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

Trainee doctors in ‘meltdown’ at major hospital maternity department

Regulators have raised serious concerns over trainee doctors within the maternity department at one of the largest trusts in the country.
The NHS’ training regulator said it had concerns over the treatment of trainee doctors within the obstetric and gynaecology department at University Hospitals Birmingham Foundation Trust, while some medics report being in ‘meltdown’.
Reviewers raised an incident where a consultant had refused to respond to an obstetric emergency in A&E which had been requested by a junior doctor.
“The panel unanimously agreed that Consultant presence was required without delay,” the report added.
The latest review follows concerns in November 2020 and June 2021 when patient safety issues were also identified.
It warned there was a “real risk” trainees would soon become “hesitant and reluctant” to call for consultant support when need.
Read full story
Source: The Independent, 5 June 2022
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One-stop shop clinics carry out 1m health tests for cancer, heart and lung disease

One million checks for cancer, heart and lung disease have been carried out at new diagnostic clinics in football stadiums and shopping centres, the NHS has reported.
In the past year, 92 “one-stop shop” centres offering scans, x-rays and blood tests have been opened in an effort to tackle the Covid care backlog after NHS waiting lists in England soared to a record 6.4 million patients.
The NHS said it will open a further 70 centres, which will operate seven days a week and allow patients to get symptoms checked “on their doorstep” following GP referrals.
The centres are staffed by nurses and radiographers who can carry out a range of diagnostic tests, including cancer scans.
This means patients can get multiple tests in one visit, rather than having to make several different trips to a hospital.
Professor Charles Swanton, chief clinician at Cancer Research UK, said the rapid diagnostic clinics were improving access to lifesaving treatment.
Speaking at the world’s largest cancer conference in Chicago, he said: “Individuals with red-flag cancer symptoms — blood in the stool, persistent cough — can bypass the bureaucratic and lengthy standard approaches to getting investigated in hospital.”
However, Swanton warned that without action to address the “chronic shortage” of 110,000 NHS staff, the new centres risked “robbing Peter to pay Paul” by taking doctors and nurses away from hospitals.
Read full story (paywalled)
Source: The Times, 6 June 2022
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‘It was horrific’: Women given saline instead of fentanyl, US lawsuit says

When a couple decides to try to have a child by in vitro fertilisation, it’s often accompanied by anticipation, anxiety and worry about whether the egg and sperm will unite and produce a healthy baby.
So when the procedure to retrieve eggs from a woman’s ovary turns out to be physically painful, it can create long-term emotional pain as well, according to a lawsuit and two women who underwent the procedure at the Yale University Reproductive Endocrinology and Infertility Clinic.
They are among dozens of women and spouses who are suing Yale University, claiming the staff at the clinic should have known that, instead of receiving fentanyl to relieve pain during the procedure, they instead were being injected with saline — salt water.
“The result was that dozens, perhaps hundreds, of women underwent the most painful fertility surgeries and procedures offered at the REI Clinic with little or no analgesia,” the lawsuit states.
Angela Cortese, 33, of Vernon, who first had her eggs retrieved on Dec. 3, 2019, said the pain was “excruciating” as a nurse wiped tears from her eyes and Cortese tried “not to flinch every time they’re using this giant needle to retrieve the follicles.”
“I want to say it was probably around 45 minutes that I was very much aware of what exactly was happening and feeling every pinch and prod,” she said. “And it doesn’t feel like somebody’s just pinching you. It feels like somebody’s stabbing you through your vagina. It was horrific.”
Read full story
Source: ctpost, 31 May 2022
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Woman loses seventh baby after concerns about delayed caesarean were ‘dismissed’ by doctors

