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

Donna Ockenden urges families to come forward for Nottingham maternity review

The midwife leading a review into Nottingham's maternity services has urged families and staff to come forward with their experiences. Donna Ockenden was appointed in May to head the inquiry into the services at Queen's Medical Centre and City Hospital.
It was launched after more than 100 families with experiences of maternity failings wrote to former Health Secretary Sajid Javid demanding the action. A much-criticised initial review was subsequently scrapped.
Ms Ockenden, who uncovered 200 avoidable baby deaths at Shrewsbury and Telford NHS Trust across two decades, said the review is now open to families, NHS workers and others who wish to contribute.
"By September 1 we'll be ready to receive contact from families," she told Nottinghamshire Live. "In the mean time if there are either families or members of the NHS that want to get in touch they can use our new email. And also those who represent communities, whether that's safe communities or women's groups in Nottingham."
People can contact the review through the email [email protected], which was launched last week. Ms Ockenden said that positive steps were being made in putting in place the "building blocks" for the review, which is due to start on 1 September 2022.
Read full story
Source: Nottinghamshire Live, 17 August 2022
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Family welcomes new guidance to prevent breathing tube deaths

A grieving family has welcomed new guidance to try to prevent a common surgical procedure from going wrong and causing deaths.
Oesophageal intubation occurs when a breathing tube is placed into the oesophagus, the tube leading to the stomach, instead of the trachea, the tube leading to the windpipe.
It can lead to brain damage or death if not spotted promptly.
Glenda Logsdail died at Milton Keynes University Hospital in 2020 after a breathing tube was accidentally inserted into her oesophagus. The 60-year-old radiographer was being prepared for an appendicitis operation when the error occurred.
Her family welcomed the guidance, saying in a statement: “We miss her terribly but we know that she’d be happy that something good will come from her tragic death and that nobody else will go through what we’ve had to go through as a family."
Oesophageal intubation can occur for a number of reasons including technical difficulties, clinician inexperience, movement of the tube or “distorted anatomy”.
The mistake is relatively common but usually detected quickly with no resulting harm.
The new guidance, published in the journal Anaesthesia, recommends that exhaled carbon dioxide monitoring and pulse oximetry – which measures oxygen levels in the blood – should be available and used for all procedures that require a breathing tube.
Experts from the UK and Australia also recommended the use of a video-laryngoscope – an intubation device fitted with a video camera to improve the view – when a breathing tube is being inserted.
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Source: The Independent,18 August 2022
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Government defends medical student number cap

Questions are being asked why the government is sticking to its cap on medical and dentistry places.
A shortage of doctors and other medical staff has been described as the biggest challenge facing the NHS. But the number of places at UK medical schools are capped - in England this year there are 7,500 places.
England's Education Secretary James Cleverly told the BBC that you can't just "flick a switch" to increase the capacity to train more doctors.
Medicine is one of a handful of courses where numbers are limited by the government, because the cost is heavily subsidised.
In 2020 and 2021 the government lifted the cap on numbers, which last year led to more than 10,000 places being accepted. But this year the cap in England is being reintroduced.
Mr Cleverly told the BBC that the nature of highly technical, vocational courses like medicine meant increasing the number of places was far from straightforward.
"To increase those numbers you would also need to increase the capacity in training institutions, both in universities and in hospitals.
"It is not something you can just flick a switch and significantly increase the capacity to train.
"The increases have got to be funded, they are technical and expensive courses and we need to understand the balance of requirements between these courses and other courses that the government is supporting financially."
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Source: BBC News, 18 August 2022
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Safety fears prompt NHS trusts to support troubled independent provider

Five East Midlands trusts are working with the country’s largest independent mental health provider in a bid to improve service quality, amid concerns patient safety would have been put at risk if they had not stepped in.
This move follows the Care Quality Commission (CQC) placing conditions on the registration of St Andrew’s Healthcare in Northampton in July and August last year after inspectors found patients were not given appropriate care in a safe environment.
The service could not admit any new patients into forensic, long-stay rehabilitation wards and the wards for people with a learning disability at the women’s service and to the wards for people with a learning difficulty at the men’s service, without consent from CQC following the inspection report. This restriction was lifted in May this year. 
Following the inspection, five local community and mental health trusts have “buddied up” to provide “targeted support” to improve the care quality provided by the charity provider. The programme is being co-ordinated by Northamptonshire Healthcare Foundation Trust.
Angela Hillery, chief executive of NHFT and Leicestershire Partnership Trust, told HSJ there was an “overwhelming” agreement amongst the pre-existing East Midlands alliance of trusts that they should work with St Andrew’s, which “clearly had an improvement journey to make”.
Ms Hillery said: “If we were not going to help, the risk was to our patients. [The initiative] was driven from us to say, ‘these are our patients and why wouldn’t we want to support each other as I know St Andrew’s would support us in the same situation.”
Read full story (paywalled)
Source: HSJ, 18 August 2022
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UK dentists should give antibiotics to patients at risk of heart infection

