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

Multiple deaths due to care delays highlighted in damning CQC report

Dozens of patients died or suffered ‘severe harm’ after long waits for ambulances during a three-month period in a health system facing ‘extreme pressure’ on its emergency services.
The 29 serious incidents in Cornwall included patients waiting many hours for assistance despite being in “extreme pain”, patients having suspected sepsis, patients in cardiac arrest, and patients experiencing a stroke.
The incidents were reported to the Care Quality Commission by staff at South Western Ambulance Service Foundation Trust during an inspection of the Cornwall integrated care system’s urgent and emergency care services.
According to the CQC, the pressures on the ambulance service were “unrelenting”, while “significant work” was needed to “alleviate extreme pressure”.
This meant there was a “high level of risk to people’s health when trying to access urgent and emergency care in the county”, the report said.
Read full story (paywalled)
Source: HSJ, 27 May 2022
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Trusts lose out on cash after safety ‘mis-declarations’

Three trusts have lost out on more than £1m in rebate from the maternity clinical negligence scheme (CNST) after they ‘mis-declared’ that they were compliant with safety requirements.
University Hospitals Sussex Foundation Trust, University Hospitals Morecambe Bay FT and Doncaster and Bassetlaw FT have all received a small amount of funding to implement their action plans but a much larger rebate on the NHS Resolution maternity section of the clinical negligence scheme for trusts has been withheld.
This amounted to a loss of close to half a million pounds for Doncaster and Bassetlaw and is likely to be more for the other two trusts, which had made bigger contributions to the maternity section of the CNST.
Western Sussex had mis-declared its compliance on five safety actions, BSUH on seven, Doncaster and Bassetlaw on five and UHMB on seven.
Read full story (paywalled)
Source: HSJ, 26 May 2022
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ECRI publicly supports IHI Declaration to Advance Patient Safety

ECRI, the nation's largest patient safety organization, announces its unity with the United States' top safety experts in calling for a total systems approach to safety, a theme that was the central focus at the May 2022 Institute for Healthcare Improvement (IHI) Patient Safety Congress.
During its annual convening of national safety leaders, IHI leadership announced its Declaration to Advance Patient Safety, an initiative focused on addressing safety from a total systems approach, as presented in the 2020 National Action Plan to Advance Patient Safety.
"As a member of the National Steering Committee for Patient Safety that created the National Action Plan to Advance Patient Safety, ECRI fully supports this renewed call to action as outlined in the recent Declaration," states Chief Medical Officer Dheerendra Kommala, MD.  "ECRI, the most trusted voice in healthcare, is in a unique position to deliver a comprehensive, robust solution that reduces preventable harm."
ECRI's total system approach to advancing safety includes the design and implementation of a proactive, coordinated strategy to establish healthcare safety processes that impact patients, families, visitors, and healthcare workers across the continuum of care.
Read full story
Source: CISION, 26 May 2022
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Ambulance trust covered up paramedics’ fatal errors like a ‘criminal gang’

An ambulance trust has been accused of acting like a “criminal gang” and lying to dead patients’ families by an employee who repeatedly warned about paramedics’ mistakes being covered up.
Paul Calvert, a coroner’s officer whose job was to produce reports on deaths, tried to raise concerns about managers at the North East Ambulance Service (NEAS) for three years before walking out last year on the verge of a breakdown.
“My life was being made a misery,” said Calvert, who was previously a detective with Northumbria police. “They were basically like a criminal gang. I had tried everything I could to warn the proper authorities about how the service was destroying and concealing evidence meant for the coroner. I spoke to my managers, to human resources, to external auditors. I even made disclosures to the Care Quality Commission and Northumbria police. Nothing was done about it.”
Despite their denials of a large-scale cover-up of mistakes, the NEAS this year offered Calvert £41,000 as part of a non-disclosure agreement it asked him to sign. One of the clauses meant destroying all the evidence he had collected. Another tried to stop him making any further disclosures to police.
Reports and witness statements from ambulance staff were not being disclosed to the coroner “on a daily basis”, according to Calvert, amounting to key pieces of evidence relating to deaths being hidden from the public.
Read full story (paywalled)
Source: The Times, 29 May 2022
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NHS Scotland to improve patient safety through 'compassionate communication'

A study conducted by NHS Education for Scotland and Health Improvement Scotland found patients felt safer by having someone listen to their experiences after adverse events.
The findings were published in the BMJ and have been positively received by NHS boards across the country.
Healthcare Improvement Scotland’s Donna Maclean said: “The compassionate communications training has seen an unprecedented uptake across NHS boards in Scotland, with the first two cohorts currently under way and evaluation taking place also.”
Clear communication and a person-centred approach was seen as being central to helping those who have suffered from traumatic events.
Researchers found many said their faith was restored in the healthcare system if staff showed compassion and active engagement.
This approach is likely to enhance learning and lead to improvements in healthcare.
Health boards were advised that long timelines can have a negative impact on the mental health of patients and their families.
Rosanna from Glasgow, who was affected by an adverse event, said: “I believe this study and its findings are crucial to truly understanding patients and families going through adverse events.
“Not only does the study capture exactly what needs to change, but it also highlights the elements that are most important to us: an apology and assurance that lessons will be learnt is all we really want.
Read full story
Source: The National, 30 May 2022
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Woman stored baby’s remains in fridge after London hospital refused them

