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

Manager ‘bootcamps’ helped eliminate two-year waiters

The chief executive of one of the first teaching trusts in the country to have eliminated two-year waiters for elective care has said there is ‘no magic to it’ and it can be replicated elsewhere.
Since the beginning of April, University Hospitals of Coventry and Warwickshire Trust has reported zero patients waiting over two years for their elective treatment – ahead of NHS England’s target of July 2022.
According to the latest data, there are now 42 trusts that have eliminated 104-week waits and UHCW is the largest trust to have done this. 
UHCW chief executive Andy Hardy said that in order to achieve this the trust had been “relentless” in its focus on waiting times and had set up “bootcamps” to help managers understand how referral to treatment works.
Mr Hardy said in an interview with HSJ: “It really does come down to a laser-like focus on waiting times, both at an executive level, down to a group level, and down to speciality level. It can be replicated. There’s no magic to it.”
He said: “We use data to drive our organisations away from bad decisions and I have a weekly access meeting with the chief operating officer to look at where we are against all access targets, but obviously we focus on waiting times."
Read full story (paywalled)
Source: HSJ, 15 June 2022
Patient Safety Learning

Review intended to drive change at NUH accused of ‘traumatising’ families – what went so wrong?

A review intended to drive ‘rapid improvements’ to maternity services in Nottingham has been scrapped after just eight months – with some bereaved families saying instead it did ‘irreparable’ damage to their mental health and trust in the system. 
It was hoped the process would lead to rapid change, restore families’ faith in maternity in Nottingham, and provide a voice for parents who wanted to share both positive and negative experiences.
Instead, some families said they found the review process slow, unprepared for the number of people who came forward and lacking the impact needed to improve a maternity service rated ‘inadequate’ by health inspectors.
The growing frustration that followed would turn to anger for some families, leading to the direct involvement of a Government minister, the arrival and rapid departure of a new chair, and the eventual disbanding of the review altogether in favour of a fresh start with one of the country’s top advisers on midwifery, Donna Ockenden – who led an in-depth review into Shrewsbury and Telford NHS Trust’s maternity services.
The U-turn came after pressure from a group of more than 100 people named ‘Families Harmed by Nottingham Maternity’ – which includes parents whose babies have died or been injured while being cared for at Nottingham’s two main hospitals.
Local Democracy Reporter Anna Whittaker looks at what led to so many families turning on a system which the NHS said was set up to bring about major changes.
Read full story
Source: Notts, 14 June 2022
Patient Safety Learning

Trust branded ‘inadequate’ for leadership and maternity

One of the trusts worst affected by coronavirus has been issued with two warning notices and rated ‘inadequate’ for leadership, following a Care Quality Commission inspection.
The regulator raised serious concerns about the safety of Countess of Chester Hospital Foundation Trust’s maternity services, as well as the oversight and learning from incidents.
It also found staff were experiencing multiple problems with a newly installed electronic patient record, while systems for managing the elective waiting list were said to be unsuitable.
In maternity services, the inspectors flagged severe staff shortages and a failure to properly investigate safety incidents.
They said there were three occasions during the inspections when the antenatal and post-natal ward was served by only one midwife, despite the interim head of midwifery saying this would never happen. 
Inspectors also highlighted five incidents last year where women had suffered a major post-partum haemorrhage, involving the loss of more than two litres of blood and which resulted in an unplanned hysterectomy. The CQC said two were not reported as serious incidents, and where learning had been identified from the others, action plans were not being completed on time.
The CQC said it was only made aware of the incidents by a whistleblower, while internal actions agreed in December 2021 had still not been implemented two months later.
Read full story (paywalled)
Source: HSJ, 15 June 2022
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USA: Four-year-old accidentally given vasectomy

