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

"I've been let down - I shouldn't have stage-4 cancer"

A woman with fast-growing stage-four breast cancer says the NHS has let her down, with delays at every stage of her treatment.
Caroline Boulton, 56, had several appointments for a mammogram, which checks for early signs of cancer, cancelled because of Covid, in March and November 2020.
In late 2021, she found a small lump, went to her GP and was referred urgently to a specialist - but then the delays began.
"They haven't moved quickly enough," Ms Boulton says, who lives in Greater Manchester. "It's been really, really slow."
"Between each appointment, each scan, there's been four-, five-, six-, seven-, eight-week waiting times and delays every time."
The referral letter came through "very quickly" but then she waited three weeks, instead of the recommended two, to see a consultant.
"When I first found the lump, it was only pea-sized," Ms Boulton says. "By the time I got to see the consultant, it was the size of a tangerine."
Her cancer was growing quickly, she was told, but it would be eight weeks before a mastectomy could be scheduled to remove her breast.
"Considering it was fast-growing, that's a huge concern - you're living with that, waiting, knowing it's growing," Ms Boulton says.
When she finally saw an oncologist seven months after finding the lump, had another scan and received the results, the cancer had spread to her liver - and there was no longer any treatment they could offer.
"I've now got stage-four cancer that I shouldn't have - and two years to live."
Read full story
Source: BBC News, 10 August 2022
Patient Safety Learning

Private providers targeted in NHSE crackdown on poor quality care

NHS England has revealed plans to crack down on poor care being provided by mental health service providers. 
There will be a particular focus on independent units treating NHS patients, as just over a quarter of these providers are failing to meet quality standards. 
Official data shared with HSJ shows that of the 238 independent NHS mental health providers licensed by the Care Quality Commission in England, 174 (73 per cent) are classed as “good” or “outstanding”. The remaining 64 (27 per cent) either “require improvement” or are considered “inadequate”. 
There have been been national concerns about repeated service failures within the sector. Independent units are often used by NHS trusts for out of area placements – a practice it is trying to end – or to cope with the lack of acute mental health beds.
Read full story (paywalled)
Source: HSJ, 11 August 2022
Sam

NHS chiefs fear cyber attackers have accessed patient data

Criminals have issued ‘demands’ to an NHS IT supplier targeted by a cyber attack, leading health chiefs to fear they have accessed confidential patient data, HSJ has learned. 
IT firm Advanced was targeted last week. The company provides electronic patient records to several trusts and most NHS 111 providers.
Multiple government agencies – including the National Crime Agency and GCHQ – are now working to identify the extent of the damage caused by the attackers, while leaders of affected mental health trusts have warned of a “pretty desperate” situation as staff are unable to access vital patient records. 
In a statement issued last night, Advanced said: “With respect to potentially impacted data, our investigation is under way, and when we have more information about potential data access or exfiltration, we will update customers as appropriate.”
Read full story (paywalled)
Source HSJ, 11 August 2022
Sam

Ambulance calls for most serious conditions hit record

Last month saw the highest number of ambulance callouts for life-threatening conditions since records began, NHS England officials say.
There were more than 85,000 category one calls, for situations like cardiac arrests and people stopping breathing.
The heatwave could have been one reason for increased demand, but experts say hospitals already face immense pressures.
Nearly 30,000 patients waited more than 12 hours to be admitted to hospital.
The number is up 33% on the previous month and the highest since records began in 2010.
Richard Murray, chief executive of The King's Fund said the pressure on hospitals was also being felt right across the health and social care system.
He added: "At the end of July, 13,014 people were still in hospital beds despite being medically fit to be discharged, often due to a lack of available social care support. The challenges affecting the NHS cannot be solved without addressing the issues in social care."
Read full story
Source BBC News, 12 August 2022
Sam