A London hospital has launched an investigation after a woman whose baby died in the womb had to deliver her son at home due to lack of beds and keep his remains in her fridge when A&E staff said they could not store them safely.
Laura Brody and her partner, Lawrence, said they were “tipped into hell” after being sent home by university hospital Lewisham to await a bed when told their baby no longer had a heartbeat but no beds were immediately available to give birth, the BBC reported.
Two days later, after waking up in severe pain, Brody, who was four months into her pregnancy, gave birth in agony on the toilet in their bathroom. “And it was then,” she told the broadcaster, “I saw it was a boy”.
The couple, who wanted investigative tests to be carried out at a later time, dialled 999 but were told it was not an emergency. They wrapped their baby’s remains in a wet cloth, placed him in a Tupperware box, and went to A&E where they were told to wait in the general waiting room, they said.
She was eventually taken into a bay and told she would require surgery to remove the placenta. But, with the waiting room hot and stuffy and staff refusing to store the remains or even look inside the Tupperware box, they decided as it got to midnight they had no option but for her partner to take their baby’s remains home.
Brody said the whole experience “felt so grotesque”.
“When things go wrong with pregnancy there are not the systems in place to help you, even with all the staff and their experts – and they are working really hard – the process is so flawed that it just felt like we had been tipped into hell,” she told Radio 4’s Today programme.
The case is said to have raised wider concerns among campaigners who argue that miscarriage care needs to be properly prioritised within hospitals including A&E.
Read full story
Source: The Guardian, 30 May 2022
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UK patients affected by infected blood scandal to receive payouts

A compensation scheme for thousands of people affected by the infected blood scandal, described as the biggest treatment disaster in the history of the NHS, will reportedly be announced within weeks.
Ministers will set up an arm’s-length body to administer the funds, which could run into hundreds of millions of pounds, and recognise culpability for the scandal for the first time, according to the Sunday Times.
As many as 30,000 people became severely ill after being given factor VIII blood products that were contaminated with HIV and hepatitis C imported from the US in the 1970s and 80s, or after being exposed to tainted blood through transfusions or after childbirth. On average, one person affected is dying every four days, with approximately 3,000 having died to date.
Last year, before the then health secretary Matt Hancock’s appearance at the public inquiry into the scandal, the paymaster general, Penny Mordaunt, announced the appointment of Sir Robert Francis QC to examine options for a framework for compensation before the inquiry reports its findings.
A Cabinet Office spokesperson confirmed the review would be published shortly. “The government intends to publish the study by Sir Robert Francis QC in time for the inquiry and its core participants to consider it before Sir Robert gives evidence to the inquiry in July,” they said. “Government will give full consideration to Sir Robert’s recommendations and evidence to the inquiry.”
Read full story
Source: The Guardian, 29 May 2022
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All neighbourhoods need “single, urgent care teams” offering same day access, says review

Proposals for primary care networks to evolve into more collaborative “integrated neighbourhood teams” to improve access to care have been broadly welcomed.
A “stocktake” report commissioned by NHS England, published on 26 May, called for urgent same day appointments to be dealt with by “single, urgent care teams” for every neighbourhood with greater use of a range of health and social care professionals. 
The report, written by Claire Fuller, a general practitioner and chief executive of Surrey Heartlands Integrated Care System, undertaken by Dr Claire Fuller, Chief Executive-designate Surrey Heartlands Integrated Care System and GP on integrated primary care, looks at what is working well, why it’s working well and how we can accelerate the implementation of integrated primary care (incorporating the current 4 pillars of general practice, community pharmacy, dentistry and optometry) across systems.
Doctors’ leaders welcomed many of the report’s recommendations but emphasised that they could only work if the government resourced primary care practices better and tackled workforce shortages.
Read full story (paywalled)
Source: BMJ, 27 May 2022
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Attacks in Wales on workers up to almost 3,000