Dentists in the UK should be encouraged to give antibiotics to patients at high risk of life-threatening heart infection before invasive procedures, a study has found.
Research suggests bacteria from the mouth entering the bloodstream during dental treatment could explain 30% to 40% of infective endocarditis cases. The rare but life-threatening condition occurs when the inner lining of the heart chambers and valves become infected.
Antibiotics could limit the number of cases and reduce the risk of heart failure, stroke and premature death in high-risk patients, the study says.
Current guidelines from the National Institute for Health and Care Excellence (Nice) advise against the routine use of antibiotics before invasive dental procedures for those at risk of infective endocarditis.
“Ours is the largest study to show a significant association between invasive dental procedures and infective endocarditis, particularly for extraction and surgical procedures,” said Prof Martin Thornhill from the University of Sheffield, who led the study.
Nice should review its guidelines advising against antibiotic prophylaxis, the researchers said.
Read full story
Source: The Guardian, 19 August 2022
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Silent crisis of soaring excess deaths gripping Britain is only tip of the iceberg

Britain is in the grip of a new silent health crisis. For 14 of the past 15 weeks, England and Wales have averaged around 1,000 extra deaths each week, none of which are due to Covid. 
If the current trajectory continues, the number of non-Covid excess deaths will soon outstrip deaths from the virus this year.
Experts believe decisions taken by the Government in the earliest stages of the pandemic – policies that kept people indoors, scared them away from hospitals and deprived them of treatment and primary care – are finally taking their toll.  
Prof Robert Dingwall, of Nottingham Trent University, a former government adviser during the pandemic, said: “The picture seems very consistent with what some of us were suggesting from the beginning.
“We are beginning to see the deaths that result from delay and deferment of treatment for other conditions, like cancer and heart disease, and from those associated with poverty and deprivation. 
“These come through more slowly – if cancer is not treated promptly, patients don't die immediately but do die in greater numbers more quickly than would otherwise be the case.”
Read full story (paywalled)
Source: The Telegraph, 18 August 2022
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NHS England’s list of trusts with worst elective and cancer problems

Almost a third of acute trusts have been identified by NHS England as being ‘at risk’ of missing key targets for electives and cancer recovery, with some facing “periodic calls between ministers and CEOs”, HSJ can reveal.
NHS England has identified 39 acute trusts at the most risk of missing the targets of having no patients waiting 78 weeks or more for elective treatment by April 2023, and returning the 62-day cancer waiting list to pre-pandemic levels by March 2023.
HSJ can reveal the full lists of 19 trusts placed in “tier one” – the most at-risk category – and 20 in “tier two” (see lists below). 
The “at risk” trusts represent 31% of the acute providers in England, with many of them among the lowest performers in the country for elective and cancer recovery.
Read full story (paywalled)
Source: HSJ, 19 August 2022
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Let patients choose hospital with shortest wait, says former health secretary

All patients should be able to choose the hospital with the shortest waiting times, a former health secretary has said.
Alan Milburn, the Labour health secretary under Tony Blair from 1999 to 2003, called for urgent reforms and warned that the NHS was “close to breaking point” and “in the worst state I have ever seen”.
A record 6.7 million people are now on waiting lists, with the numbers waiting in Accident and Emergency departments for at least 12 hours surging by more than a third in a month.
Writing for The Telegraph, Mr Milburn called for urgent reforms to give patients more choice and control while preventing a “tsunami” of chronic diseases fuelled by unhealthy lifestyles.
In recent months, ministers have promised that those facing the longest waits will be offered treatment further away and offered travel and accommodation costs, but only around 140 patients were booked in for such surgery by June.
Mr Milburn called for the option to be offered to all patients, urging health officials to use the NHS app as a way for people to chose the hospital with the shortest wait. So far, officials have promised to ensure that the app allows patients to check the average waiting time at their local hospital for their condition and compare it with others.
Read full story (paywalled)
Source: The Telegraph, 17 August 2022
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Injured 90-year-old, in 40-hour ambulance wait

