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

Covid redeployment ‘wrong’ and ‘will never be repeated’

Redeployment of community staff to other services – meaning visits for babies and parents were missed – was the “wrong decision” and would “never be repeated”, a provider has stated.
Nikki Lawrence, the head of public health nursing at Sirona Care and Health, which provides community services for Bristol and the surrounding area, appeared to blame the government for about 70% of its health visiting staff being redeployed to adult services, leaving around 30% to care for new families at the height of the pandemic.
Health visitors take over from midwives to monitor the health of children and parents for a period after the baby is born, including to guard against safeguarding threats.
Ms Lawrence said: “The national learning about redeployment – we have reflected on it, the government has reflected on it and they have agreed it was the wrong decision to make.
“We basically abandoned families at a time of need, and that decision will never, ever be taken again, from what I’ve been told. In hindsight it was the wrong decision to make, and… it did have a detrimental impact on families and we really regret that, but it was out of our hands.”
Read full story (paywalled)
Source: HSJ, 16 August 2022
Patient Safety Learning

Lamborghinis, ski trips used to market controversial mesh implant to surgeons, documents show

Lamborghinis and ski trips to the Swiss Alps were among the incentives a pharmaceutical giant developed to market a surgical device that has ruined the lives of hundreds of Australian women.
Documents obtained by the ABC show the extent to which Johnson and Johnson oversold its surgical mesh products, which are used to treat incontinence and prolapse after childbirth.
They paint a picture of a company that tried to sell surgeons a jet-setting lifestyle where they could insert four devices "before lunch" and notch up $10,000 in surgeries in a single morning.
The mesh devices have left at least 3,000 Australian women with serious side effects including chronic pain, infections and inability to have sex, and are the subject of both a Senate inquiry and a class action.
New court documents released in the class action against Johnson and Johnson show that as early as 2009, concerns were raised inside the company that it was making "a huge mistake" by commercialising its latest brand of mesh, was "rushing to market", and opening up the use of the product to "unqualified surgeons".
Lawyers from Shine, who are representing the women in the class action, claim the pharmaceutical giant did not investigate proper clinical trials on the possible complications of the mesh.
Read full story
Source: ABC News, 13 August 2022
Patient Safety Learning

Ministers admit 34 hospital buildings in England have roofs that could collapse

Thirty-four hospital buildings in England have roofs made of concrete that is so unstable they could fall down at any time, ministers have admitted.
The revelation has prompted renewed fears that ceilings at the hospitals affected might suddenly collapse, injuring staff and patients, and calls for urgent action to tackle the problem.
Maria Caulfield, a health minister, made the disclosure in a written answer to a parliamentary question asked by the Liberal Democrats’ health spokesperson, Daisy Cooper.
Caulfield said surveys carried out by the NHS found that 34 buildings at 16 different health trusts contained reinforced autoclaved aerated concrete (RAAC), which one hospital boss has likened to a “chocolate Aero bar”. RAAC was widely used in building hospitals and schools in the 1960s, 70s and 80s but has a 30-year lifespan and is now causing serious problems.
In 2020 Simon Corben, NHS England’s director of estates, declared that RAAC planks posed a “significant safety risk” because their age meant they could fall down without warning.
Read full story
Source: The Guardian, 14 August 2022
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Poorest women in England have same ill health at 60 as richest at 76