"I shouldn't have to work out my escape route when I walk into a property."
Paramedic Joanna Paskell was a victim of one of the near-3,000 attacks on emergency workers in Wales last year.
The patient who punched her got a 12-month community order, but it left the 45-year-old suffering with anxiety and meant she was off work for four months.
"It took four security guards to calm her down so she could be treated," said Mrs Paskell, who has worked with the ambulance service for more than 25 years.
She said at first she tried to laugh it off, but it was only when getting ready for her next shift, five days later, that she felt the emotional toll.
"All I want to do is make a difference - that's why I joined this job. We can't do that if we're working in fear of our own safety."
Last year there were 2,838 assaults against police officers, firefighters, ambulance staff, NHS workers and prison staff - a 4.9% rise.
Read full story
Source: BBC News, 30 May 2022
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Close contacts of monkeypox cases ‘left in the dark’ as experts call for greater support

Close contacts of people infected with monkeypox have criticised health officials for a lack of communication and support while they have to isolate.
Public health experts and scientists have said the government needs to offer financial support to people forced to self-isolate for 21 days, as it emerged that one local council has already stepped in to provide sick pay for an infected man who could not work from home and was told he would not be paid.
With cases of monkeypox on the rise in the UK – 106 were infections detected as of Friday – it’s thought hundreds of people have been told to self-isolate since the beginning of May.
The UK Health Security Agency (UKHSA) said it was providing daily calls for infected individuals and close contacts to offer support.
However, one man from Leicester, whose housemate contracted monkeypox after visiting Gran Canaria pride festival, described UKHSA’s handling of his case as a “farce”, saying he has waited days for instruction from officials.
“They couldn’t provide any meaningful or helpful information and nothing about housemates or close contacts,” the housemate told The Independent.
The World Health Organisation (WHO) has meanwhile said countries should take quick steps to contain the spread of monkeypox and share data about their vaccine stockpiles.
Read full story
Source: The Independent, 29 May 2022
Patient Safety Learning

Childbirth: Mum left feeling dirty by incontinence injuries

"It's isolating, debilitating and you feel dirty."
Too many women have to cope with bowel incontinence from injuries during childbirth, according to one charity.
Anna Clements, from Masic, said stigma and a lack of information meant women were unaware of the medical support available.
The Welsh government said a plan would be published in the summer on how health boards should provide "high-quality women's health services".
A coalition of charities said this was one of a number of ways women experience poor health outcomes.
Women need to be listened to and not just dismissed and told 'this happens with birth - just get on with it'," added Ms Clements.
Masic supports women who have experienced anal sphincter injuries - an issue which carries so much stigma that few will speak to anyone about their symptoms.
Julie Cornish, a colorectal surgeon, was instrumental in setting up a hub which helps patients with pelvic organ prolapse, incontinence and bowel dysfunction.
"These are really common conditions - they mainly affect women, but can affect men as well," she said.
Clinics for things such as bowel, bladder or gynaecological issues are held simultaneously in the hub, based at Barry Hospital, Vale of Glamorgan. This means patients can get immediate advice from different specialists without joining separate waiting lists which cuts waiting times significantly.
Ms Cornish acknowledged the numbers currently seeking help were "the tip of the iceberg" because of the stigma.
Read full story
Source: BBC News, 28 May 2022
Patient Safety Learning

Loss of 25,000 NHS beds caused ‘serious patient safety crisis’, finds report

The NHS has lost almost 25,000 beds across the UK in the last decade, according to a damning report  says the fall has led to a sharp rise in waiting times for A&E, ambulances and operations.
The Royal College of Emergency Medicine said the huge loss of beds since 2010-11 was causing “real patient harm” and a “serious patient safety crisis”. At least 13,000 more beds are urgently needed, it added, in order to tackle “unsafe” bed occupancy levels and “grim” waiting times for emergency care and handover delays outside hospitals.
Patients are increasingly “distressed” by long waiting times, the college said, as are NHS staff who face mounting levels of burnout, exhaustion and moral injury. The UK has the second lowest number of beds per 1,000 people in Europe at 2.42 and has lost the third largest number of beds per 1,000 population between 2000 and 2021 (40.7%), the report said.
There are currently 162,000 beds in the NHS across the UK, according to the college.
“The situation is dire and demands meaningful action,” said Dr Adrian Boyle, the college’s vice-president. “Since 2010-11 the NHS has lost 25,000 beds across the UK, as a result bed occupancy has risen, ambulance response times have risen, A&E waiting times have increased, cancelled elective care operations have increased.
“These numbers are grim,” Boyle added. “They should shock all health and political leaders. These numbers translate to real patient harm and a serious patient safety crisis. The health service is not functioning as it should and the UK government must take the steps to prevent further deterioration in performance and drive meaningful improvement, especially ahead of next winter.”
Read full story
Source: The Guardian, 31 May 2022
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NHS will not hit virtual wards target, internal data suggests