Pharmacists warn shortages of drugs putting patients at risk

A shortage of some medicines is putting patients at risk, pharmacists have warned.
A poll of 1,562 UK pharmacists for the Pharmaceutical Journal found more than half (54%) believed patients had been put at risk in the past six months due to shortages.
A number of patients have been facing difficulties accessing some medicines in recent months, sometimes having to go to multiple pharmacies to find their prescription or needing to go back to their GP to be prescribed an alternative.
Since June, the government has issued a number of "medicine supply notifications", which highlight shortages.
Some of these include: pain relief drugs used in childbirth; mouth ulcer medication; migraine treatment; an antihistamine; a drug used by prostate cancer and endomitosis patients; an antipsychotic drug used among bipolar disorder and schizophrenia patients; a type of inhaler and a certain brand of insulin.
Read full story
Source Sky News, 11August 2022
Sam

Negligence legal costs can be three times as much as compensation

Legal costs in some lower-value medical negligence claims can be double or even triple the amount of compensation paid to patients. 
Figures in the Medical Defence Union’s (MDU’s) annual report for 2021 reveal the average sum paid in claimants’ legal costs on medical claims settled for up to £10,000 was in excess of £18,500. 
For claims settled between £10,000 and £25,000, the average was nearly £35,000. 
The not-for-profit indemnifier called on the Government to proceed quickly with the reforms needed to the clinical negligence system to make disproportionate legal costs a thing of the past. 
Its chief executive Dr Matthew Lee said: "Disproportionate legal costs are one of several defects in the current litigation system and particularly affect lower value claims. 
"It cannot be right for legal costs paid to claimants’ lawyers to regularly exceed the damages paid to claimants by double or triple the amount."
Read full story
Source: Independent Practitioner Today, 9 August 2022
Patient Safety Learning

Dr Penny Kechagioglou on digitising patient reported outcome measures

Dr Penny Kechagioglou, Chief Clinical Information Officer and Deputy Chief Medical Officer at University Hospitals Coventry and Warwickshire, kindly shared her thoughts on digitising patient reported outcome measures in a blog for HTN.
The UK digital transformation wave is mainly characterised by the roll-out of electronic health records and is an opportunity to transform patient care by collecting and analysing patient reported outcome measures digitally.
A recent study at the European Society of Medical Oncology open journal (Modi, 2022) showed that patient reported outcome measures are predictive of cancer patient treatment response and quality of life for physical and mental parameters. The knowledge of patient reported outcomes (PRO) and experience (PRE) measures can be valuable in the monitoring of individual patient symptoms in clinic or remotely in the community and also for aggregating and interpreting population health data.
To read the full article, click here
Clive Flashman

Virtual reality transports hospice patients to other side of the world

A hospice is using virtual reality (VR) to help patients relax and transport them away from their beds.
St Giles Hospice, which has bases in Lichfield and Sutton Coldfield, said the headsets allowed patients "to escape the realities of their present situation".
"I've never experienced anything quite like it in my life - I was totally lost in the moment," Janet, 71, said.
The VR experiences include cities of the world, space, and wildlife.
Beth Robinson, Occupational Therapist at St Giles Hospice, said the VR headsets helped patients "immerse themselves into a calming space".
To read the full article, click here
Clive Flashman

Heart check app keeps patients out of hospital

Monitoring heart patients via a smartphone app prevented readmissions and sped up discharges in a pilot scheme that its developers hope will be introduced across the country.
Patients sent data including their blood pressure, heart rate, oxygen levels and details of developing symptoms to their clinical team on an app.
The figures were collated on a “dashboard”, which flagged any signs that a patient might need medical help, allowing doctors and nurses to bring them into hospital or alter their medication as required.
The 12-week pilot by Huma, a healthcare technology company based in London, involved 40 patients at Cwm Taf Morgannwg University Health Board in south Wales and Betsi Cadwaladr University Health Board in north Wales.
Click here to read full article (paywalled)
 