A 60-year-old woman in England’s poorest areas typically has the same level of illness as a woman 16 years older in the richest areas, a study into health inequalities has found.
The Health Foundation found a similarly stark, though less wide, gap in men’s health. At 60 a man living in the most deprived 10% of the country typically has the burden of ill-health experienced by a counterpart in the wealthiest 10% at the age of 70.
The thinktank’s analysis of NHS data also shows that women in England’s poorest places are diagnosed with a long-term illness at the age of 40 on average, whereas that does not happen to those in the most prosperous places until 48.
The findings underline Britain’s wide and entrenched socio-economic inequalities in health, which the Covid-19 pandemic highlighted. Ministers have promised to make tackling them a priority as part of the commitment to levelling up, but a promised white paper on that has been delayed.
Researchers led by Toby Watt said their findings were likely to be the most accurate published so far because they were based on data detailing patients’ interactions with primary care and hospital services, and unlike previous studies did not rely on people’s self-reported health.
“In human terms, these stark disparities show that at the age of 40, the average woman living in the poorest areas in England is already being treated for her first long-term illness. This condition means discomfort, a worse quality of life and additional visits to the GP, medication or hospital, depending on what it is. At the other end of the spectrum, the average 40-year-old woman will live a further eight years – about 10% of her life – without diminished quality of life through illness,” Watt said.
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Source: The Guardian, 17 August 2022
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Safety requirements for use of valproate ‘still not being fully met’, finds NHS audit

Only a quarter of patients on valproate, who do not have appropriate contraception, are being referred by their pharmacist to their GP or a specialist about the issue, an audit carried out by NHS England has found.
A report on the 2019/2020 Pharmacy Quality Scheme Valproate Audit — which was carried out in community pharmacies across England — published on 11 August 2022, has indicated that the Medicines and Healthcare products Regulatory Agency’s (MHRA’s) safety requirements for use of valproate in women and girls of childbearing age, and trans men who are biologically able to be pregnant, are “still not being fully met”.
Since 2018, the MHRA has advised that valproate, a treatment for epilepsy and bipolar disorder, must not be used in anyone of childbearing potential, unless a Pregnancy Prevention Plan (PPP) is in place.
As part of a PPP, pharmacists are required to remind patients of the risks of taking sodium valproate in pregnancy and the need for highly effective contraception; ensure patients have been given the patient guide; and remind patients of the need for an annual specialist review.
However, the audit, which was conducted by 10,293 community pharmacies in England, including responses from 12,068 patients and patient representatives, found that pharmacists were not referring or signposting “a sizeable minority”, who appeared to be without appropriate contraception, back to the prescriber.
The report said that community pharmacists should refer “all people aged 12–55 who are biologically able to be pregnant and have not had their valproate medication reviewed within the last 12 months to their GP or specialist, as well as to local contraception services as appropriate”.
For patients not referred to their GP or specialist, the report said that the pharmacist should be able to confirm that the patient is fully informed, understands the risks of not using highly effective contraception and knows who to contact if their circumstances change.
Read full story
Source: The Pharmaceutical Journal, 12 August 2022
Patient Safety Learning

Survivors of contaminated blood scandal awarded interim payments

Survivors of the contaminated blood scandal have been awarded interim government payments after a 40-year battle, but thousands of parents and children of the victims have still received nothing.
Ministers have accepted the urgency of the need to make the £100,000 payments to about 3,000 surviving victims, after being warned that those mistakenly infected with HIV and hepatitis C were dying at the rate of one every four days.
But parents and children of the victims accused the government of perpetuating the scandal by failing to recognise their own trauma and loss in today’s announcement.
Contaminated blood products administered in the 1970s and 1980s to up to 6,000 people have already led to the deaths of more than 2,400 people in the biggest treatment scandal in NHS history.
The government said it intends to make payments to those who have been infected and bereaved partners in England by the end of October. The same payments will be made in Scotland, Wales and Northern Ireland.
Announcing the plan, the prime minister, Boris Johnson, said: “While nothing can make up for the pain and suffering endured by those affected by this tragic injustice, we are taking action to do right by victims and those who have tragically lost their partners by making sure they receive these interim payments as quickly as possible.
“We will continue to stand by all those impacted by this horrific tragedy, and I want to personally pay tribute to all those who have so determinedly fought for justice.”
Read full story
Source: The Guardian, 17 August 2022
Patient Safety Learning