A family in Texas is suing a Houston-based doctor after their 4-year-old on son underwent an "unintended vasectomy" during a surgery.
The child was reportedly in the hospital for a hernia surgery at the time of the incident, according to Randy Sorrels, the family's personal injury attorney. He told Fox4 that part of the procedure involved work near the child's groin.
The attorney claimed the surgeon "cut the wrong piece of anatomy."
“The surgeon, we think, cut accidentally the vas deferens, one of the tubes that carries reproductive semen in it. It could affect this young man for the rest of his life,” Mr Sorrels told the broadcaster.
The surgeon who operated on the boy has no history of malpractice and has otherwise never received any negative reports on their work.
Mistakes like the one made on the toddler are generally very rare due to safety precautions built into the surgery process.
“It’s not a common mistake at all,” Mr Sorrels said. “Before a doctor transects or cuts any part of the anatomy, they are supposed to positively identify what that anatomy is and then cut. Here, the doctor failed to accurately identify the anatomy that needed to be cut. Unfortunately, cut his vas deferens. That wasn’t found out until it was sent in for pathology.”
The attorney said his and the family’s top concern is for the boy’s health. They are considering options for reversing the procedure, but the attorney noted that doing so would require the boy to undergo more surgery.
Read full story
Source: The Independent, 15 June 2022
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Language around birth should be less judgemental, midwives' report says

The language used around childbirth should be less judgemental and more personal, a report led by midwives has found.
Most women consulted said terms such as "normal birth" should not be used, it says.
The report recommends asking pregnant women what language feels right for them.
Maternity care has been under the spotlight after a recent review found failures had led to baby deaths.
The new guidance "puts women's choices at its heart, so that they are in the driving seat when it comes to how their labour and birth are described", Royal College of Midwives chief executive Gill Walton said.
About 1,500 women who had given birth in the past five years gave their views. Most preferred the term "spontaneous vaginal birth" to "normal birth", "natural birth" or "unassisted birth". Words suggesting "failure", "incompetence" or "lack of maternal effort" should also be avoided, they said.
They wanted labour and birth to be a positive experience and for the language used to be non-judgemental, accurate and clear.
Read full story
Source: BBC News, 15 June 2022
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NHS England reviewing bed capacity

The NHS has a low bed base, and NHS England is reviewing ‘how we right-size our capacity’ across hospital, community and ‘virtual’ services, Amanda Pritchard has said.
The NHSE chief executive addressed the annual NHS Confederation this week and said: “The NHS has long had one of the lowest bed bases among comparable health systems. And in many respects this reflects on our efficiency and our drives to deliver better care in the community.
“But it was true before the pandemic, and it remains true now that we have passed the point at which that efficiency actually becomes inefficient.
“So the point has come where we need to review how we right-size our capacity across the NHS. That will of course look at the whole picture of hospital, community and virtual capacity.”
Ms Pritchard also highlighted the current pressures on the emergency care system, which has widely been linked to slow discharges from hospital and insufficient social care provision.
She cited the “unacceptable rise in 12-hour waits for admission from [accident and emergency]” which “underlines that the issue is flow”, and said “we know we will need to make more progress before winter”. 
Read full story (paywalled)
Source: HSJ, 15 June 2022
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NHS risks losing one third of Black and Asian doctors over racism, finds landmark survey

The NHS is facing a major exodus of doctors of ethnic minority backgrounds due to persistent levels of racism faced at a personal and institutional level, a ground breaking study has revealed.
Nearly one third of doctors surveyed have considered leaving the NHS or have already left within the past two years due to race discrimination, with 42 per cent of Black and 41 per cent Asian doctors in particular having considered leaving or having left.
The survey paints a picture of institutional barriers to career progression, dangerously low levels of reporting of racist incidents and a growing mental health burden on ethnic minority doctors.
With more than 2,000 responses from doctors and medical students across the UK, the BMA – a professional association representing all doctors in the UK – believes that this survey is one of the largest of its kind to document the experience of racism in the medical profession and workplace.
Dr Chaand Nagpaul, BMA chair of council, said: “The NHS was built on the principle of equality of care for patients whoever they are, but this report shows that the NHS is shamefully failing in this principle for its own doctors, with those from ethnic minorities reporting alarming levels of unfair treatment and racial inequality at work.
Read full story
Source: The Independent, 15 June 2022
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Ambulance waits: 'Can you please tell them to hurry up or I shall be dead'