Clive Flashman

IUD perforation is rare, but women should still know about it

New study results in more precise language in the federally mandated warning about this possibility. (Article from the USA)
Women who choose to use an intrauterine device, or IUD, for birth control should be aware of the very small possibility that the device could puncture their uterus. They should know how to recognize that circumstance if it occurs, according to a new study published in The Lancet.
The U.S. Food and Drug Administration mandated the study to evaluate women's risks when an IUD is placed in the year after giving birth and when an IUD is placed during the period that a woman is breastfeeding a baby. These results were compared, respectively, with non-postpartum insertions and insertions in non-breastfeeding individuals, explained UW Medicine’s Dr. Susan Reed, the study’s lead author.
Across the study cohort of 327,000 women, the percentage of perforation cases diagnosed within five years of IUD insertion was 0.6 %, the study concluded.
The risk of perforation increased by nearly seven times if it was inserted between four days and six weeks postpartum, and increased by about one-third if inserted during the span of breastfeeding. The risk of an IUD-related perforation was relatively lower when inserted in women who were more than a year beyond delivery, in women who had never had a baby, and when the insertion occurred at delivery. Read full article here
Clive Flashman

Inspection blitz on maternity units amid new system safety concerns

Almost 200 maternity units in England will be inspected by the Care Quality Commission amid fears for mothers and babies’ safety and concerns that improvements are not happening fast enough.
The commission is taking the unusual step as NHS England faces accusations of pressuring hospitals to reorganise the way midwives work when they lack the staff to do it safely.
The new model of care, which is designed to provide mothers with a dedicated midwife throughout pregnancy, has been introduced only partially across the NHS, leading to a two-tier service in which hospital wards are left short of staff and women face potentially dangerous delays.
Under “continuity of carer”, midwives work in teams and are on call for specific mothers when they go into labour. But this can leave hospital wards understaffed and women not included in the programme waiting for a midwife.
NHS England is pushing hospitals to make this the default model of care by March 2024 despite a warning by Donna Ockenden, who led the inquiry into baby deaths at the Shrewsbury and Telford Hospital Trust, and who said in her final report that introduction of the new model should be suspended if services lack enough staff.
Read full story
Source: The Times, 14 August 2022
Further reading - Midwifery continuity of carer resources on the hub.
Patient Safety Learning

Colchester nurse struck off for withholding morphine from brain tumour patient for being 'lazy'

A care home nurse has been struck off after he gave a brain tumour patient sugar and water instead of pain relief.
Vijayan Rajoo said he felt the patient was "just being lazy" and did not need pain relief.
Rajoo, 64, also failed to check supplies in the controlled drug cupboards at the start and end of his shifts, according to a misconduct panel.
He was struck off for 18 months after a deputy manager at the home, St Fillans in Colchester, Essex, discovered 20ml of liquid morphine Oramorph was unaccounted for in June 2019.
Rajoo later confessed to not giving the brain tumour patient a dose of Oramorph as a form of pain relief as he felt the patient "did not need it".
It was reported the patient could immediately tell the sugar and water mix "didn't taste right".
The misconduct panel found all charges against Rajoo proven. In their conclusions, the panel said Rajoo showed a "serious lack of compassion".
Read full story
Source: ITV News, 13 August 2022
Patient Safety Learning

Covid: UK first country to approve dual-strain vaccine

The UK has become the first country to approve a dual vaccine which tackles both the original Covid virus and the newer Omicron variant.
Ministers say the vaccine will now form part of the autumn booster campaign.
Moderna thinks 13 million doses of its new vaccine will be available this year, but 26 million people are eligible for some form of booster.
Health officials say people should take whichever booster they are offered as all jabs provide protection.
Moderna's latest vaccine - called Spikevax - targets both the original strain and the first Omicron variant (BA.1), which emerged last winter. It is known as a bivalent vaccine as it takes aim at two forms of Covid.
The UK's Medicines and Healthcare Products Regulatory Agency has considered the evidence and given the vaccine approval for use in adults.
Dr June Raine, the regulator's chief executive, said: "What this bivalent vaccine gives us is a sharpened tool in our armoury to help protect us against this disease as the virus continues to evolve."
Read full story
Source: BBC News, 16 August 2022
Patient Safety Learning