A 90-year-old woman waited 40 hours for an ambulance after a serious fall.
Stephen Syms said his mother, from Cornwall, fell on Sunday evening and an ambulance arrived on Tuesday afternoon.
She was then in the vehicle for 20 hours at the Royal Cornwall Hospital. It comes as an ambulance trust warns lives are at risk because of delays in patient handovers.
It was also reported a man, 87, who fell, was left under a makeshift shelter waiting for an ambulance.
South Western Ambulance Service said it was "sorry and upset" at the woman's wait for an ambulance.
Mr Syms, from St Stephen, told BBC Radio Cornwall: "We are literally heartbroken to see a 90-year-old woman in such distress, waiting and not knowing if she had broken anything.
"The system is totally broken."
He said it took nine minutes before his 999 call was answered.
"If that was a cardiac arrest, nine minutes is much too long, it's the end of somebody's life," he said.
Mr Syms said paramedics were "absolutely incredible people".
He added: "The system is not deteriorating, it's totally broken and needs to be urgently reviewed."
Read full story
Source: BBC News, 19 August 2022
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Avoid A&E, says NHS as winter crisis bites early

The NHS is to launch a campaign urging the public to avoid A&E in an echo of appeals to protect the health service during the Covid pandemic.
The head of the NHS has instructed hospitals to prepare a public awareness campaign calling for people to “minimise” pressures on urgent and emergency services.
Such an instruction has never been issued so early in the year, and comes amid concerns that hospitals and ambulance services are already facing strains usually seen in the depths of winter.
People suffering a genuine emergency will still be encouraged to go to A&E, but on Friday night there were warnings that the campaign risks exacerbating the problems caused by patients staying away from the health service during Covid.
Prof Carl Heneghan, an urgent care doctor and professor of evidence-based medicine at the University of Oxford, said the NHS needed to be very careful about trying to dissuade the public from using services.
“The NHS seems to be the only business I know that doesn’t know how to deal with demand, and work with the needs of its customers,” he said.
“As an urgent care doctor, I need to be in front of the patient to do my job. It’s often too difficult for the new mum to know when it’s appropriate to turn to emergency services. These decisions are difficult – it’s the job of a doctor.
“Too often I see elderly patients who apologise for taking my time and I say ‘don’t apologise – you could have been 24 hours away from death’.”
Read full story (paywalled)
Source: The Telegraph, 19 August 2022
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Deaths rise as A&E crisis leads to ambulance delays

On Monday, September 20, 2021, Michael Wysockyj felt unwell and did what any gravely sick person would do: he put his life in the hands of the ambulance service. The 66-year-old from Norfolk was whisked by paramedics to the Queen Elizabeth hospital in King’s Lynn at 6.28pm. Nearly four hours later, he was still trapped inside the vehicle. The hospital was too full to take him. He died at 4.42am.
So great were the concerns of the coroner, Jacqueline Lake, that she took the unusual step of issuing a “prevention of future death” notice. “The emergency department was busy at the time and unable to offload ambulances,” she said in her report. “An x-ray cannot be carried out in an ambulance and must wait until the patient is in [the emergency department].”
This episode should be an anomaly in the failure of emergency services. It is not.
The crisis is “heartbreaking”, according to Dr Ian Higginson, vice-president of the Royal College of Emergency Medicine. “If you call for an ambulance and you’re waiting many hours for one and you have a serious condition, that is going to have an impact on your outcome. It would be reasonable to assume the long delays that patients are subjected to waiting for ambulances at the moment will filter through into excess mortality.”
Read full story (paywalled)
Source: The Times, 21 August 2022
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Revealed: CEO and exec turnover at each acute trust

Some acute trusts have kept more than half of their executive directors over a five-year period – whereas others have seen all of them change, according to HSJ analysis of top-level managerial stability.
HSJ looked at the number of executive directors who had been in place between April 2017 and April 2022, by examining annual reports and board papers.
One trust – Southport and Ormskirk – had five CEOs during the five year period, and three other trusts had four.
The national average was more than two different CEOs at each trust across the five years. Thirty-one trusts (out of 108 listed) had three different CEOs during the period, and just 23 trusts had one.
NHS Providers interim chief executive Saffron Cordery said: “This analysis underlines the value of long-term investment in NHS trust leadership. It highlights too the danger of chopping and changing leaders amid longstanding financial, capacity, workforce and other structural pressures on the health system.
“It is vital to invest in people alongside operational priorities. More must be done to guarantee a robust and diverse pipeline of leaders, equipped to take on crucial roles.”
Read full story (paywalled)
Source: HSJ, 22 August 2022
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GPs to prescribe walking and cycling in bid to ease burden on NHS

