Skip to content
the hub has moved to a new software platform. You will need to login using your email address. Find out more here.

News

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

Rail strikes ‘will kill people’, warns NHS leader

Next week’s rail strikes will ’probably end up killing people’ as they will prevent staff working for already struggling ambulance trusts from getting to work, a senior NHS leader has told HSJ.
Both London Ambulance Service Trust and South Central Ambulance Service Foundation Trust have moved to ”Reap 4”, This is the highest level of alert, meaning they are under extreme pressure. 
Ambulance trusts are already experiencing high demand amid soaring temperatures and continuing problems with lengthy handovers at the accident and emergency departments. Fears are now growing that next week’s rail strikes will push services to breaking point as many ambulance staff travel to work by public transport.
The three days of rail strikes – on Tuesday, Thursday and Saturday next week – will see many lines with very limited services. Tube services in London will also be hit by a strike on Tuesday and the London Overground and some tube lines will be affected on rail strike days. 
A senior leader closely involved in southern England’s emergency and urgent care services told HSJ: “Next week’s rail strikes will probably end up killing people because they’ll prevent ambulance trust staff getting to work.”
Other ambulance trusts are understood to be monitoring the situation closely. Trusts in REAP 4 (REAP stands for resource escalation action plan) normally take a series of measures including diverting more staff to frontline duties, asking some patients to make their own way to hospital and concentrating on reaching the most serious patients.
Read full story (paywalled)
Source: HSJ, 16 June 2022
Patient Safety Learning

Over half of ethnic minority NHS leaders consider quitting due to racism

Just over half of senior ethnic minority leaders have considered leaving the NHS due to experiencing workplace racism a survey suggests.
The survey was carried out by the NHS Confederation’s BME Leadership Network and its 123 respondents included chief executives, directors and senior managers.
Responses were collected from network members online before three roundtables were held with senior ethnic minority leaders to understand their experiences and the challenges they have faced in relation to discrimination.
The survey found:
51% of respondents said they had considered leaving the NHS in the past three years because of their experience of racist treatment while working. More than 20% said they had experienced verbal abuse or abusive behaviour targeting racial, national or cultural heritage five times or more in the last three years. 69% had experienced this behaviour from other leaders or managers within their organisation at least once in the same timeframe. 57% had experienced it from leaders or managers in another organisation at least once over the same period. Joan Saddler, NHS Confederation’s director of equality and partnerships, said the NHS was at risk of losing “committed, highly skilled and motivated talent to institutional racism and discrimination”.
Read full story (paywalled)
Source: HSJ, 17 June 2022
You may also be interested in reading: BMA: Racism in medicine
Patient Safety Learning

England appoints ambassador to shake up women's health

England's first women's health ambassador is calling for "one-stop shops" where women can sort out their health needs.
Dame Lesley Regan, also a practising doctor, wants to make it easier for women and girls to access care such as contraception and smear tests in the community.
Her new role aims to close the "gender health gap". She will also support the upcoming government-led women's-health strategy.
"At the moment, we waste a lot of resource in telling girls and women that they cannot have things," she told BBC News.
"So you might go off to your doctor or gynaecologist or heart specialist and get told, well, you cannot have a smear here, even if it is due, or you need to go somewhere else for this, that and the other.
"We should make it very, very easy for people to access this out in the community - why do you need to go to a secondary or tertiary facility for things that are very easy to provide?"
Instead, she wants health hubs where women could "go for half a day and get all these things sorted out" and then get on with their lives.
"A one-stop shop is what I want for myself and what I want for my daughters and I'm sure it is what every other girl and woman wants and what every man and boy wants for the women in their lives, to be looked after that way," Dame Lesley said.
Read full story
Source: BBC News, 17 June 2022
Patient Safety Learning

