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

Trust was sent ‘unfit’ ventilators at height of pandemic

A trust was supplied with ventilators that were not ‘fit for NHS purposes’ by two suppliers at the height of the first Covid wave, HSJ  has revealed.
Guy’s and St Thomas’ Foundation Trust has now received a refund for both contracts, which were signed in March 2020 just as the pandemic began to hit the NHS.
The service rushed to secure the equipment in response to fears that existing ventilator capacity would be inadequate to deal with the rising number of seriously ill Covid patients. At the time, the use of ventilators was the only effective therapy for the sickest Covid patients. 
Minutes published by the trust at its most recent board meeting revealed the issue. GSTT then told HSJ in a statement: “Two contracts for ventilators were in dispute. In one case, the trust has already received a refund. In the other, which involved equipment we do not assess as fit for NHS purposes, the trust was reimbursed by central funding.”
The trust would not confirm the number of ventilators involved, the cost or the issue that meant they were not “fit for NHS purposes”.
Read full story (paywalled)
Source: HSJ, 23 June 2022
Patient Safety Learning

Watchdog warns over medication risk to vulnerable

Vulnerable patients cared for in secure mental health units across England could miss out on vital medications due to a shortage of learning disability nurses, the Healthcare Safety Investigation Branch (HSIB) has  warned.
The report into medication omissions in learning disability secure units across the country highlights problems with retaining learning disability nurses, with the number recruited each year matching those leaving.
Figures quoted in the report suggest the number of learning disability nurses in the NHS nearly halved from 5,500 in 2016 to 3,000 in 2020.
The HSIB launched a national investigation after being alerted to the case of Luke, who spent time in NHS secure learning disability units but was not administered prescribed medication for diabetes and high cholesterol on several occasions. 
At Luke’s facility, which included low and medium secure wards, HSIB investigators considered that the quality and style of care provided to patients had been directly impacted by a lack of nurses with required skill sets.
Findings from HSIB’s wider national investigation link a shortfall of learning disability nurses to instances of patients missing their medication, with the report’s authors describing a “system in which medicines omissions were too common and prevention, identification and escalation processes were not robust”. 
Read full story (paywalled)
Source: HSJ, 23 June 2022
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NHS warns of scam Covid-test texts

The NHS is warning about widespread scam text messages telling recipients they have been in close contact with a Covid case.
"We've seen reports of fake NHS text messages about ordering Omicron Covid-19 test kits," it tweeted.
Close contacts of people who have tested positive are no longer advised to test.
The aim of the messages appears to be harvesting financial and personal information.
In its alert, the NHS says it will "never ask for bank details, so please be aware of suspicious messages".
Most people are no longer advised to test for Covid and are ineligible for free tests - but some some pharmacies and shops sell them.
Read full story
Source: BBC News, 22 June 2022
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RCGP warns 19,000 GPs could quit in 'mass exodus' over next five years

Polling by the Royal College of General Practice (RCGP) as part of a campaign to make NHS GP services sustainable for the future found that 42% of 1,262 GPs and trainees who took part said they were likely to quit the profession in the next five years.
A workforce exodus on this scale would strip the health service of nearly 19,000 of the roughly 45,000 headcount GPs and GP trainees currently working in general practice.
RCGP chair Professor Martin Marshall warned that general practice was a profession in crisis - with the intensity and complexity of GP workload rising as the workforce continued to shrink.
He warned that 'alarming' findings from the RCGP poll must serve as a stark warning to politicians and NHS leaders over the urgent need for solutions to begin to tackle the crisis facing general practice.
Four in five respondents told the RCGP they expect working in general practice to get worse over the next few years - while only 6% expected things to improve.
Nearly two in five respondents said GP practice premises are not fit for purpose, and one in three said IT for booking systems is not good enough.
Professor Marshall said: 'What our members are telling us about working on the frontline of general practice is alarming. General practice is significantly understaffed, underfunded, and overworked and this is impacting on the care and services we’re able to deliver to patients.
Read full story
Source: GP, 22 June 2022
Patient Safety Learning

USA: Cerner’s VA software rollout report cites 150 “cases of harm”

