HSJ have announced the HSJ Patient Safety Awards 2022 shortlist.
View the finalists here
174 projects, teams and organisations impressed the judges with their entries following a rigorous benchmarking process and have been shortlisted.
The award ceremony will be held on 15 September 2022, at Manchester Central.
Heather Lawrence was shocked at the state she found her 90-year-old mother, Violet, in when she visited her in hospital.
"The bed was soaked in urine. The continence pad between her legs was also soaked in urine, the door wide open, no underwear on. It was a mixed ward as well," Heather says.
"I mean there were other people in there that could have been walking up and down seeing her, with the door wide open as well. My mum, she was a very proud woman, she wouldn't have been wanted to be seen like that at all."
Violet, who had dementia, was taken to Tameside General Hospital, in Greater Manchester, in May 2021, after a fall. Her health deteriorated in hospital and she developed an inflamed groin with a nasty rash stretching to her stomach - due to prolonged exposure to urine. She died a few weeks later.
Heather tells BBC News: "I don't really know how to put it into words about the dignity of care. I just feel like she wasn't allowed to be given that dignity. And that's with a lot of dementia patients. I think they just fade away and appear to be insignificant, when they're not."
New research, shown exclusively to BBC Radio 4's File on 4 programme, has found other dementia patients have had to endure similar indignity.
Dr Katie Featherstone, from the Geller Institute of Ageing and Memory, at the University of West London, observed the continence care of dementia patients in three hospitals in England and Wales over the course a year for a study funded by the National Institute for Health and Care Research.
She found patients who were not helped to go to the toilet and instead left to wet and soil themselves.
"We identified what we call pad cultures - the everyday use of continence pads in the care of all people with dementia, regardless of their continence but also regardless of their independence, as a standard practice," Dr Featherstone says.
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Source: BBC News, 21 June 2022
Government will pick five or six ‘integration frontrunner’ areas ‘to lead the way in developing and testing radical new approaches’ to speeding up discharge from acute hospitals.
Along with NHS England, ministers today wrote to local NHS and council directors asking for bids to take part by 30 June.
They said there was “a need to take a more fundamental look at [how the] system currently manages the discharge of patients, their post-acute care, and their access to high-quality social care”.
The “discharge integration frontrunner sites” will focus on exploring “new service models, such as the delivery of a more integrated model for intermediate care across existing health and social care”, and “designing and testing new enabling arrangements, which might include new funding models, more integrated workforce models, or the deployment of new technologies”, their letter said.
They said speeding up hospital discharge was “just one” potential benefit from integration and indicated that “future phases” of frontrunners may focus elsewhere.
But delayed discharge has been a major pressure on the system over the past year, particularly last winter, and the letter says: “Delayed discharges are one very visible signal that the health and care system remains fragmented and too often fails to deliver joined-up services that meet people’s needs.”
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Source: HSJ, 21 June 2022
More than 80% of UK medical certificates recording stillbirths contain errors, research reveals.
More than half the inaccurate certificates contained a significant error that could cause medical staff to misinterpret what had happened.
The study, published in the International Journal of Epidemiology, also shows that three out of four stillbirths certified as having an "unknown cause of death" could, in fact, be explained.
A team from the Universities of Edinburgh and Manchester examined more than 1,120 medical certificates of stillbirths, which were issued at 76 UK obstetric units in 2018.
Of the 421 which were resolved, 195 were re-designated as foetal growth restriction (FGR), and 184 as placental insufficiency.
Dr Michael Rimmer, clinical research fellow at Edinburgh University’s MRC Centre for Reproductive Health, said: “This study shows some medical certificates of stillbirths contain significant errors.
"Reducing these errors and accurately recording contributing factors to a stillbirth is important in shaping research and health policies aimed at reducing the number of stillbirths.
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Source: The Herald, 21 June 2022
People with disabilities must be helped more by health providers to access information, a report has found.
Over 300 people in North Yorkshire were asked about communication from GPs, hospitals, and healthcare providers in a survey by watchdog Healthwatch.
The report said there is "some good practice" but many patients are not being contacted in their preferred format. This leads to missed appointments which "costs time and money".
Since 2016, the Accessible Information Standard means health and care organisations must legally provide a "consistent approach to identifying, recording, flagging, sharing, and meeting the information and communication support needs of patients, service users, carers and parents with a disability, impairment, or sensory loss," Healthwatch said.