Almost 100,000 facing excessive wait for serious cardiac care in England

Almost 100,000 people with serious heart problems, including some “living on borrowed time”, are enduring long waits for potentially life-saving NHS care because hospitals are so busy.
Some of them are in such poor health they will have a heart attack and die as a consequence of facing such “dangerous” long delays, the British Heart Foundation has warned.
The number of patients in England being forced to wait more than the supposed maximum 18 weeks for cardiac treatment has trebled since Covid-19 struck, from 32,186 in February 2020 to an unprecedented 96,321, a BHF analysis of published NHS England data shows.
They are waiting for procedures such as having a stent or balloon inserted to reopen a blocked artery, a pacemaker or implantable defibrillator fitted, or open heart surgery, including bypasses or valve replacement operations. Others urgently need to have an echocardiogram, CT or MRI scan to help doctors decide on treatment.
Dr Sonya Babu-Narayan, a consultant cardiologist who is also the BHF’s associate medical director, said: “Cardiac care can’t wait. Without timely treatment, heart patients may be living on borrowed time.”
“Tens of thousands of people feel in limbo, waiting many months or even years for cardiac surgery, invasive heart procedures or important diagnostic tests. During this time they could quite quickly become much sicker, and tragically some could even die before they can receive the heart care they so desperately need,” she added.
Read full story
Source: The Guardian, 16 June 2022
Patient Safety Learning

Sweden: surgeon convicted of bodily harm over synthetic trachea transplant

A Swedish court has found an Italian surgeon, once hailed for pioneering windpipe surgery, guilty of causing bodily harm to a patient, but cleared him of assault charges.
Paolo Macchiarini won praise in 2011 after claiming to have performed the world’s first synthetic trachea transplants using stem cells while he was a surgeon at Stockholm’s Karolinska University hospital. The experimental procedure was hailed as a breakthrough in regenerative medicine.
But allegations soon emerged that the procedure had been carried out on at least one person who had not been critically ill at the time of the surgery.
During the May trial, held in the Solna district court, prosecutors argued that the surgeries on three patients in Sweden constituted assault, or alternatively bodily harm due to negligence, as Macchiarini disregarded “science and proven experience”.
The district court agreed with the prosecutors, but cleared Macchiarini on two counts as the patients’ health was in such a dire state. “Given the patients’ condition, the district court finds that the procedures on the first two patients were justifiable,” it said in a statement.
However, in the third patient, the court found him guilty of "causing bodily harm". 
"At the time of the third procedure, the experience from the first procedures was such that the surgeon should have refrained from letting yet another patient go through the operation", the court said.
Macchiarini was handed a suspended sentence.
Read full story
Source: The Guardian, 16 June 2022
Patient Safety Learning

'Urgent' changes needed for child disability care

The mothers of two teenage boys who died after failures in their care have called on the government to make "urgent improvements" to how children with disabilities are assessed.
Sammy Alban-Stanley, 13, and 14-year-old Oskar Nash both died in 2020. Inquests for both boys recorded they had received inadequate care from local authorities and mental health services.
The calls were made in an open letter to the secretaries of state for health and social care, and education.
Patricia Alban and Natalia Nash asked Sajid Javid and Nadim Zahawi to make fundamental changes to several care areas to prevent future deaths.
The pair said they both experienced problems with support for disabled children and families.
Services lacked understanding of neurological conditions like autism, they said.
The pair also pointed to a lack of access to children and adolescent mental health services (CAMHS), and failure to assess or review the severity of a child's developing needs.
Read full story
Source: BBC News, 16 June 2022
Patient Safety Learning

Coeliac patient died after being fed Weetabix in hospital, inquiry hears

An 80-year-old woman with coeliac disease died within days of being fed Weetabix in hospital, an inquest has heard.
Hazel Pearson, from Connah’s Quay in Flintshire, was being treated at Wrexham Maelor hospital and died four days later on 30 November from aspiration pneumonia. Although her condition was recorded on her admission documents, there was no sign beside her bed to alert healthcare assistants to her dietary requirements.
Coeliac disease is a condition where the immune system attacks the body’s own tissues after consuming gluten, a type of protein found in wheat, rye and barley, causing damage to the small intestine.
The hospital’s action plan to avoid similar fatal incidents lacked detail and had “narrow vision”, the coroner said.
The hospital’s matron, Jackie Evans, told the inquest that changes, including placing signs above the beds of patients with special dietary requirements, had been implemented since Pearson’s death. But Sutherland raised concerns that the hospital had yet to carry out a formal investigation into what went wrong.
She said: “The action plan lacks detail. What has happened locally is commendable, but it lacks detail and it has narrow vision.” She added that the plan that had been put in place was “amateurish with no strategic vision”.
The assistant coroner said she would be unable to make a decision on a prevention of future deaths report until the Betsi Cadwaladr University Health Board (BCUHB) provided a witness to answer further questions about changes.
Read full story
Source: The Guardian, 17 June 2022
Patient Safety Learning