A serious revelation may derail the Cerner Millenium rollout. A draft report by the Department of Veterans Affairs (VA) Office of Inspector General (OIG) states that a flaw in Cerner’s software caused the system to lose 11,000 orders for specialty care, lab work, and other services – without alerting healthcare providers the orders (also known as referrals) had been lost. This created ‘cases of harm’ to at least 150 veterans in care. 
The VA patient safety team classified dozens of cases of “moderate harm” and one case of “major harm.” The major harm cited affected a homeless veteran, aged in his 60s, who was identified as at risk for suicide and had seen a psychiatrist at Mann-Grandstaff in December 2020, after the implementation. After prescribing medication to treat depression, the psychiatrist ordered a follow-up appointment one month later. That order disappeared in the electronic health record and was not scheduled. The consequences were that the veteran, weeks after the unscheduled appointment date, called the Veterans Crisis Line. He was going to kill himself with a razor. Fortunately, he was found in time by local first responders, taken to a non-VA mental health unit, and hospitalized.
The draft report implies that the ‘unknown queue’ problem has not been fixed and continues to put veterans at risk in the VA system.
There may be as many as 60 other safety problems. Other incidents cited in the draft report include one of “catastrophic harm” and another case the VA told the OIG may be reclassified as catastrophic. Catastrophic harm is defined by the VA as “death or permanent loss of function.”
Read full story
Source: Telehealth and Telecare Aware, 21 June 2022
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Birmingham hospital faces criminal probe after death of vulnerable man

A hospital and one of its managers are facing a criminal investigation into the death of a vulnerable man who absconded by climbing a fence.
An inquest concluded failings amounting to neglect contributed to the death of Matthew Caseby in 2020, after he fled from Birmingham's Priory Hospital Woodbourne and was hit by a train.
The investigation will be carried out by the Care Quality Commission (CQC). Priory said it would co-operate fully "if enquiries are raised by the CQC".
Mr Caseby, 23, climbed over a 2.3m-high (7ft 6in) courtyard fence on 7 September 2020. He was found dead the following day after being hit by a train near Birmingham's University station.
The inquest in April heard other patients had previously climbed the fence and, despite concerns by members of staff, no action was taken to improve security in and around the courtyard until another patient absconded two months after Mr Caseby's death.
Following the inquest, coroner Louise Hunt said she was concerned the fence and courtyard area may still not be safe and urged health chiefs to consider imposing minimum standards for perimeter fences at mental health units.
She also criticised record-keeping and how risk assessments were carried out.
Read full story
Source: BBC News, 23 June 2022
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Leak reveals priorities of NHS long-term plan refresh

A drive to ‘transform’ access to urgent, emergency and planned care will be added to the goals of the NHS long-term plan, a document leaked to HSJ has revealed
The  long-term plan for the NHS was originally published in January 2019. Last September, NHS England said it was reviewing the commitments made within the plan, with senior officials warning that many of them could not be met after the damage of the pandemic.
HSJ has seen a document prepared for the most recent meeting of the NHS Assembly which sets out NHSE’s approach to the refresh.
Strategic developments expected include better joined-up community based and preventive care, transform access to urgent, emergency and planned care, improve care quality and operations, and tackle health inequalities, improve population health and develop a sustainable health service through greater collaboration.
Read full story (paywalled)
Source: HSJ, 24 June 2022
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Cost of living: GPs warning over rise in prescription requests

The cost of living crisis is adding to pressures on GPs, the British Medical Association (BMA) in Northern Ireland has warned.
The BMA said that is because the number of people asking for prescriptions for medicines that can be bought over the counter is increasing.
That includes medicines like painkillers and allergy medication, Dr Alan Stout of the BMA said.
Prescriptions are free for everyone in Northern Ireland.
The rise in prescription request increases "the cost to the health service as a whole and the pressure on GPs", Dr Stout told Ulster's Good Morning Ulster programme.
"We have talked before about the difficulties people have accessing GPs and this is just more demand and difficulties," he said.
Dr Stout added: "I absolutely don't hold that against anyone, it is not our position as GPs to deny people medication or deny people prescriptions if they need this medication."
Read full story
Source: BBC News, 23 June 2022
Patient Safety Learning

Race to find children without full vaccination against polio in London

The NHS is urgently tracking down the parents of 35,000 five-year-old children in London who are not fully vaccinated against polio.
Health officials are hoping to contain the spread of the virus after detecting the first outbreak since 1984.
They are trying to trace it back to a “single household or street” after identifying polio in a sewage plant serving four million people in northeast London.
Experts are concerned polio, which had been eradicated in Britain in the 1980s, could take off again due to relatively low vaccination uptake in London.
Latest NHS data shows 101,000 five-year-olds in England — 15% of the total — have not had their booster polio dose, offered when they reach the age of three.
One third of these, 34,104 in total, live in London. Jane Clegg, the chief NHS nurse for London said they are “reaching out to parents of children aged under five in London who are not up-to-date with their polio vaccinations to invite them to get protected.”
Read full story
Source: The Times, 23 June 2022
Patient Safety Learning