The NHS is on trajectory to fall short of a flagship pledge to have around 24,000 “virtual ward beds” in place by December 2023, internal data has revealed.
NHS England’s figures from March, seen by HSJ, suggest the system is instead more likely to have created around 18,500 virtual beds by the 2023 deadline. 
Senior clinicians, including the Royal College of Physicians and the Society of Acute Medicine, have recently raised concerns about the speed and timing of the roll-out and staffing implications.
And now fresh concerns are also being raised about the programme following publication of a new academic study which suggests virtual wards set up by the NHS during Covid made little impact on length of stay or readmissions rates.
Alison Leary, professor of healthcare and workforce modelling, London South Bank University, was one of the first senior leaders to publicly voice concerns about the NHS’s virtual wards programme.
Professor Leary told HSJ: “I am not surprised [systems are falling] short. Since Elaine [Elaine Maxwell, visiting professor, London South Bank University] and I published our piece in HSJ, I have been contacted by several clinicians who have serious concerns over virtual wards and staffing them.”
Read full story (paywalled)
Source: HSJ, 31 March 2022
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Covid lockdown blamed for deaths of more than 3,000 people with diabetes

A lack of diabetes checks following the first Covid lockdown may have killed more than 3,000 people, a major NHS study suggests.
Those with the condition are supposed to undergo regular checks to detect cardiac problems, infections and other changes that could prove deadly.
But researchers said a move to remote forms of healthcare delivery and a reduction in routine care meant some of the most crucial physical examinations did not take place during the 12 months following the first lockdown.
Experts said the findings showed patients had suffered “absolutely devastating” consequences and were being “pushed to the back of the queue”.
The study, led by Prof Jonathan Valabhji, the national clinical director for diabetes and obesity, links the rise in deaths to a fall in care the previous year.
It showed that, during 2020/21, just 26.5% of diabetes patients received their full set of checks, compared with 48.1% the year before.
Those who got all their checks in 2019-20 but did not receive them the following year had mortality rates 66% higher than those who did not miss out, the study, published in Lancet Diabetes and Endocrinology, found.
The study shows that foot checks, which rely on physical appointments, saw the sharpest drop, falling by more than 37%.
“The care process with the greatest reduction was the one that requires the most in-person contact – foot surveillance – possibly reflecting issues around social distancing, lockdown measures, and the move to remote forms of healthcare delivery,” the study found. Those in the poorest areas were most likely to miss out.
Read full story (paywalled)
Source: The Telegraph, 30 May 2022
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Clearing NHS Covid backlog in Wales could take seven years

It may take seven years to get NHS Wales waiting lists of 700,000 back to 2020 levels, Wales' auditor general has said.
The number of patients waiting for non-urgent treatment has doubled since February 2020, just prior to the Covid pandemic.
They include Patient Michael Assender, 74, who has spent two years on a waiting list with severe back pain. After struggling with his back, Mr Assender, from Cwmbran, Torfaen, paid £1,500 for a private scan, which revealed he had two slipped discs.
"At the moment I'm coping pretty well, taking pills for the pain and trying to stay active," he said. "But something that took me half hour before now takes an hour."
Mr Assender said he knew others waiting for surgery who had become depressed and considered taking their lives, adding: "A lot of people out there are in a constant pain and I do pity them."
"It's a dire situation really."
The Welsh government said it had a plan to deal with backlogs.
But Wales' Auditor General Adrian Crompton said: "Just as the NHS rose to the challenge of the pandemic, it will need to rise to the challenge of tackling a waiting list which has grown to huge proportions."
"Concerted action is going to be needed on many different fronts, and some long-standing challenges will need to be overcome."
Read full story
Source: BBC News, 31 May 2022
 
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Bristol woman 'still devastated' after being put through unnecessary mesh bowel surgery

A Bristol woman says her life has 'never been the same' since receiving unnecessary operations on her bowel more than ten years ago.
Following a recent review, Mandy Giltrow is one of more than 200 patients who received a mesh bowel procedure - which she says may not have been needed.
The operations were all conducted by surgeon Tony Dixon who has been sacked by the North Bristol NHS Trust.
Mandy Giltrow underwent a mesh bowel procedure which was performed by Mr Dixon at Frenchay Hospital in April 2011.
Following the surgery her symptoms continued. Following follow up appointments Mandy, a mum-of-four, underwent a further procedure in April 2013.
Mr Dixon carried out a further operation in October 2014 at Spire Bristol to replace mesh.
However Mandy, who is 49 and lives in Staple Hill, continues to suffer issues including stomach and bowel pain as well as recurrent water infections. She also has a hernia near her surgery scars.
North Bristol NHS Trust has since admitted liability.
Mandy told ITV West Country: "I got anxiety for all the different operations I had and then I physically could not do anything. I was stuck for three months in a bubble."
"I couldn't go out, I couldn't do anything with my children not even take them to school."
Mandy says her mental health was badly affected by the operations leading to a nervous breakdown and agoraphobia, meaning she could not lead the house.
"You have an operation. It doesn't resolve the original problem and now you have another problem which is twice as bad."
Read full story
Source: ITV, 30 May 2022
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