Midwife numbers fall in every English region, figures show

The number of midwives has fallen in every English region in the past year, figures show.
Numbers dropped by around 600 on top of a longstanding shortage of more than 2000 midwives, according to analysis of NHS Digital data by the Royal College of Midwives (RCM).
The RCM said more investment is needed in maternity services to ensure the safety and quality of care, as "even the smallest falls are putting increasing pressures on services already struggling with shortages, worsened by the pandemic".
Dr Suzanne Tyler of the RCM said midwife numbers had "fallen significantly over the past year on top of already serious shortages" in England.
Dr Tyler said: "The falls across the regions are compounding the difficulties employers are facing to recruit and keep their midwives.
"We are raising these issues because we want women to get the best possible care and midwives to not only stay in the profession, but to encourage others to become one.
"These figures must shock this moribund Government into action for the sake of women, babies, their families and staff."
Read full story
Source: Medscape, 16 August 2022
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Internal memo warns of ‘increasingly common’ deaths in A&E

Senior doctors have raised concerns about the numbers of patients now dying in their A&E department due to extreme operational pressures.
HSJ has seen an internal memo sent to staff at Royal Albert Edward Infirmary in Wigan, which warns it is becoming “increasingly common” for patients to die in the accident and emergency department.
The memo suggests the department has reported five deaths in the latest weekly audit, when it would normally report one or two fatalities.
The memo said: “Of the 72 patients in A&E as I write this, 16 have been there over 24 hours and 34 over 12 hours. The longest stay is almost 48 hours…
“It’s becoming increasingly common to die in A&E. We have included A&E deaths [in weekly audits] for the last 4 years. They used to be 1 or 2. This week there were 5. They used to die at or just after arrival, but that’s changing too…
“There is every reason to think winter will be worse.”
The memo echoes warnings made by numerous NHS leaders in recent months around the intense service pressures and an increased risk of incidents and mistakes. 
Read full story (paywalled)
Source: HSJ, 17 August 2022
Patient Safety Learning

Dozens of referrals for vulnerable mothers refused due to ‘lack of beds’

Dozens of referrals to specialist care for women with serious mental health problems during or after pregnancy are being turned down because no bed was available, data collected by HSJ reveals.
HSJ submitted freedom of information requests to 19 trusts running mother and baby units (MBUs) – which are inpatient services where women who experience serious mental health problems during or after pregnancy can stay with their child – asking for the “total number of referrals… which could not be admitted because no bed was available”. 
Although all of the 19 trusts HSJ sent freedom of information requests to responded, many said they did not hold this information. However, five – Cumbria, Northumberland, Tyne and Wear Foundation Trust, Essex Partnership University FT, Greater Manchester Mental Health FT, Hertfordshire Partnership University FT, and Nottinghamshire Healthcare FT – together identified 197 referrals which were rejected. Greater Manchester identified a further three which were turned down in the calendar year 2022, although it did not specify which financial year this was.
Several experts told HSJ the figures reflected a lack of capacity for mothers with serious mental health problems.
Maternal Mental Health Alliance campaign manager Karen Middleton said MBUs offered “the best outcomes” for new mothers who needed inpatient treatment".
Ms Middleton continued: “When a much-needed MBU bed isn’t available, women instead face admission to general adult psychiatric wards, separating them from their newborn babies at a crucially important time for relationship development. These wards lack appropriate facilities and expertise to support postnatal mothers with their specific physical and emotional needs.”
Read full story (paywalled)
Source: HSJ, 16 August 2022
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Government examines surge in ‘potentially preventable’ deaths

Department of Health and Social Care (DHSC) officials are concerned that many more people are dying than expected in recent months – particularly older working-age people – with NHS care delays and interruptions a likely cause.
HSJ understands there is concern and analysis under way across the chief medical officer’s team and in the Office for Health Improvement and Disparities.
The DHSC told HSJ initial work showed the biggest causes of the “excess deaths” were cardiovascular disease (heart attacks and strokes) and diabetes.
This supports the case they are being caused by a combination of the current very long delays for ambulances and other emergency care, and by people with heart disease and diabetes missing out on routine checks due to Covid and its knock-on effects, HSJ was told.
Read full story (paywalled)
Source: HSJ, 17 August 2022
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'Sticking plaster' NHS winter plan criticised for lacking workforce strategy

