. Pilgrim asked her if she felt like a scapegoat, Ms. Vaught said, "I think the whole world feels like I was a scapegoat."
"There's a fine line between blame and responsibility, and in healthcare, we don't blame," she said. "I'm responsible for what I failed to do. Vanderbilt is responsible for what they failed to do."
Read full story
Source: Becker's Hospital Review, 23 May 2022
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‘Global crisis’ of violence: 161 healthcare workers were killed last year, study finds

Violence against healthcare workers has become a “global crisis”, with 161 medics killed and 188 incidents of hospitals being destroyed or damaged last year, according to a new report.
Data collected from 49 conflict zones by the Safeguarding Health in Conflict Coalition (SHCC), also found that 320 health workers were wounded in attacks, 170 were kidnapped and 713 people were arrested in the course of their work.
The US-based group said on Tuesday that, although the total number of attacks was similar to those recorded in recent years, there had been an increase in violence in areas of new or renewed conflict in 2021, “underlining the fact that attacks on healthcare are a common feature in many of today’s conflicts”.
Christina Wille, director at Insecurity Insight, which led the data collection and analysis, said: “Violence against healthcare resulted in widespread impacts on public health programmes, vaccination campaigns and population health, contributing to avoidable deaths and long-term consequences for individuals, communities, countries and global health writ large.”
Read full story
Source: The Guardian, 24 May 2022
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‘Total IT failure’ at four hospitals sparks safety concerns

Four hospitals in Greater Manchester are struggling with a near ‘total IT failure’ which has forced staff in all key services to use handwritten lists and notes.
The problems have affected multiple IT systems across Royal Oldham, Fairfield General, Rochdale Infirmary and North Manchester General hospitals.
Staff at the sites are running theatre and emergency departments using handwritten patient lists and notes, while bloods and scan results are also being written by hand. Patient histories are largely unavailable.
HSJ spoke to staff who said there are major concerns over patient safety, as the lack of digital systems increases the risk of errors, and also slows down multiple processes. They described the problems as a “total IT failure”.
Chris Brookes, deputy CEO and chief medical officer, said: “Patient safety and maintaining essential services remains our priority. We are doing everything we can to fix the IT issues and to limit disruption to patients and our services."
Read full story (paywalled)
Source: HSJ, 25 May 2022
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Covid-19: Vaccine effectiveness wanes more rapidly for cancer patients, study finds

Covid-19 vaccination is effective for cancer patients but protection wanes much more rapidly than in the general population, a large study has found.
Vaccine effectiveness is much lower in people with leukaemia or lymphoma, those with a recent cancer diagnosis, and those who have had radiotherapy or systemic anti-cancer treatments within the past year, according to the research published in Lancet Oncology.
The authors of the world’s largest real world health system evaluation of Covid-19 in cancer patients highlighted the importance of booster programmes, non-pharmacological strategies, and access to antiviral treatment programmes in order to reduce the risk that Covid-19 poses to cancer patients.
Peter Johnson, professor of medical oncology at the University of Southampton and joint author of the study, said, “This study shows that for some people with cancer, covid-19 vaccination may give less effective and shorter lasting protection. This highlights the importance of vaccination booster programmes and rapid access to covid-19 treatments for people undergoing cancer treatments.”
Study leader, Lennard Lee, department of oncology, University of Oxford, said, “Cancer patients should be aware that at 3-6months they are likely to have less protection from their coronavirus vaccine than people without cancer. It is important that people with a diagnosis of cancer are up to date with their coronavirus vaccination and have had their spring booster if they are eligible.”
Read full story
Source: BMJ, 24 May 2022
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Safety regulator refused to investigate some NHS staff Covid deaths

Britain’s safety at work regulator refused to investigate reports from NHS trusts that 10 frontline staff had died as a result of catching Covid-19 during the pandemic.
The Health and Safety Executive (HSE) declined to look into at least 89 dangerous incidents that NHS trusts said involved healthcare workers being exposed to Covid, including 10 deaths.
The stance taken by the HSE, which oversees workplace health and safety and can bring prosecutions, is disclosed in freedom of information requests by the Pharmaceutical Journal. It has prompted concern that the regulator is too strict in its definition of workplace harm.
It found that 173 trusts in England submitted at least 6,007 reports about employees’ exposure to Covid-19 in the course of their duties to the HSE between 30 January 2020 and 11 March 2022, under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR).
They included 213 “dangerous occurrences”, which are incidents that have the potential to cause significant harm; 5,753 cases where a staff member had caught Covid-19; and 41 deaths among people who had been exposed to the disease at their workplace.
However, the HSE refused to look into five Covid deaths reported under the RIDDOR scheme by the Yorkshire ambulance service (YAS) because of what it considered a lack of evidence.
The regulator also decided not to look into the Covid deaths of five staff at University College London hospital acute trust, despite the trust’s belief they had caught it at work. “The HSE found that there was no reasonable evidence that the infection was contracted at work,” a trust spokesperson said.
Shelly Asquith, the health, safety and wellbeing officer at the Trades Union Congress, said the HSE’s decisions and claimed lack of evidence was “really concerning”. It suggested a continued “element of denial about Covid being airborne and it not being possible to necessarily pinpoint where exactly somebody was exposed once it’s in the air”, she added.
Read full story
Source: Guardian, 26 May 2022
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Nottingham maternity scandal: Government rejected proposed inquiry chair as ‘too independent,’ claims Jeremy Hunt