Delays unloading ambulances at busy hospitals are causing serious harm to patients, a safety watchdog is warning.
The Healthcare Safety Investigation Branch has been investigating how the long waits are delaying 999 emergency response times across England.
Kenneth Shadbolt, 94, waited more than five hours for an ambulance after a bad fall - an accident that proved fatal.
Logs show that in his final 999 call he asked: "Can you please tell them to hurry up or I shall be dead."
Ken Shadbolt had been in good shape for his age. On the night of Wednesday, 23 March 2022, just before 03:00, he got out of bed to go the bathroom and fell, hitting a wardrobe before collapsing on the floor.
He had hurt his hip - how badly he didn't know - and couldn't get up. He could reach his mobile on his bedside, though, and dialled 999 for help.
The BBC has seen transcripts of the three separate phone calls he made to South Western Ambulance Service that night.
The first was short and factual, covering the basic details of his injury. 
He seemed calm and lucid but made clear he was in pain and needed an ambulance. Internal call logs seen by the BBC show that at this point Ken was triaged as a category two emergency, meaning paramedics should arrive in 18 minutes, on average.
About 15 minutes later, Ken called 999 for a second time.
An internal ambulance service log seen by the BBC shows that South Western Ambulance Service was indeed busy that night.
It talks about "high demand" in the Gloucester area, with more than 60 patients waiting for help, some for more than eight hours.
Another hour passed before Ken made his third and final call to 999.
It was clear now that he was in serious pain. He felt "terrible sick" and said his "breathing is going too".
"I need an ambulance because I'm going to fade away quite quickly," he said.
The same reply came back: "The ambulance service is just under a lot of pressure at the moment... we are doing our best."
An ambulance finally got to Kenneth Shadbolt's house at 08:10 that morning, four hours after that final call.
Ken died at 14:21 that afternoon, with the cause of death given as a "very large subdural haematoma" or bleed on the brain.
His son Jerry Shadbolt said: "The doctors were saying his injuries were non-survivable but would they have been non-survivable if he'd arrived at hospital four hours earlier? I'd like an answer to that question.
"He was on his own and he knew he was on his own. He must have felt abandoned and alone on his bedroom floor. That's the most troubling part of it for me."
Read full story
Source: BBC News, 16 June 2022
 
Patient Safety Learning

New drugs to fight superbugs will save 1,700 lives a year

Two drugs that combat superbugs are being introduced on the NHS, offering a lifeline to thousands of patients with deadly infections such as sepsis which fail to respond to antibiotics.
About 65,000 people a year in the UK develop drug-resistant infections and 12,000 die, many after routine operations or from infections such as pneumonia or urinary tract infections.
These superbugs such as MRSA have mutated to develop resistance to many different types of antibiotics as a result of overuse of the drugs. It means patients end up dying from common infections that would previously have been easily treatable with antibiotics.
In a attempt to “turn the tide” on antibiotic resistance, the NHS has announced a deal for two drugs, cefiderocol and ceftazidime–avibactam, which can kill bacteria that is resistant to many other types of drugs.
The drugs, manufactured by Shionogi and Pfizer respectively, will save the lives of about 1,700 patients a year. They will be offered to patients with conditions such as drug-resistant pneumonia, sepsis or tuberculosis who have run out of other treatment options.
Amanda Pritchard, NHS chief executive, said this would make the UK a world leader in tackling “the global challenge of antimicrobial resistance”.
Read full story (paywalled)
Source: The Times, 15 June 2022
Patient Safety Learning

Diabetes: Warning that missing eye test appointments risks sight loss

Diabetes patients have been warned that non-attendance at eye-test appointments puts them at greater risk of developing unnecessary sight loss.
The Royal National Institute for the Blind (RNIB) has described the attendance rates at clinics in Northern Ireland as "alarmingly low" .
It said 20% to 40% of patients were not showing up for their appointments on any given day.
Prof Tunde Peto, clinical lead for the NI Diabetic Eye Screening Programme, said the most common of many complications caused by diabetes was diabetic eye disease.
Diabetes can cause cataracts early on but it can also affect the retina at the back of the eye, "which will eventually lead to sight loss if not treated on time," Prof Peto explained.
"Diabetic retinopathy causes no symptoms until it can be just about too late to treat," she said.
Ian Catlin from Ballymoney has experienced sight loss due to diabetic retinopathy.
He has had Type 1 diabetes since childhood and became aware of problems with his eyesight in his mid-30s.
Mr Catlin said he put off asking for medical help because of the fear of what he would be told."I did eventually go, but you're scared and you put your head in the sand," he said.Read full story
Source: BBC News, 15 June 2022
Sam