A woman who suffered six miscarriages lost her seventh baby after doctors delayed her caesarean section, a report has found.
Chyril Hutchinson was admitted to hospital in February 2021 with high blood pressure when she was 37 weeks pregnant with her daughter Ceniyah Cienna Carter, and was told by doctors at Mid and South Essex NHS Foundation Trust she would need a caesarean.
But the procedure was delayed as a result of staffing pressures and because Ms Hutchinson’s blood pressure stabilised. She was then told she would have to wait another two weeks for it to be carried out.
Given her previous miscarriages, Ms Hutchinson said she pleaded for her baby to be delivered earlier, but her concerns were “dismissed” and she was sent home. Days later, a scan revealed that her baby had died.
A trust investigation into Ms Hutchinson’s care found that staff had failed to properly monitor the growth of her baby, which could have indicated the need for an earlier delivery.
The internal report, seen by The Independent, also revealed that on the day Ms Hutchinson was told she should have a casaerean, the hospital was six midwives short and the department was busy - a situation the trust said “places additional pressures and possible overload on medical staff”.
However, the report concluded that staffing levels did not affect Ms Hutchinson’s care, and it did not state whether the wider failings had led directly to her child being stillborn.
Read full story
Source: The Independent, 5 June 2022
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Inquiry opens into alleged patient abuse at Muckamore Abbey

A public inquiry has opened into allegations of extensive and repeated abuse of patients at Muckamore Abbey, a hospital for vulnerable adults in Northern Ireland.
The inquiry’s chair, Tom Kark, said at the first hearing on Monday that the allegations of abuse and neglect at the psychiatric facility outside Belfast, in County Antrim, brought the medical, nursing and care professions into disrepute.
“Many of the parents and relatives and carers who trusted the hospital have been let down and they are understandably furious and some feel guilty,” he said. Kark, a QC, said a civilised society had a duty to care for people with learning disabilities and mental illness.
Police have arrested 34 people and more than 70 staff have been suspended as a precaution since the alleged abuse came to light in 2017. The police investigation will proceed in parallel to the inquiry. Detectives have viewed about 300,000 hours of CCTV footage from the hospital.
Relatives of patients hope the inquiry will shed light on accounts of mental and physical abuse and neglect at what used to be considered one of the best facilities of its kind in Northern Ireland. The hospital currently has about 60 patients, down from about 1,500 in the 1980s.
“Without pre-determining any issues, it’s quite obvious that bad practices were allowed to persist at the hospital to the terrible detriment to a number of patients,” Kark told the inquiry.
Read full story
Source: The Guardian, 6 June 2022
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Long Covid patients face lottery over treatment

Patients with long Covid are facing a postcode lottery across the UK when it comes to getting care, nurses say.
The Royal College of Nursing (RCN) said treatment varied hugely with some services treating it as a physical condition, but others as psychological.
The union also highlighted long waits in parts of England, which has a network of specialist clinics. It warned that patients in Scotland and Wales may be missing out because of a lack of dedicated clinics.
Speaking at the RCN's conference in Glasgow, nurses said they had seen first-hand how debilitating the symptoms could be.
Nearly half of patients referred to specialist services are aged 35 to 54.
Jo Strucke, a mental health nurse who works in a specialist service in Yorkshire, said: "Some of our patients have really complex physical health problems and their lives have been transformed.
"They may be unable to work, socialise and do things they previously enjoyed."
Helen Donovan, the RCN's public health lead, added: "As nursing staff we see first-hand how life-limiting long Covid can be."
But she said: "There aren't enough specialist services to meet growing demand and the help patients get varies hugely across the country."
Read full story
Source: BBC News, 7 June 2022
 
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Staff shortages leaving women in ‘barbaric’ pain