The former health secretary Jeremy Hunt has claimed the government snubbed bereaved families’ requests for Donna Ockenden to chair a review into maternity services in Nottingham as she is “too independent”.
Hundreds of families involved in the Nottingham maternity scandal review have called for Ms Ockenden, chair of the Shrewsbury maternity scandal inquiry, to take over the investigation.
NHS England had attempted to appoint a former healthcare leader, Julie Dent to chair the review. However, following pressure from families not to accept, Ms Dent announced shortly after she would be declining the role.
Following the families’ calls for Ms Ockenden, Mr Hunt, chair of the government’s health committee, said on Wednesday: “I can’t see any other barriers to appointing her but sounds like she still won’t be. For some reason the Department of Health appears to think she is too independent – which is of course precisely why Nottingham families do have confidence in her. It feels like another own goal.”
Families involved in the Nottingham maternity review, which will now cover almost 600 cases, have said they’ve been left in limbo by NHS England after if informed them of an interim report which has been completed by the review team.
This follows several letters from families to health secretary Sajid Javid raising concerns over the review and calls for it to be overhauled.
Speaking with The Independent, a couple whose son died under the care of Nottingham University Hospitals Foundation Trist said: “The key to successful long term change is developing a relationship with harmed families, built on trust, sensitivity and understanding. The current review does not command this. The relationship is untenable.”
Read full story
Source: The Independent, 26 May 2022
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Healthcare services in Northern Ireland 'on its knees'

Waiting times for outpatient appointments, hospital procedures, emergency care, GPs and community health services have all hit record levels in Northern Ireland, with health care staff and patients declaring it the "worst ever" crisis to hit health services in the region.
The impact of the COVID-19 pandemic, ever-growing patient demand, staff shortages, and the failure to put together a new Executive government following the recent Northern Ireland elections are being cited as the key drivers of the crisis, with health care staff now at breaking point.
Speaking to Medscape UK, British Medical Association Northern Ireland (BMA NI) council chair Dr Tom Black said the current crisis in Northern Ireland's health services essentially boils down to "workload and workforce" issues.
Waiting lists to access hospital appointments in Northern Ireland were already long before COVID-19, but the pandemic has significantly exacerbated the situation, he noted. Northern Ireland has the worst waiting lists in the UK, with more than 350,000 people currently waiting for a consultant-led appointment – more than half of them waiting over a year, with many waiting two, three, and even more years for an appointment.
"We're now heading towards nearly 400,000 on hospital waiting lists, which is a huge number when you consider that is one-in-five of the total population," Dr Black commented.
This week a judicial review is due to get underway at the High Court in Belfast after two patients initiated a legal case against the health services over excessive waiting times for access to care. One of the women has been waiting over five years to see a neurologist after being referred by her GP for suspected multiple sclerosis. The case is seeking a judicial declaration that the length of the waiting lists are unlawful and breached their human rights.
Read full story
Source: Medscape UK, 24 May 2022
Patient Safety Learning

New safety warnings on risk of insulin leakage from Roche Accu-Chek Insight Insulin pumps

The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a national patient safety alert for the NovoRapid PumpCart prefilled insulin cartridge and the Roche Accu-Chek Insight Insulin pump system following concerns raised about cracked cartridges and insulin leaks.
Patients are being asked to check the pre-filled glass insulin cartridge for cracks prior to use. The cartridge should not be used if it has been dropped even if no cracks are visible. Closely follow the updated handling instructions in the pump user manual when changing pre-filled glass insulin cartridges.
The device, which releases the insulin your body needs through the day and night, comprises a pump, tube, battery and a pre-filled glass insulin cartridge. In some of the reported leakage incidents, the cartridges were found to be cracked and provided an inadequate supply of insulin to patients. However, leakages also occurred in cases where no cracks in the cartridge were visible. In some patients there were consequences of not receiving enough insulin from their pump system, including reports of severely high blood sugar and diabetic ketoacidosis (a serious complication of diabetes when the body produces high levels of blood acids called ketones).
Health care professionals are being advised to contact patients over the next six months using said device to discuss their individual needs and source an alternative pump where appropriate.
Key patient recommendations are:
Check the pump and cartridge regularly for damages, for example cracks or leakage. If you smell insulin (a strong antiseptic chemical smell) this could also indicate a leakage. Do not use the cartridge if cracks or leakage are seen or if the cartridge was dropped. Follow the instructions of your Accu-Chek Insight user manual for replacing a cartridge and for cleaning the cartridge compartment in the insulin pump. During the day and before going to sleep please carefully check that your insulin pump is delivering insulin and there are no leakages. Never change treatment delivery methods without first consulting a relevant healthcare professional. Failure of insulin delivery due to leakage may not result in an alert notification from the insulin pump and cracks and leakages may not always be visible. You should check blood glucose levels multiple times throughout your day whilst using pumps. Tell your healthcare professional immediately if you suspect a problem with your insulin delivery. Read full story
Source: Gov.UK, 26 May 2022
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Australia: No action taken against Victorian mental health services despite more than 12,000 complaints