ICSs will be first to intervene in failing trusts, says NHS England

NHS England has said integrated care systems (ICSs) will be responsible for ‘initial problem solving and intervention’ if trusts fail to deliver against key targets to prepare for winter.
NHSE’s letter on winter planning and response, published on Friday, said system working “means a new approach to accountability” and that ICBs – the NHS executive of ICSs – would be accountable for ensuring that providers and others “deliver their agreed role in their local plans and work together effectively”.
The document, signed by NHSE’s leadership, says: “ICBs are responsible for initial problem solving and intervention should providers fail, or be unable, to deliver their agreed role.
“Intervention support can be provided from NHS England regional teams as required, drawing on the expertise of our national level urgent and emergency care team as needed.”
Read full story (paywalled)
Source: HSJ, 15 August 2022
Patient Safety Learning

New approach to safety incidents will see fewer investigations

Major reforms have been set out on how NHS organisations should respond to patient safety incidents, which are aimed at ensuring better engagement with patients and families.
The Patient Safety Incident Response Framework (PSIRF), published today, replaces the serious incident framework and provides guidance to trusts on how and when they should conduct investigations.
According to NHSE, a key aim is to allow trusts to focus resources on where investigations will have the greatest impact, rather than investigating all incidents as they did under the old framework.
NHSE said the more flexible approach should make it easier to address concerns specific to health inequalities, as incidents can be learnt from that would not have met the serious incident definition.
However, it does not affect the need for a patient safety incident investigation following a never event’ or maternity incident; this is still required.
Helen Hughes, chief executive of charity Patient Safety Learning, said the new framework “places an emphasis on individual organisations assessing their patient safety risks”, and provided a “welcome acknowledgement of the importance of engaging patients and families as part of the investigation process”.
However, she said there would need to be a “significant training programme for staff in a range of human factors informed approaches”, to ensure reviews lead to safety improvements.
She added: “What is being proposed is a complex innovation in the NHS’s approach to incident investigation. Its success to a large part will depend on having the right organisational leadership and resources to support this transition. [NHSE has] now provided a set of tools and a timetable for this. However, ultimately this initiative should be judged on its implementation and effectiveness in reducing avoidable harm.”
Read full story (paywalled)
Source: HSJ, 16 August 202
Patient Safety Learning

‘Underfunded’ FDA falls short in ensuring medical devices protect against cyberattacks, experts say

As the risk of cyberattacks on medical devices continues to mount, the Food and Drug Administration isn’t doing enough to ensure device makers include adequate security in their products, experts say. 
They charge that part of the problem is that the agency lacks the funds and the trained personnel to evaluate the cyber risk the devices carry and enforce the rules it does have on the books for approving devices.
“I’ve spoken to device manufacturers, specifically product security people at device manufacturers, saying that they’ve been telling their organizations for the last year or two that they need to include cybersecurity as part of their submissions or else they’re going to get rejected,” said Mike Kijewski, CEO of medical device cybersecurity firm MedCrypt. “Yet for some of their recent submissions, they didn’t have a lot of cybersecurity documentation and they still got accepted by the FDA.”
Cyberattacks remain a significant risk for healthcare companies. US patient safety group ECRI reported 173 medical device cybersecurity alerts in the past five years. The organisation warned that cybersecurity incidents don’t just disrupt business operations, but can “pose a real threat of physical harm.” For instance, ransomware attacks on hospitals can cause device outages that disrupt patient care, and at worst, put lives at risk. 
Read full story
Source: MedTech Dive, 11 August 2022
Patient Safety Learning
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