Patient safety campaigners have said ‘too many women’ are still not being offered a general anaesthetic for a diagnostic test because of staff shortages, leaving them in severe pain.
A survey by the Campaign Against Painful Hysteroscopies found around 240 women – which equates to 80 per cent of respondents – who had a hysteroscopy since the start of 2021 said they were not told they could have a general anaesthetic prior to the procedure.
This suggests the situation has only improved marginally since 2019, when the campaign group first started collecting data. A spokeswoman from the campaign group called the pain being endured by women “barbaric” and said staffing shortages need to be addressed.
Guidance from the Royal College of Obstetricians and Gynaecologists said all pain relief options, including general anaesthetic, should be discussed.
Helen Hughes, chief executive of Patient Safety Learning, said: “We are hearing from too many women that they are not being given the full information about the procedure. It damages their trust and makes them worry about accessing future services.”
She said: “It’s distressing that despite what we know, [the guidance] is not being implemented properly. Informed consent is essential for patient safety as well as a legal requirement.”
Read full story (paywalled)
Source: HSJ, 7 June 2022
What is your experience of having a hysteroscopy? Share your experiences on the hub in our community forum.
Further reading:
House of Commons Debate - NHS Hysteroscopy Treatment Through the hysteroscope: Reflections of a gynaecologist Minister acknowledges patients’ concerns about painful hysteroscopies; but will action be taken? Improving hysteroscopy safety: Patient Safety Learning blog Outpatient hysteroscopy: RCOG patient leaflet
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Innovative Medicines Fund launched to fast-track drugs

Patients in England can get early access to more cutting-edge medicines through a new fund.
The Innovative Medicines Fund (IMF) works like the existing Cancer Drugs Fund (CDF), fast-tracking promising treatments, even if they are expensive and have not yet been approved for routine NHS use.
It will cover potentially life-saving drugs for rare and genetic diseases. The government has allocated up to £680m a year to be shared by the funds.
The IMF, like the CDF, will mean a newly approved medicine could be prescribed immediately, before final recommendations on it are drawn up by the advisory body that weighs the cost versus benefit of drugs used by the NHS - an organisation called NICE (the National Institute for Health and Care Excellence).
Patients would be able to access the treatment while data is collected for NICE to determine whether the medicine is affordable and effective enough to offer more widely.
A similar fund for innovative treatments - the New Medicines Fund - already exists in Scotland. Wales has a New Treatments Fund that helps pay for high-cost drugs which have been recommended as cost-effective by NICE.
Experts hope funds like these will improve the lives of many who might otherwise miss out.
Read full story
Source: BBC News, 7 June 2022
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Inadequate Reading surgery had 'backlogs of test results', CQC says

A GP surgery that provides treatment to about 5,600 patients has been placed in special measures by a regulator.
London Street Surgery, in Reading, Berkshire, was found to have "significant backlogs of test results and care-related tasks".
The Care Quality Commission (CQC) found there was "poor identification of risks to patients" during an inspection in April.
The surgery has been approached for comment.
The regulator rated the surgery's safety and leadership as inadequate, and said it had insufficient processes to ensure services' safety and effectiveness.
Repeat prescriptions and medicines were "not managed safely", which could have posed risks to patients, and there were "risks associated" with the storage of blank prescriptions, it found.
Staff training was "not monitored appropriately" and inspectors found patients with learning disabilities were not provided with health checks to make sure their wellbeing was properly monitored.
Read full story
Source: BBC News, 7 June 2022
Patient Safety Learning

USA: Job burnout threatens health care workforce

The U.S. is facing high levels of burnout among health care workers, which could lead to serious shortcomings in patient care, a new report from the U.S. Surgeon General has found.
Burnout among health care workers was a serious problem even before the COVID-19 pandemic, but the stress caused by the ongoing pandemic has made things much worse, said Surgeon General Dr. Vivek Murthy.
“The pandemic has accelerated the mental health and burnout crisis that is now affecting not only health workers, but the communities they serve,” Murthy said.
“Already, Americans are feeling the impact of staffing shortages across the health system in hospitals, primary care clinics, and public health departments. As the burnout and mental health crisis among health workers worsens, this will affect the public’s ability to get routine preventive care, emergency care, and medical procedures. It will make it harder for our nation to ensure we are ready for the next public health emergency. Health disparities will worsen as those who have always been marginalized suffer more in a world where care is scarce. Costs will continue to rise.”
The report calls for several steps to address the burdens on health care workers. These include:
Protecting the health, safety, and well-being of all health workers by ensuring they have proper equipment, training, and are protected against workplace violence. Eliminating punitive policies for seeking mental health and substance abuse care. Reducing administrative and documentation burdens and improving health information technology and payment models. Prioritising health worker well-being on an organizational level—this includes providing competitive wages, paid sick and family leave, rest breaks, educational debt support, and other steps to ease the burden on health workers. Read full story
Source: BenefitsPro, 6 June 2022
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Royal Surrey County Hospital to launch virtual ward to free up beds