But the report said some people receive printed letters which they are unable to read meaning they have to ask for private and confidential information to be relayed.
Scarborough respondent Ian said it was "amazing" that in the 21st Century many are still facing such issues.
"The [GP booking] system doesn't anticipate that not everyone can use the phone," he said.
"The problem is a lot of organisations haven't moved with the times".
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Source: BBC News, 21 June 2022
Ground breaking new data on community services appears to show enormous variation between areas in the number of referrals for a “two-hour urgent response” being recorded.
NHS England has published new provisional data on the performance of urgent community response services against a key NHS long-term plan target of reaching at least 70% of patients referred to them within two hours by December 2022.
It is the first time performance data has been published for community health services.
It also includes the number of referrals made which are reported as “in scope” of the target, and the total number of service contacts. There is huge variation in both referrals and contacts, not accounted for by the size of areas or population need.
The publication of the first national performance data for community services was described as “an important moment for community providers” by Siobhan Melia, chair of the Community Network, which is part of NHS Providers and the NHS Confederation. She added it would “raise the profile of community services, and shine a light on the important work taking place in the sector”.
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Source: HSJ, 21 June 2022
Systems and processes in place around patient safety failed in terms of the work of a Belfast-based neurologist, an inquiry has found.
Dr Michael Watt was at the centre of Northern Ireland’s largest ever recall of patients, which began in 2018, after concerns were raised about his clinical work.
More than 4,000 of his former patients attended recall appointments.
Almost a fifth of patients who attended recall appointments were found to have received an “insecure diagnosis”.
The final report following the Independent Neurology Inquiry found that problems with Dr Watt’s practice were missed for years and opportunities to intervene were lost.
It makes 76 recommendations to the Department of Health, healthcare organisations, General Medical Council and the independent sector.
“While one process or system failure may not be critical, the synergistic effect of numerous failures ensured that a problem with an individual doctor’s practice was missed for many years and, as this inquiry finds, opportunities to intervene, particularly in 2006/2007, 2012/2013, and earlier in 2016 were lost,” the inquiry found.
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Source: The Independent, 21 June 2022
Some pharmacies run by the High Street chain Boots have been criticised for telling some patients on multiple drugs that they can no longer have blister pack boxes, known as dosette boxes or multi-compartment compliance aids (MCCAs).
Weekly pill organisers can help users keep track of their daily medication and stay safe. Pharmacists put the tablets into individual boxes in the trays, each one indicating when they should be taken.
The NHS says boxes are not always available for free on the NHS and they're not suitable for every type of medicine.
Tracey Hobbs' mother, Pat Garner, lives at home with care visits. For several years, she has had her MCCAs provided by her local Boots pharmacy. She takes more than 15 pills each day.
Tracey says she was phoned by Boots and told that from one month later her mother would receive all the drugs in the original packaging, rather than organised into morning and night doses for each day of the week.
Tracey told the BBC: "I pointed out that the blister packs were the only way we could know she had taken her medication at the right time. Handing seven individual boxes with different instructions on each one was totally unworkable and - quite frankly - dangerous".
A Boots spokesperson said: "The latest Royal Pharmaceutical Society guidance indicates that the use of multi-compartment compliance aids is not always the most appropriate option for patients that need support to take their medicines at the right dose and time."
"Pharmacists are speaking with patients who we provide with MCCAs to discuss whether it is the right way to support them, depending on their individual circumstances and clinical needs."
Prof Gill Livingston, an expert in elderly medicine at University College London, said she was concerned to hear that some patients and their families were being told the boxes were being scrapped.
She said: "Blister packs enable people with mild dementia or some memory problems to take their own medication and remain independent. They can check that they have taken it and they know they have taken the right thing, as it is already sorted out.
"Later on in dementia or with other disabilities, it enables paid carers and families to help them take their medication and remain in the community and remain as well as possible."
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Source: BBC News, 21 June 2022
An ambulance trust has been placed in special measures after the Care Quality Commission (CQC) rated its leadership ‘inadequate’ and said staff felt unable to raise concerns without fear of reprisal
The CQC inspected South East Coast Ambulance Service Foundation Trust after being contacted by staff with concerns about bullying and harassment, inappropriate sexualised behaviour and a leadership team which failed to address concerns.