Sickle cell: Just half of nurses and doctors feel confident about treating illness, report finds

Only half of healthcare professionals feel they have sufficient tools to manage the long-term damage that sickle cell disease brings, new research has revealed.
The in-depth study by Global Blood Therapeutics - carried out across 10 countries including the UK, US and Canada - shows that patients living with the illness remain dramatically underserved by healthcare systems, while healthcare professionals don’t feel like they have the knowledge of the disease or their patients, to properly treat them.
More than two in five (43%) doctors and nurses cited difficulties due to having different ethnic backgrounds from their patients, it was revealed, while almost three quarters (73%) stated patients of lower economic status can be more difficult to treat. Almost a third of healthcare professionals (31%) found it challenging to understand their patients’ needs.
Sebastian Stachowiak, Head of Europe and GCC at Global Blood Therapeutics, told The Independent that the survey “confirms the lack of options for physicians” and expressed hope that, with recent advances in available treatment, patients can be better served in the future.
The study also found that almost half (46%) of patients say that emergency room healthcare providers did not believe them about their symptoms, while 48% said that they have been treated like a drug seeker in the emergency room.
Read full story
Source: The Independent, 14 June 2022
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Covid care home restrictions in Scotland caused harm, says report

Severe restrictions imposed on care home residents in Scotland during the Covid pandemic caused "harm and distress" and may have contributed to some deaths, academics have said.
A 143-page report has been produced by Edinburgh Napier University. It had been commissioned by the independent inquiry into the country's handling of the pandemic.
The report says that the legal basis for confining residents to their rooms and banning visitors was "unclear".
And it said care home residents were arguably discriminated against compared to other citizens.
The report is 1 of 14 that have been published by the Scottish Covid-19 Inquiry, which is chaired by Lady Poole.
It found that in the early months of the pandemic there was "little evidence" that the human rights of residents and their families had been considered.
It said: "There is substantial evidence of the harm and distress caused to residents and their families by the restrictions imposed in care homes.
"This includes concerns that, particularly for people with dementia, being unable to maintain contact with their family exacerbated cognitive and emotional decline, potentially hastening their death."
Read full story
Source: BBC News, 16 June 2022
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Bristol NHS 'causing harm' to patients by withholding thyroid drug

Bristol's NHS commissioning group is one of many across the country which is "causing harm" to people with thyroid problems by limiting the provision of a drug, a new report says.
Analysis from the Thyroid Trust says that 58 per cent of NHS Clinical Commissioning Groups in England are withdrawing, refusing or reducing prescriptions of T3 for people with underactive thyroids - against national guidance. People who have thyroid problems can suffer from depression, crippling fatigue, weight gain and muscle weakness, which can be alleviated by the drug.
But the Bristol, North Somerset and South Gloucestershire CCG does not permit prescribing the drug for new patients, according to the report. One Westcountry woman told the Express that she had her T3 prescription withdrawn, which caused her significant problems.
Former police officer Carole Morgan-Anstee, 62, told the website she went through "hell" after her T3 was stopped. The Somerset woman was prescribed the drug after suffering symptoms including chronic fatigue and hair loss for 15 years.
But after being treated with T3 for five years, her endocrinologist told her he had been ordered to stop prescribing it for her. He reportedly said the problem was that her local Bristol North Somerset and South Gloucestershire CCG had began cutting back on T3 supplies.
Carole said: "I was really upset. It was hell. My treatment was completely within the guidelines and he knew how ill I would get if they took it away.
The Thyroid Trust report says: "Around the country most Clinical Commissioning Groups have policies in place which are causing harm to patients by denying treatment. In those cases where this has occurred, patients have resorted to the private sector or to informal means, such as buying the medication online, or even travelling abroad where it is sometimes available to buy over the counter, to source the medicine they need which the NHS should be providing.
Read full story
Source: Bristol Post, 15 June 2022
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Hospitals have become less safe during the pandemic. So why does the US government want to suppress hospital safety data?

There’s little question that US hospitals—up against COVID, patient surges, and labor and supply shortages—have become less safe for patients during the pandemic, as preventable events and complications have become more common.