Man paralysed from neck down ‘not eligible’ for night-time care

A quadriplegic man was told his care funding would be revoked, after NHS officials deemed him not disabled enough to qualify for support.
Simon Shaw, 54, has received 24-hour care since he was left paralysed from the neck down after a car accident in 1984.
He relies on carers at night to help him with everything from turning in bed to having a drink of water. They also intervene with medical aid if he develops life-threatening complications related to his paralysis, which could happen at any time, without warning.
But a recent NHS assessment controversially ruled Shaw’s health needs were not severe enough to warrant full-time medical care. Local health authority officials told him he did not meet eligibility criteria and his NHS funding would be stopped from 20 June.
Shaw, from Clapham, south London, said that meant there was no money for his night-time care and he would be left unsupported from 8pm to 8am for the first time in nearly four decades.
“It’s frightening, to be honest,” Shaw said. “I don’t know what I’m going to do when they take my care away.
“I don’t cease to exist after 8pm. I still need to get into bed, have a drink of water and use the toilet – and I can’t do any of it on my own.
“There are a lot of things that can go wrong with my health and when they do, they usually need urgent attention. If there’s no one there, to be frank… it could mean death.”
Mandy Jamieson, a caseworker for the Spinal Injuries Association, said: “We have noticed an increase in patients with severe disabilities being turned down for funding in recent years, particularly since the introduction of assessments via video call since the pandemic.
“But I feel particularly in Simon’s case the decision that has been made is wrong. He has so many health needs that I find it incredible that they turned him down.”
Read full story
Source: The Guardian, 19 June 2022
Patient Safety Learning

MHRA joins international partnerships to set global standards for medicines and medical devices regulation

The UK is set to play a greater international role in making sure medicines and medical devices are regulated safely and efficiently worldwide, the Medicines and Healthcare products Regulatory Agency (MHRA) announced after being accepted as a full member of three international work-sharing partnerships.
Two of these, the International Medical Device Regulatory Forum (IMDRF) and the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) are focused on improving the harmonisation and convergence of medicines and medical devices regulation globally.
Through these partnerships, the MHRA will share expertise with other leading organisations, support the development of regulatory guidelines and drive greater harmonisation of regulation around the world. This will help deliver timely access to innovative medical products not just in the UK but globally.
The MHRA has also been accepted as a member of the US-based Medical Devices Innovation Consortium (MDIC). This public-private partnership brings together representatives of regulatory bodies, industry, non-profits, and patient organisations from different countries to improve the processes for development, assessment, and review of new medical technologies. This enables transformational medical technology to get to the people who need it sooner, by shortening the path from innovation to safety to access.
Read full story
Source: Gov.uk, 16 June 2022
Patient Safety Learning

Epilepsy drug that harms babies may damage their children too

An epilepsy drug that caused disabilities in thousands of babies after being prescribed to pregnant women could be more dangerous than previously thought.
Sodium valproate could be triggering genetic changes that mean disabilities are being passed on to second and even third generations, according to the UK’s medicines regulator.
The Medicines and Healthcare Products Regulatory Agency (MHRA) has also raised concerns that the drug can affect male sperm and fertility, and may be linked to miscarriages and stillbirths.
Ministers are already under pressure after it emerged in April that valproate was still being prescribed to women without the legally required warnings. Six babies a month are being born after having been exposed to the drug, the MHRA has said. It can cause deformities, autism and learning disabilities.
Cat Smith, the Labour chairwoman of the all-party parliamentary group on sodium valproate, said: “This transgenerational risk is very concerning. There have been rumours that this was a possibility, but I had never heard it was accepted until last week by the MHRA."
“The harm from sodium valproate was caused by successive failures of regulators and governments, and this news means it could be an order of magnitude worse than we first thought. It underlines the need for the Treasury to step up to their responsibilities around financial redress to those families.”
Read full story (paywalled)
Source: Sunday Times, 19 June 2022
Patient Safety Learning