The Royal Surrey County Hospital is preparing to open its first virtual ward.
From this summer 15 patients will receive treatment at home using apps and wearable technology, as an alternative to a stay in hospital.
The ward will be overseen by a consultant, working with therapists, nursing staff and pharmacists.
The hospital, in Guildford, plans to extend the ward to 52 patients by April 2024.
Health providers across England have been asked to deliver virtual wards at a rate of 40 to 50 beds per 100,000 people by December 2023.
It is hoped they will free up beds more quickly, speeding up admissions from A&E and for elective surgery.
Read full story
Source: BBC News, 7 June 2022
Patient Safety Learning

Why are mesh victims still being betrayed two years after excoriating official inquiry?

Two years ago, it seemed that thousands of British women afflicted with crippling pain, ruined sex lives, shattered relationships and wrecked careers would finally get justice and practical redress.
A government-commissioned report, following a campaign backed by Good Health, recognised that the plastic mesh tape surgeons had used to treat their incontinence and prolapse had caused some women catastrophic harm.
How many women’s lives have been ruined by this mesh is unknown, but Baroness Cumberlege, who led the official review, estimated it to be ‘tens of thousands’.
The use of the mesh for stress urinary incontinence was paused in July 2018 as recommended by the inquiry’s preliminary report — then the concluding report, in July 2020, said that this pause should continue until strict requirements on safety and recompense are met.
These include the establishment of specialist centres to remove mesh from afflicted women, and financial compensation from government and mesh manufacturers for women affected, as well as the setting up of a database of victims to ascertain the numbers involved and their injuries.
The final report also urged that the watchdog, the Medicines and Healthcare products Regulatory Agency (MHRA), which had approved the use of mesh tape in the 1990s, should be reformed to improve its vigilance on such problems.
Matt Hancock, then Health Secretary, apologised for the women’s pain. ‘We are going to look carefully at the recommendations,’ he told reporters in July 2020. ‘We need to take action.’
But words can be cheap: a Good Health investigation has found none of the recommendations has been implemented properly and the use of mesh in women is continuing.
Read full story
Source: MailOnline, 6 June 2022
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Government plans ‘single set of management standards’ for the NHS

A government review of health and care leadership has recommended a single set of ‘core leadership and management standards’ for NHS managers.
The report by General Sir Gordon Messenger and Dame Linda Pollard calls for “consistent management standards delivered through accredited training”, according to a government statement this morning.
The full document has yet to be published but the statement summarises the findings and says an “institutional inadequacy” has formed in the way leadership and management is trained and developed in the NHS.
It says the report has produced seven recommendations, which have all been accepted in full by the health and social care secretary Sajid Javid, who said they must be taken forward “urgently”.
Among them is a call for a more “effective and consistent” appraisal system to reduce variation in how performance is managed. This is after the review concluded a greater focus was needed on “how people have behaved [and] not just what they have achieved”.
The recommendations do not include any registration system for NHS managers, despite calls from some over many years for more regulation of the roles, nor appear to include specific reform of the “fit and proper person” test, which has been discredited and under review.
Read full story (paywalled)
Source: HSJ, 8 June 2022
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Community pharmacists speak out against rise in abuse and attacks