Many of the concerns echo those raised in 2017 in an independent review into a “culture of fear” at the trust, shortly after it was first placed in regulatory special measures. It was taken out in 2019 but has now been placed back in the equivalent “recovery support programme” on the CQC’s recommendation.
CQC director of integrated care Amanda Williams praised staff who had contacted the regulator. She said: “While staff were doing their very best to provide safe care to patients, leaders often appeared out of touch with what was happening on the front line and weren’t always aware of the challenges staff faced. Staff described feeling unable to raise concerns without fear of reprisal – and when concerns were raised, these were not acted on.
“This meant that some negative aspects of the organisational culture, including bullying and harassment and inappropriate sexualised behaviour, were not addressed and became normalised behaviours."
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Source: HSJ, 22 June 2022
Health trackers worn on the wrist could be used to spot Covid-19 days before any symptoms appear, according to researchers.
Growing numbers of people worldwide use the devices to monitor changes in skin temperature, heart and breathing rates. Now a new study shows that this data could be combined with artificial intelligence (AI) to diagnose Covid-19 even before the first tell-tale signs of the disease appear.
“Wearable sensor technology can enable Covid-19 detection during the presymptomatic period,” the researchers concluded. The findings were published in the journal BMJ Open.
The discovery could lead to health trackers being adapted with AI to detect Covid-19 early, simply by spotting basic physiological changes. This could help provide an early warning system to users that they may be infected, which may in turn help to prevent the spread of the disease more widely.
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Source: The Guardian, 21 June 2022
Women including refugees, asylum seekers, and undocumented migrants are being charged as much as £14,000 to give birth on the NHS in England, a report by Doctors of the World (DOTW) has found.
The report, which examined inequalities in maternity care among migrant pregnant women and babies, gathered the experiences of 257 pregnant women accessing DOTW’s services from 2017 to 2021. It found that over a third (38%) who accessed its services had been charged for healthcare, often inappropriately. The women were charged £296 to £14 000, and half of them were billed over £7000.
The report said that inequalities in access to antenatal care experienced by migrant women were likely to lead to poorer outcomes for their pregnancy and the health of their children.
The evidence highlights the need for urgent action to address the inequalities experienced by migrant pregnant women and their babies. There is a pressing need for immigration status to be considered as part of the ethnic and racial health inequalities agenda and for independent action to be taken to review the impact of NHS charging policy.
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Source: BMJ, 20 June 2022
Student paramedics are missing out on learning how to save lives because they are wasting hours in ambulances outside A&E instead of attending calls, it has been revealed.
The College of Paramedics and ambulance directors say the hold-ups mean trainees are missing vital on-the-job experience, leading to fears over the safety of patients.
Will Boughton, of the College of Paramedics Trustee for Professional Standards, said handover delays had become a problem for trainees’ development and exposure to real-life experience, meaning training had become “unpredictable”.
If steps weren’t taken to increase training opportunities and address wider quality concerns in education, “it is very possible that patient safety may be at risk due to missed experience during practice education”, he warned.
“A student could complete a regular shift and see lots of patients, getting lots of things in their portfolio signed off, or they could be the unlucky ambulance that joins the back of a queue and is then at hospital X for however many hours waiting to release that patient, so and it varies from county to county and service to service,” he said.
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Source: The Independent, 22 June 2022
Last year, Diana Berrent—the founder of Survivor Corps, a US Long COVID support group—asked the group’s members if they’d ever had thoughts of suicide since developing Long Covid. About 18% of people who responded said they had, a number much higher than the 4% of the general US adult population that has experienced recent suicidal thoughts.
A few weeks ago, Berrent posed the same question to current members of her group. This time, of the nearly 200 people who responded, 45% said they’d contemplated suicide.
While her poll was small and informal, the results point to a serious problem. “People are suffering in a way that I don’t think the general public understands,” Berrent says. “Not only are people mourning the life that they thought they were going to have, they are in excruciating pain with no answers.”
Long Covid, a chronic condition that affects millions of Americans who’ve had COVID-19, often looks nothing like acute COVID-19. Sufferers report more than 200 symptoms affecting nearly every part of the body, including the neurologic, cardiovascular, respiratory, and gastrointestinal systems. The condition ranges in severity, but many so-called “long-haulers” are unable to work, go to school, or leave their homes with any sort of consistency.