Thousands of women given ‘dangerous’ electric shocks as mental health treatment in England

Thousands of women in England with mental health problems are being given electric shock treatment despite concerns the therapy can cause irreparable brain damage.
NHS data seen by The Independent reveals the scale of electroconvulsive therapy (ECT) prescribed disproportionately to women, who make up two-thirds of patients receiving the treatment.
Health professionals have warned the therapy can cause brain damage so severe recipients are unable to recognise family and friends or do basic maths.
While some patients say the therapy profoundly helped them, leading mental charities have branded it “damaging” and “outdated” and called for its use to be halted pending an urgent review or banned entirely.
Statistics obtained through Freedom of Information requests by Dr John Read, a professor at the University of East London and leading expert on ECT, showed 67% of 1,964 patients who received the treatment in 2019 were female.
ECT was given to women twice as often as men across 20 NHS trusts in the UK, his research found. The trusts also said some 36% of their patients in 2019 underwent ECT without providing consent.
A spokesperson added patients should be fully informed of the risks associated with ECT and the decision to deploy the treatment “should be made jointly with the person with depression as far as possible”.
Read full story
Source: The Independent, 19 June 2022
Patient Safety Learning

Newborn infection trial ‘will fail’ unless Government intervenes, experts warn

A clinical trial to test pregnant women for Group B Strep (GBS) – the most common cause of life-threatening infection in newborn babies – will fail unless the Government intervenes, experts have warned.
Some 80 hospitals are needed for the trial to go ahead but only 32 have committed to it, with a deadline for registering of September.
The trial is being funded by the National Institute for Health Research (NIHR) and will look at whether testing women for Group B Strep reduces the risk of babies dying or suffering harm.
Now Dr Jane Plumb, chief executive of Group B Strep Support, who lost her son Theo to the infection, is calling on the Government and NHS England to intervene to make sure the trial goes ahead.
She said: “The reality is that unless a further 48 hospitals sign up for this trial, then it will fail.
“The Government is waiting for the results from this trial to determine whether to test pregnant women for Group B Strep.
“Yet there seems to be little acknowledgement that this trial is heading towards failure.
“We need more hospitals on board and we need to make sure that the investment in this trial is not wasted.
“This is about saving the lives of babies, and it really is now or never.”
Read full story
Source: The Independent, 20 June 2022
Patient Safety Learning

Patient safety incidents are the third leading cause of death in Canada

The COVID-19 crisis has both divided and galvanised Canadians on healthcare. While the last three years have presented new challenges to healthcare systems across the country, the pandemic has also exacerbated existing challenges, most notably the high levels of errors and mistreatment documented in Canadian health care.
According to a 2019 report from the Canadian Patient Safety Institute, Canada was already facing a public health crisis prior to the pandemic: a crisis of patient safety. As the report details, patient safety incidents are the third leading cause of death in Canada, following cancer and heart disease.
Few studies calculate national data on this topic, but a 2013 report found that patient safety events resulted in just under 28,000 deaths. Many Canadians who have experienced these errors have shared their experiences with media in an effort to raise awareness and demand change.
The impact of the COVID-19 pandemic has created a moment of dual crises. First, the pre-existing crisis of patient safety, and second, healthcare overall is now at a breaking point after three years of COVID-19, according to healthcare workers.
Edmonton physician Dr. Darren Markland, for example, recently closed his kidney specialist practice after making a few "profound mistakes." In an interview with Global News, he explains he could no longer work at the current pace.
He is not alone in this decision. Across the country, there have been waves of resignations in health care, leaving some areas struggling with a system that is "degrading, increasingly unsafe, and often without dignity."
Read full story
Source: MedicalXpress, 17 June 2022
Patient Safety Learning