Doctor struck off for ‘repeated dishonesty’ over death of child in 1995

A doctor who attempted to cover up the true circumstances of the death in 1995 of a four-year-old patient has been struck off.
Consultant paediatric anaesthetist Dr Robert Taylor dishonestly misled police and a public inquiry about his treatment of Adam Strain, who died at the Royal Belfast Hospital for Sick Children, a medical tribunal found.
The youngster was admitted for a kidney transplant at the hospital following renal failure but did not survive surgery in November 1995.
Six months later an inquest ruled Adam died from cerebral oedema – brain swelling – partly due to the onset of dilutional hyponatraemia, which occurs when there is a shortage of sodium in the bloodstream.
Two expert anaesthetists told the coroner that the administration of an excess volume of fluids containing small amounts of sodium caused the hyponatraemia.
But Dr Taylor resisted any criticism of his fluid management and refused to accept the condition had been caused by his administration of too much of the wrong type of fluid.
In 2004 a UTV documentary When Hospitals Kill raised concerns about the treatment of a number of children, including Adam, and led to the launch of the Hyponatraemia Inquiry.
The tribunal found Dr Taylor acted dishonestly on four occasions in his dealings with the the public inquiry, including failing to disclose to the inquiry a number of clinical errors he made and falsely claiming to detectives he spoke to Adam’s mother before surgery.
Read full story
Source: The Independent, 22 June 2022
Patient Safety Learning

Covid-positive hospital patients rise a quarter in one week

The number of patients in English hospitals who have tested positive for Covid has increased 28% in a week, the steepest rise since mid-March
The third Covid wave of 2022 has now seen Covid occupation levels rise from 3,835 on 4 June to 6,401 yesterday.
The sharpest rise in the number of Covid positive patients came in the North West region, where the total rose by 43% in a week.
There are now over 1,000 Covid positive hospital patients in the North West, North East and Yorkshire, Midlands and London regions for the first time since 11 May.
Some 38% of Covid hospital patients are being treated primarily for the condition.
Read full story (paywalled)
Source: HSJ, 24 June 2022
Patient Safety Learning

Updated Freedom to Speak Up policy and guidance published

NHS England has published its new and updated national Freedom to Speak Up policy, which is applicable to primary care, secondary care and integrated care systems.
Together with NHS England, the National Guardian’s Office has also published new and updated Freedom to Speak Up guidance and a Freedom to Speak Up reflection and planning tool.
Each will help organisations deliver the People Promise for workers, by ensuring they have a voice that counts, and by developing a speaking up culture in which leaders and managers value the voice of their staff as a vital driver of learning and improvement.
NHSE is asking all trust boards to be able to evidence by the end of January 2024:
An update to their local Freedom to Speak Up policy to reflect the new national policy template. Results of their organisation’s assessment of its Freedom to Speak Up arrangements against the revised guidance. Assurance that it is on track implementing its latest Freedom to Speak Up improvement plan. Dr Jayne Chidgey-Clark said: “The publication of the updated universal Freedom to Speak Up Policy for the sector is an opportunity for organisations to refresh their Freedom to Speak Up arrangements. The new guidance we have developed in collaboration with NHS England will help leaders throughout the sector turn that policy into a healthy and supportive Speak Up, Listen Up, Follow Up culture.”
Read more
Source: National Guardian Freedom to Speak Up, 23 June 2022
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Covid vaccines cut global death toll by 20m in first year, study finds

Covid vaccines cut the global death toll by 20 million in the first year after they were available, according to the first major analysis.
The study, which modelled the spread of the disease in 185 countries and territories between December 2020 and December 2021, found that without Covid vaccines 31.4 million people would have died, and that 19.8 million of these deaths were avoided. The study is the first attempt to quantify the number of deaths prevented directly and indirectly as a result of Covid-19 vaccinations.
“We knew it was going to be a large number, but I did not think it would be as high as 20 million deaths during just the first year,” said Oliver Watson, of Imperial College London, who is a co-first author on the study carried out by scientists at the university.
Many more deaths could have been prevented if access to vaccines had been more equal worldwide. Nearly 600,000 additional deaths – one in five of the Covid deaths in low-income countries – could have been prevented if the World Health Organization’s global goal of vaccinating 40% of each country’s population by the end of 2021 had been met, the research found.
“Our findings show that millions of lives have likely been saved by making vaccines available to people everywhere, regardless of their wealth,” said Watson. “However, more could have been done.”
Read full story
Source: The Guardian, 24 June 2022
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Lack of diagnostic testing for bacterial infections is ‘alarming’, warns AMR review chair