Long COVID can also be incredibly painful, and research has linked chronic physical pain to an increased risk of suicide. Nick Güthe has been trying to spread that message since his wife, Heidi Ferrer, died by suicide in 2021 after living with Long Covid symptoms for about a year. Among her most disruptive symptoms, Güthe says, were foot pain that prevented her from walking comfortably, tremors, and vibrating sensations in her chest that kept her from sleeping.
“My wife didn’t kill herself because she was depressed,” Güthe says. “She killed herself because she was in excruciating physical pain.”
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Source: Time. 13 June 2022
Public health officials have declared a national incident after routine surveillance of wastewater in north and east London found evidence of community transmission of poliovirus for the first time.
The UK Health Security Agency (UKHSA) said waste from the Beckton sewage treatment works in Newham tested positive for vaccine-derived poliovirus in February and that further positive samples had been detected since.
No cases of the disease or related paralysis have been reported, and the risk to the general public is considered low, but public health officials urged people to make sure that they and their families were up to date with polio vaccinations to reduce the risk of harm.
“Vaccine-derived poliovirus has the potential to spread, particularly in communities where vaccine uptake is lower,” said Dr Vanessa Saliba, consultant epidemiologist at the UKHSA. “On rare occasions it can cause paralysis in people who are not fully vaccinated, so if you or your child are not up to date with your polio vaccinations it’s important you contact your GP to catch up or if unsure check your red book.”
“Most of the UK population will be protected from vaccination in childhood, but in some communities with low vaccine coverage, individuals may remain at risk,” she added.
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Source: The Guardian, 22 June 2022
A leading NHS hospital failed to publicly disclose that four very ill premature babies in its care were infected with a deadly bacterium, one of whom died soon after, the Guardian has revealed.
St Thomas’ hospital did not admit publicly that it had suffered an outbreak of Bacillus cereus in the neonatal intensive care unit (NICU) of its Evelina children’s hospital in late 2013 and early 2014.
It occurred six months before a well publicised similar incident in June 2014 in which 19 premature babies at nine hospitals in England became infected with it after receiving contaminated baby feed directly into their bloodstream. Three of them died, including two at St Thomas’.
Leaked documents show that both the first outbreak and newborn baby’s death were investigated but never publicly acknowledged by the NHS trust that runs the hospital.
GSTT insists that it did not acknowledge the baby’s death publicly in any reports because it believed the child had died of other medical conditions, not the bacteria. However, it declined to say if it had told the baby’s parents that it had become infected with Bacillus cereus.
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Source: The Guardian, 23 June 2022
A group of 95 people who developed health problems or lost relatives as a result of rare side-effects of the Oxford-AstraZeneca Covid-19 vaccine say they have been let down by the "out-of-date" government payment scheme.
One woman whose fiancé died after the jab was awarded £120,000 this week.
BBC News has since learned two more people have been told they will receive payments. But many more are still waiting for their cases to be assessed, despite some having final death certificates meaning senior doctors and lawyers have concluded the vaccine caused their loved one's death.
As of May, more than 1,300 claims had been made to the Vaccine Damage Payment Scheme (VDPS) but only 20 referred for medical assessment.
Meanwhile, some fear their genuine but rare cases are being drowned out by a flurry of people making unproven claims about vaccine damage online.
Claire Hibbs was unable to work for a year after developing vaccine-induced immune thrombotic thrombocytopenia (VITT) and struggles with chronic fatigue, migraines and brain fog and fears her job could be at risk - but believes she will not be considered 60% disabled.
Like others in the group, she has been upset by suggestions she might be opposed to vaccines - "it's a pro-vaccination campaign," Ms Moore says.
But Ms Hibbs acknowledges false claims about damage from Covid vaccines have been widely circulated online - and research suggests such claims can increase vaccine hesitancy and put people's lives at risk.
Members of the group, Vaccine, Injured, Bereaved UK (VIB UK) have all received official confirmation of a link to the vaccine. But underneath many of its factual posts, other accounts share reams of false and misleading claims about the vaccine
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Source: BBC News, 23 June 2022
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