Doctors and health service providers welcomed publication of an NHS strategy for managing demand ahead of another busy winter for health and social care, but said it failed to address underlying problems with the system.
In a letter to the heads of NHS trusts and integrated care boards, NHS England chiefs said they had begun planning for capacity and operational resilience in urgent and emergency care ahead of "significant challenges" during the coming months.
The British Medical Association (BMA) said the strategy was a "step in the right direction", but "lacks detail", while the Royal College of Emergency Medicine (RCEM) said it amounted to little more than "a crisis mitigation plan".
The package of measures included creating the equivalent of 7000 extra general and acute beds through a mix of new physical beds, scaling up 'virtual' beds, and "improvements in discharge and flow". The letter acknowledged that there was "a significant number of patients spending longer in hospital than they need to" and that whilst "the provision of social care falls outside of the NHS’s remit, the health service must ensure patients not requiring onwards care are discharged as soon as they are ready and can access services they may need following a hospital stay."
Read full story
Source: Medscape, 15 August 2022
Patient Safety Learning

Covid-19 'unmasked' existing problems in Irish healthcare

The Irish health services did “relatively well” during Covid-19 but, as in other countries, the pandemic unmasked existing problems, a renowned patient safety expert has said.
Peter Lachman of the Royal College of Physicians of Ireland (RCPI), was one of nine international experts who consulted on a new World Health Organization (WHO) report on the implications of the Covid-19 pandemic for patient safety.
Dr Lachman said the impact is only starting to be understood.
“Ireland did very well early on [in the pandemic], then opened up over Christmas [2020] which led to our numbers going sky-high, then we clamped down again,” he said.
"We did well on some things and not so well on others. We have done relatively well when compared with other countries." 
“Covid-19 was an event which around the world unmasked problems which were there already rather than creating them necessarily,” he said.
“The findings start with safety problems — we’ve had safety problems in Ireland but things are getting better.  There is a good strategy coming on. I’ve worked with hospitals around the country on this. It’s no worse than other countries.”
Read full story
Source: The Irish Examiner, 12 August 2022
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Poor quality monkeypox guidelines 'impeding patient care'

There is an urgent need to develop evidence based clinical guidelines for managing cases of monkeypox, scientists said, after finding that existing guidance frequently lacked detail and was based on poor research.
They urged establishing a 'living guideline' for infectious disease to ensure that up-to-date information, based on robust research, was available globally and in any setting.
The study, published in BMJ Global Health, also called for investment to back research into optimal treatments and prophylaxis strategies.
The study authors wrote: "The lack of clarity between guidelines creates uncertainty for clinicians treating patients with MPX [monkeypox] which may impact patient care."
They concluded: "Our study highlights a need for a rigorous framework for producing guidelines ahead of epidemics and a recognised platform for rapidly reviewing and updating guidance during outbreaks, as new evidence emerges."
Current global concern over the spread of monkeypox was an opportune time to act, they argued.
Read full story
Source: Medscape, 17 August 2022
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Covid: Brain fog more common two years on, study suggests

Two years after having Covid-19, diagnoses of brain fog, dementia and epilepsy are more common than after other respiratory infections, a study by the University of Oxford suggests.
But anxiety and depression are no more likely in adults or children two years on, the research found.
More research is needed to understand how and why Covid could lead to other conditions.
This study looked at the risks of 14 different disorders in 1.25 million patients two years on from Covid, mostly in the US. It then compared them with a closely-matched group of 1.25 million people who had a different respiratory infection.
In the group who had Covid, after two years, there were more new cases of:
dementia, stroke and brain fog in adults aged over 65 brain fog in adults aged 18-64 epilepsy and psychotic disorders in children, although the overall risks were small. Some disorders became less common two years after Covid, including:
anxiety and depression in children and adults psychotic disorders in adults. The increased risk of depression and anxiety in adults lasts less than two months before returning to normal levels, the research found.
Read full story
Source BBC News, 18 August 2022
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‘This tiny piece of tape is ruining my life’: Women left in agony by vaginal mesh still struggling to get help