Violence against ambulance staff in England at record high

Violence against ambulance staff in England has reached a record high, as the NHS crisis in emergency care continues to deepen.
An estimated 12,626 incidents were reported in the 12 months to April 2022, according to nationwide data shared with The Independent – a 7% rise on the previous year.
However, since 2016, the number of paramedics who have been verbally or physically assaulted, or threatened with assault, has nearly doubled, rising from 7,689.
Adam Hopper, the national ambulance violence prevention and reduction lead for the Association of Ambulance Chief Executives (AACE), which provided the data, said the findings “confirm the worrying trend of increasing violence against ambulance staff”.
One paramedic told The Independent a bone was broken in his neck after he was strangled by a drunken patient he was attempting to treat.
Matthew Taylor, chief executive of the NHS Confederation, a membership body for trusts in England, said that alcohol is the most prominent factor in such assaults, followed by drugs and people being in mental health crisis. “Race and sexuality have also increased as exacerbating factors in these assaults, as have delays to treatment and arrival times,” he added.
Read full story
Source: The Independent, 19 June 2022
Patient Safety Learning

USA: Boston Scientific faces vaginal mesh lawsuit alleging Obtryx II exposed patients to unreasonable risk of problems

Women continue to file vaginal mesh lawsuits against Boston Scientific and other manufacturers, years after most products were removed from the market due to an alarming number of complications and health risks associated with the designs.
In a complaint (PDF) filed last month in the U.S. District Court for the Southern District of Indiana, Tanya Davis indicates that problems with Boston Scientific Obtryx II mesh placed in her body only four years ago has left her with severe injuries, including pelvic pain and dyspareunia, abdominal pain, urinary problems, prolapse and incontinence. The lawsuit names Boston Scientific Corporation as the defendant.
Transvaginal mesh products like the Obtryx II have been marketed and sold by Boston Scientific Corporation and a number of different companies over the past decade, for treatment of pelvic organ prolapse or female stress urinary incontinence. Most of the products were introduced under a controversial FDA “fast track” approval process, which allowed manufacturers to introduce new products based on the design of prior mesh, without conducting thorough research to evaluate the safety or effectiveness of the specific designs.
Following widespread reports of vaginal mesh complications, including infections, erosion of the mesh into the vagina and organ perforation, the FDA required manufacturers to conduct post-marketing research and most companies decided to withdraw their products.
According to the lawsuit, Davis received an Obtryx II System in May 2018, to treat her urinary incontinence. However, after experiencing painful and debilitating complications, Davis had vaginal mesh explanted in May 2020; just two years after it was implanted.
“Neither Plaintiff nor her physicians and/or healthcare providers were warned that the Obtryx II was unreasonable dangerous or of the risks of the product, outlined herein, even when used exactly as intended and instructed by Defendant,” the lawsuit indicates. “To the contrary, Defendant promoted and sold the type of product implanted in the Plaintiff and thousands of women like Plaintiff, to healthcare providers as a safe alternative to other procedures that did incorporate Defendant’s products.”
Read full story
Source: About Lawsuits, 10 May 2022
Patient Safety Learning

Henrietta Hughes is preferred candidate for the role of Patient Safety Commissioner

Henrietta Hughes has been named as the government’s preferred candidate for the role of Patient Safety Commissioner.
Sajid Javid, the Secretary of State for Health and Social Care, has today, 20 June 2022, invited the Health and Social Care Committee to hold a pre-appointment scrutiny hearing with Henrietta.
Henrietta is a practising GP with a background in women’s health who was the National Guardian for the NHS until 2021. In addition to her clinical work, she is an appraiser for NHS England and Chair of Childhood First.
She was selected following an open public appointment process to appoint the first Patient Safety Commissioner.
Following the select committee hearing, the committee will set out its views on the candidate’s suitability for the role. The Secretary of State will then consider the committee’s report before making a final decision on the appointment.
Source: Gov.UK, 20 June 2022
Patient Safety Learning
Registered address: Patient Safety Learning, China Works SB203, 100 Black Prince Road Vauxhall, London, SE1 7SJ

Account

Navigation

Search

Search

Configure browser push notifications
Chrome (Android)
  1. Tap the lock icon next to the address bar.
  2. Tap Permissions → Notifications.
  3. Adjust your preference.
Chrome (Desktop)
  1. Click the padlock icon in the address bar.
  2. Select Site settings.
  3. Find Notifications and adjust your preference.