Pharmacists say physical and verbal abuse against them has become unacceptably common and many now feel unsafe when at work.
Police forces say they are being called out to handle pharmacy-based crimes.
The Pharmacists' Defence Association (PDA) says there have been reports of a stabbing and physical attacks in pharmacies around the UK and that more needs to be done to enforce the NHS's zero tolerance policy on worker abuse..
Pharmacist Conor McAreavey was stabbed in the hand with a knife at his pharmacy in Belfast in March. He told the BBC he was "very lucky" not to have suffered tendon damage.
Glasgow pharmacist Chand Kausar was threatened with a knife by an agitated patient, who - after demanding non-prescribed medication - produced a six-inch knife and cornered her against a wall.
"I just froze," explains Ms Kausar. "My hands were above my head and I could hear all the noise around me, but I actually felt very calm. In my head all was quiet. I remember thinking it was like a movie scene. I'd never seen a knife like that, and I never imagined I'd have one held to my throat."
The PDA launched an online survey in April 2022 and nearly 550 community pharmacists, mostly staff working in England, have responded so far.
Some 468 of them - 85% - say they, or someone they work with, experienced verbal or racial abuse in the previous month while at work.
One respondent said: "I feel terrified going to work every single day, and yet management are ignoring the issue."
Read full story
Source: BBC News, 6 June 2022
 
Sam

A&E staff warn patients they face 13 hour waits and no hospital beds

A struggling A&E told patients they had no beds in the hospital and would face waits of 13 hours, The Independent has learned.
NHS staff at Harlow A&E, run by Princess Alexandra Hospital Trust, warned patients on Monday: “We’ve got 170 patients in the department, there are 90 patients waiting to be seen at the moment…our current wait time for a doctor is seven and half hours I will estimate by the time I go home in the morning at 8 ‘clock some of you will still be waiting because the waits will get up to 13 hours.
“There are currently no beds in the trust we’re trying to make space if we can but if people are admitted there’s a chance they’ll stay in A&E overnight."
“We will do our best to make you comfortable but please don’t expect you will be going direct to a ward because that might not happen.”
The staff member asked relatives to leave as the department was so busy.
Speaking with The Independent an emergency department consultant from the Midlands said they were “fed up”.
He added: “It’s just so unfair on patients and staff. The best ones are burning out and wanting to leave. The only way to survive seems to be to stop caring/trying It’s just so unfair on patients and staff. The best ones are burning out and wanting to leave. The only way to survive seems to be to stop caring/trying.”
Read full story
Source: The Independent, 8 June 2022
Patient Safety Learning

Is nitrous oxide a climate risk? Yes, but doctors say effective pain relief in childbirth should be the priority

Greenpeace and obstetricians have questioned a scientific report warning pregnant women to consider alternatives to nitrous oxide as pain relief during childbirth because of the environmental impact of its emissions.
A report in Australasian Anaesthesia notes that while nitrous oxide – known as laughing gas when used as an anaesthetic – is an effective method of pain relief during labour, the gas represents 7% of global emissions, according to the World Meteorological Organization. 
Using nitrous oxide as pain relief during a four-hour labour creates a carbon footprint equivalent to driving an average car for 1,500km, the report’s authors found, whereas an epidural is equivalent to driving 6km.
The report explores methods to capture and destroy waste from the nitrous oxide, and suggests that pregnant women consider alternatives, such as epidurals, as well as acupuncture, massaging and hypnobirthing to manage their pain during labour.
“While it may be innocuous for the pregnant woman and unborn baby, that is certainly not the case for the environment,” the report states, noting its use should ultimately continue in some capacity due to its convenience and safety.
A Greenpeace spokesperson said that the health sector accounts for about 7% of Australia’s emissions, and that while it was important for all industries to assess their climate impact, the focus should be on the worst polluters such as the energy sector.
Associate Prof Gino Pecoraro, president of Australia’s National Association of Specialist Obstetricians and Gynaecologists, said that while some pregnant women might be concerned about the environmental impact of their childbirth, alternative pain relief such as epidurals are not available at every hospital, especially outside of capital cities.
He added that nitrous oxide can be a more attractive pain relief option as it doesn’t restrict walking or movement ability to the extent epidurals do.
“If you’re in rip-roaring pain during labour, carbon footprint might not be the thing you most want to discuss,” Pecoraro said. 
Pecoraro said that ultimately it was important to offer as many different options for pain relief during labour as possible, as different methods are effective for different women.
Read full story
Source: The Guardian, 31 May 2022
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