At 34 years old, Dawn Jaxson had two young daughters. Since going through childbirth she had been experiencing a prolapsed bladder and urinary incontinence. Her doctors recommended she have a vaginal mesh fitted to treat the problem, and she didn’t question their advice.
But more than 15 years later, she wishes she had. “As soon as I’d actually had it fitted, I felt discomfort,” says Jaxson, now 50. “Then the pain just didn’t go.” After years of almost constant pelvic pain and “countless” medical appointments, Jaxson says: “This little tiny piece of tape is still ruining my life.”
“I can literally be sat down and then out of nowhere, it will be like somebody is shoving a red-hot poker through my bladder,” she tells iNews. “Being intimate with somebody is just impossible. Sex is no joy. Imagine your worst period pain you could possibly have, and that’s what it’s like on a daily basis.”
NHS Digital records show that between April 2008 and March 2017, 100,516 patients had a tape insertion procedure for stress urinary incontinence. A further 27,016 patients had a mesh procedure for pelvic organ prolapse. But the surgery was suspended in Scotland in 2014 and across the rest of the UK by 2018 following complaints about complications – and a review ordered.
The review panel, overseen by Baroness Julia Cumberlege, spoke to more than 700 affected individuals and concluded that pelvic mesh procedures had caused “anguish, suffering, and many ruined lives”.
In 2020, the panel set out nine recommendations to help the thousands of women affected, including the creation of specialist centres, so patients could have their mesh removed or receive further treatment. But two years on from that landmark report, women say they are still suffering debilitating symptoms and struggling to access the help they so desperately need.
Kath Sansom, the founder of the campaigning group Sling the Mesh, has heard many similar stories from among the group’s 9,700 members. 
“The lack of action on financial redress is the biggest disappointment for women,” she says. “Pelvic mesh caused lifelong damage, and worse, the majority of us were not given any information on the risks. It’s not our fault this happened to us."
“Some women have been left disabled in wheelchairs or walking with sticks. Others have had organs removed where mesh has turned brittle and sliced into them. Seven in 10 have lost their sex life. Everyone suffers chronic pain in varying degrees. Women have lost jobs, marriages, homes, and their quality of life.”
Read full story
Source: iNews, 18 August 2022
Patient Safety Learning

Joint Commission Resources appoints two leading international healthcare experts to board of directors

The Joint Commission Resources (JCR) has announced the appointment of two world-class and leading healthcare experts to serve as international outside directors on its board of directors: Abdulelah M. Alhawsawi and Sangita Reddy.

As international outside directors, Dr. Alhawsawi and Ms. Reddy will provide their global expertise and direction to improve safety and quality of healthcare in the United States and abroad. They will be full voting members of the 13-person board of directors, which serves as JCR’s governing body. The board includes healthcare professionals, business executives and quality experts from around the world. 
“Dr. Alhawsawi and Ms. Reddy have dedicated their lives to transforming healthcare globally, and we are thrilled to welcome them to Joint Commission Resources’ Board of Directors,” says Jonathan B. Perlin, president and chief executive officer, The Joint Commission. “These board appointments bring unique international expertise and perspective on healthcare policy and the challenges and opportunities to advance quality and safety worldwide.” 

“We are so pleased that Dr. Alhawsawi and Ms. Reddy are joining Joint Commission Resources’ Board of Directors,” says Jean Courtney, interim president and chief executive officer, and chief operating officer, JCR. “They each bring in-depth and unparalleled international healthcare expertise. This will be invaluable as JCR continues to expand its mission to improve patient safety and quality of care around the globe.”
Read full story
Source: Joint Commission Resources, 16 August 2022
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