GPs around England are to prescribe patients activities such as walking or cycling in a bid to ease the burden on the NHS by improving mental and physical health.
The £12.7m trial, which was announced by the Department for Transport and will begin this year, is part of a wider movement of “social prescribing”, an approach already used in the NHS, in which patients are referred for non-medical activities.
Minister for health, Maria Caulfield, said the UK is leading the way in embedding social prescribing in the NHS and communities across the country.
“Getting active is hugely beneficial for both our mental and physical health, helping reduce stress and ward off other illness such as heart disease and obesity,” she said.
Paul Farmer, chief executive of the mental health charity Mind, said he welcomed news of the extra investment, enabling the NHS to try new ways of supporting mental health, such as through social prescribing schemes.
But, he added, prescribing exercise is not a miracle cure for treating mental health problems.
“What we urgently need to see is proper investment into our country’s mental health services,” he said. “Only that will enable us to deliver support to the 1.6 million people currently sat on waiting lists, and the 8 million people who would benefit from mental health support right now but are deemed by the system not to be unwell enough to access it.”
Read full story
Source: The Guardian, 22 August 2022
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Energy costs risk humanitarian crisis, says NHS leaders

Rising numbers of people will fall sick and see their health worsen unless the government takes further action to limit energy price rises, the NHS says.
The NHS Confederation said the UK was facing a "humanitarian crisis". The group, which represents health bosses, said many people would face the awful choice between skipping meals to heat their homes or having to live in cold and damp conditions.
But ministers said action was already being taken and the NHS supported. This includes £400 payments to every household this autumn to help pay energy bills.
However, in a letter to ministers, NHS leaders said that rapidly rising energy prices, along with other cost-of-living pressures, will still leave individuals and families facing impossible choices.
They warn that if people are forced to live in cold homes and cannot afford nutritious food, then their health will quickly deteriorate and the NHS will be left to pick up the pieces.
Cold conditions can lead to a rise in respiratory conditions, and in older people can also increase the risk of heart attacks, strokes and falls.
Cold homes are already linked to 10,000 deaths a year, the NHS Confederation said.
The group warned the risk of ill-health linked to the energy crisis would come on top of what many expect to be one of the toughest winters on record because of the combination of flu, norovirus and Covid outbreaks.
As well as leading to more sickness and illness, the NHS Confederation said it would also have a major impact on mental health and well-being.
Read full story
Source: BBC News, 20 August 2022
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Trusts warn of continued care delay as IT outage goes on

Mental health trusts continue to suffer much disruption after a cyber attack left them unable to access their electronic patient records.
Several trusts which use Advanced’s CareNotes EPR are grappling with the system being down, although the company said on Friday some progress had been made to restore the EPR.
One source at an affected mental health trust said there had been “not much in the way of improvements”, while another said they feared it could be “months” before they can fully access the EPR.
NHS England’s mental health director Claire Murdoch is regularly raising issue nationally, HSJ was told, as response teams work with Advanced to investigate and restore IT systems, which were taken offline after the company was hit by a cyber attack two weeks ago.
Hereford and Worcestershire Health and Care Trust has told its patients they might have to “provide more detail on your medical history to ensure clinicians have the most up-to-date information”, while Oxford Health Foundation Trust warned the technical issues could cause delays to patient care.
Read full story (paywalled)
Source: HSJ, 21 August 2022
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Covid death payments unavailable for staff who died in most recent waves

The families of any NHS and social care staff who died from Covid in the most recent waves will not be eligible for the Covid death assurance scheme launched at the start of the pandemic, it has emerged. 
The scheme closed on 31 March, despite pleas from the Royal College of Nursing (RCN) to keep it open. Since it was set up in April 2020, it has paid out £60,000 lump sums to the estates of 688 workers. A further 42 cases have been declined and 29 applications are still being processed.
The RCN wrote to then health and social care secretary Sajid Javid on 30 March, calling for the scheme to be extended. General secretary and chief executive Pat Cullen wrote: “The over-riding principle must be that no member of nursing staff who loses their life this year should be afforded any less respect and family support than one who died in 2020 or 2021…
“With a distinct possibility of new variants at any point, staff deserve assurance that they and their loved ones will not go unnoticed should they contract and ultimately lose their life to covid.”
Read full story (paywalled)
Source: HSJ, 19 August 2022
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