Leaders with the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS) said as much, earlier this year, in an article for the New England Journal of Medicine: “Many indicators make it clear that health care safety has declined,” they wrote, noting, “the fact that the pandemic degraded patient safety so quickly and severely suggests that our health care system lacks a sufficiently resilient safety culture and infrastructure.”
Despite such frank assessments, CMS is now at odds with public safety advocates about whether to make some of the hospital-specific data behind those trends publicly available. 
Read full story (paywalled)
Source: Fortune, 14 June 2022
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Time for change: The College of Medicine launches its Beyond Pills campaign

On Thursday 16 June, The College of Medicine launched its Beyond Pills campaign – calling for Government intervention on over-prescribing – at the Integrated and Personalised Medicine Congress 2022.
Around 1.1 billion medicines are currently prescribed unnecessarily. Supported by eminent voices in both the Government and our healthcare system, the Beyond Pills campaign calls for the Government to immediately address the nation’s unsustainable prescription service through re-prescribing and social prescribing.
Speaking at the Integrative and Personalised Medicine Congress 2022, The College of Medicine Chair Dr Michael Dixon said: “Medicine, as we know it, is no longer affordable or sustainable. Nor is it able to curb the increase in obesity, mental health problems and most long-term diseases.
“A new medical mindset is needed, which goes to the heart of true health care. The advantages and possibilities of social prescription are limitless.
“An adjustment to the system now will provide a long-term, sustainable solution for the NHS to meet the ever-increasing demand for funding and healthcare professionals.”
The Campaign was established in the wake of the Chief Pharmaceutical Officer’s National Overprescribing Review published in September 2021.
The Beyond Pills Campaign aims to reduce drug prescription, expand the number of social prescribing link workers, save crucial funds, and provide support to individuals and local communities hampered by health inequalities. To achieve these goals, it has today launched a campaign that includes six specific actions that need to be taken:
Improving medical and healthcare training. Social prescribing and a psychosocial approach to treatment needs to be embedded throughout the curriculum Addressing financial incentives within the NHS. Financial incentives in the system should centre around community health. For those patients already on a cocktail of pills, medication reviews and appropriate deprescribing need to be emphasised Increasing the number of social prescribing link workers. Primary Care Networks need to employ more link workers to enable access to social prescribing for everyone who could benefit Increasing support for the voluntary sector. Government departments need to fund and support voluntary initiatives that encourage healthy communities Empowering individuals and communities. Informing individuals about social prescribing and collaborating with volunteers involved in social prescription and local health creation and showcasing benefits Further systematic research. Mobilising the research community to develop a fully-fledged programme review into topics including the therapeutic efficacy of social prescribing Read full story
Source: College of Medicine, 16 June 2022
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Doctors warn against over-medicalising menopause after UK criticism

Doctors have hit back at critics saying they are failing menopausal women, and said that treating menopause as a hormone deficiency that requires medical treatment could fuel negative expectations and make matters worse.
Writing in the British Medical Journal they said there was an urgent need for a more realistic and balanced narrative which actively challenges the idea that menopause is synonymous with an inevitable decline in women’s health and wellbeing, and called for continued efforts to improve awareness about the symptoms and how to deal with them.
“Menopause is a natural event for half of humankind. While media attention in the UK may give the impression that growing numbers of women are struggling to cope with menopausal symptoms and are seeking hormonal treatment, there is no universal experience and most women prefer not to take medication unless their symptoms are severe,” wrote Martha Hickey, a professor of obstetrics and gynaecology at the University of Melbourne, Australia, and colleagues.
They added that over-medicalisation of the menopause risked collapsing this wide range of experiences into a narrowly defined disease requiring treatment.
“It tends to emphasise the negative aspects of menopause and, while effective treatments are important for those with troublesome symptoms, medicalisation may increase women’s anxiety and apprehension about this natural life stage.”
Women’s experiences of menopause were strongly influenced by personal, family and social factors, they said. For instance, a recent review found that negative attitudes and expectations before menopause predicted the likelihood of women experiencing distressing symptoms.
“Changing the narrative by normalising menopause and emphasising positive or neutral aspects such as freedom from menstruation, pregnancy and contraception, together with information about managing troublesome symptoms might empower women to manage menopause with greater confidence,” Hickey said.
Read full story
Source: The Guardian, 15 June 2022
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