After receiving more than 12,000 complaints about Australia's Victorian mental health services, the state’s regulator has not taken compliance action against a single mental healthcare provider in seven years.
This is despite the royal commission into the Victorian mental health sector last year finding systemic breaches of the law and human rights across the system.
Annual reports from Victoria’s mental health complaints commissioner (MHCC) showed that in the seven years since it was first established in July 2014, it received 14,160 inquiries, of which 12,470 were complaints. Yet no compliance notices were issued, despite the MHCC having regulatory powers to compel providers to improve.
The MHCC is an independent body that resolves complaints about Victoria’s public mental health services and makes recommendations for improvements.
The MHCC’s service provider complaint reports, obtained under freedom of information, show that some mental health services do not hand over data on the outcomes of complaints, in breach of the state’s Mental Health Act (2014).
The chief executive of Mind Australia – a community-based mental health provider, Gill Callister, said it was vital people with mental health concerns, their families and carers had access to “information about the performance and approach” of the mental health services they access.
“For a lot of people, a lack of transparency reinforces the view that they’re sitting at the bottom of the pile in terms of priority even when seeking information about their own care,” she said.
Read full story
Source: The Guardian, 25 May 2022
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Bristol surgeon ‘harmed’ 203 women with unnecessary operations

More than 200 women were harmed when a rogue surgeon carried out operations on them unnecessarily, an NHS inquiry has found.
Some of the women were left with life-changing physical problems or unable to work, while many also suffered trauma and serious psychological harm as a result.
Overall, 203 women on whom Anthony Dixon performed procedures between 2007 and 2017 came to harm, according to a review by the North Bristol NHS trust (NBT). Dixon, who for years was Britain’s most influential pelvic surgeon, worked for both the trust and the private Spire hospital in the city.
In 2017, NBT launched a review of Dixon’s performance and suspended him after dozens of women he had performed procedures on complained that they had experienced appalling consequences, including unmanageable pain and incontinence. The Guardian revealed in late 2017 that 100 women were suing him for medical negligence. Some cases have since been settled, but dozens are ongoing.
NBT sacked Dixon in 2019 and he is currently banned from practising in the UK.
During the review, 378 women were recalled and asked to set out their dealings with Dixon. All had undergone a procedure called laparoscopic ventral mesh rectopexy (LVMR), in which plastic mesh is inserted to repair weakened tissue in the pelvic floor.
In papers presented to NBT’s board on Thursday, board members were told that the inquiry had concluded. “The trust has notified 203 NHS patients that, although their LVMR operation was carried out satisfactorily, they should have been offered alternative treatments before proceeding to surgery. We have defined these patients as suffering ‘harm’ as a result,” it said.
Read full story
Source: The Guardian, 26 May 2022
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Nottingham maternity scandal: Donna Ockenden to chair new review in victory for families

Donna Ockenden, the midwife who investigated the Shopshire maternity scandal, has been appointed to lead a review into failings in Nottingham following a dogged campaign by families.
The current review will be wound up by 10 June after concerns from NHS England and families that it is not fit for purpose.
It was commissioned after revelations from The Independent and Channel Four News that dozens of babies had died or been brain-damaged following care at Nottingham University Hospitals Foundation Trust.
In a letter to families on Thursday, NHS England chief operating officer David Sloman said: “I want to begin by apologising for the distress caused by the delay in our announcing a new chair and to take this opportunity to update you on how the work to replace the existing Review has been developing as we have taken on board various views that you have shared with us.”
“After careful consideration and in light of the concerns from some families, our own concerns, and those of stakeholders including in the wider NHS that the current Review is not fit for purpose, we have taken the decision to ask the current Review team to conclude all of their work by Friday 10 June.”
“We will be asking the new national Review team to begin afresh, drawing a line under the work undertaken to date by the current local Review team, and we are using this opportunity to communicate that to you clearly.”
Ms Ockenden said: “Having a baby is one of the most important times for a family and when women and their babies come into contact with NHS maternity services they should receive the very best and safest care."
“I am delighted to have been asked by Sir David Sloman to take up the role of Chair of this Review and will be engaging with families shortly as my first priority. I look forward to working with and listening to families and staff, and working with NHS England and NHS Improvement to deliver a Review and recommendations that lead to real change and safer care for women, babies and families in Nottingham as soon as possible.”
Read full story
Source: BBC News, 26 May 2022
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