The UK needs to do more to use diagnostic testing in the fight against antimicrobial resistance (AMR), the chair of a government-commissioned review on AMR told MPs.
Lord O’Neill, an economist and former treasury minister, warned in the review’s final report in 2016 that a continued rise in AMR would lead to 10 million people dying each year by 2050 and made ten recommendations, including the need for rapid diagnostics to reduce unnecessary use of antimicrobials.
Speaking to a Commons Science and Technology Committee evidence session on 22 June 2022, Lord O’Neill said that while he was pleased with progress on some of the recommendations published in his review in 2016, especially in the reduction of antimicrobials in agriculture, progress on diagnostics was “woeful”.
He said it was “alarming to me how we are not embedding state-of-the-art diagnostic technology right in the middle of our health systems”, adding that it could “really make a huge difference about whether an antibiotic is needed or not, and the right kind of antibiotic”.
“Our most aggressive recommendation was that we should ban the use of subjective prescriptions in secondary settings, at least in Western countries, until they’ve gone through a state-of-the-art diagnostics,” he continued.
“And nobody’s done it; they claim it’s a vicious circle, the technology isn’t there, but we have to give incentives in order to get this embedded because that would make a permanent difference.”
Read full story
Source: The Pharmaceutical Journal, 24 June 2022
Patient Safety Learning

NHS crisis caused by Tory underfunding not Covid, say doctors

Senior doctors have drawn up a major dossier refuting Sajid Javid’s claim that the pressures on the NHS were created by the Covid pandemic, amid continued warnings over patient safety, scarce beds and staff morale.
The health secretary has repeatedly suggested that the problems around record waiting lists and ambulance waiting times have been prompted by the pandemic. Last week in parliament, he accused shadow health secretary Wes Streeting of having his “head under a rock for two years” for not seeing that the pressures stemmed from Covid.
However, in a major review of evidence shared with the Observer, doctors pointed to issues around funding, bed capacity, staffing and recruitment that pre-dated the arrival of Covid. The dossier, drawn up by the British Medical Association as it gathers for its annual conference this week, finds that the UK’s health services were ill-prepared for the pandemic as a result of “historical underfunding and under-resourcing in the decade preceding the virus”.
Denise Langhor, an emergency medicine consultant in the north-west of England, said that the pandemic had “laid bare” the health service’s problems, but did not create them. “Those problems and those holes already existed,” she said. “It is entirely disingenuous of this government to claim the waiting lists and the difficulties people are experiencing with NHS care at the moment are due to Covid. They have been building for a decade.
“Every day, I have patients that I wish I could have treated sooner. It’s an awful thing as a doctor to be trying to look after patients on a corridor, and knowing they are not getting the standard of care that you want to give them.
“Frequently it feels like we’re operating by choosing the least worst option rather than the best option.”
Read full story
Source: The Guardian, 26 June 2022
Patient Safety Learning

Patients' champion 'won't speak to patients'

Patients will not be able to directly contact Scotland’s new Patient Safety Commissioner under the role’s proposed remit, according to the Sunday Post.
Officials drawing up the job description for the position are proposing patients with concerns and complaints should go through their local health boards instead of dealing directly with the commissioner.
Last week, Henrietta Hughes was named as the government’s preferred candidate for the role of Patient Safety Commissioner in England. In that role, Hughes will be able to be directly contacted by the public.
Despite being the first UK country to announce the intention to appoint a commissioner two years ago the role in Scotland is not yet filled.
The decision not to allow patients to directly contact the commissioner in Scotland has been criticised by Baroness Julia Cumberlege, author of the report, First Do No Harm.
She said: “Of course, patients must be able to communicate directly with the commissioner and their office. In our review we said the healthcare system is not good enough at spotting trends in practice and outcomes that give rise to safety concerns. Listening to patients is pivotal to that.
“This is why one of our principal recommendations was the appointment of an independent Patient Safety Commissioner, a person of standing who sits outside the healthcare system, accountable to parliament through the Health and Social Care Select Committee."
Read full story
Source: The Sunday Post, 26 June 2022
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