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

Nottingham maternity failings: Hundreds of families contact review team

More than 350 families have already contacted a review team which is examining failings at maternity units in two Nottingham hospitals.
The review was opened on 1 September by Donna Ockenden, who previously led an inquiry into the maternity scandal at Shrewsbury and Telford NHS Trust.
She will examine how dozens of babies died or were injured in Nottingham.
Nottingham University Hospitals NHS Trust has apologised for "unimaginable distress" caused by its failings.
More affected families, as well as staff with concerns, have been asked to come forward.
Ms Ockenden said: "We are really pleased with the large numbers of families and staff that have already come forward in the first week of the review, and we actively encourage others to do the same."
Read full story
Source: BBC News, 12 September 2022
Patient Safety Learning

‘I was worried I was going to die’: why one NHS patient had to go private

Dee Dickens, 52, from Pontypridd, made the difficult choice to seek private healthcare even though she is ideologically opposed to it. After discovering a lump in her breast she was referred for a scan on the NHS’s two-week rule for suspected cancer. But after waiting six weeks, and being continually being told the waiting time was going up, eventually to a three-month wait, she was forced to pay for her own scan and appointment privately.
“In February last year, I found a lump in my breast, and went to the doctor that day. The doctor examined me and said, ‘I don’t like that.’ She said the lump was the size of the top of her index finger and she would rush me through for an urgent screening that would take no longer than two weeks.
“Two weeks later, I’d heard nothing so I gave them a call. They said that because of Covid, things had slowed down and it might take four weeks. 
“A week later, one of my breasts had swelled up. It was itching and hot and it felt like it was infected. I felt unwell, too. But I was stressed to the gills. Every day, I was worried I was going to die. We know that we’re against the clock when it’s cancer.
“I went straight back to the doctor and she rang the hospital. They said, ‘We will put your patient right at the top of the waiting list, but it will now be six weeks.’
“At six weeks, I still hadn’t heard anything, so I called the hospital. They said that I was at the top of the list still, but it would now be 10 weeks. The wait was going up because, during the worst of Covid, they hadn’t seen anyone so they were now on catchup."
“I’d had enough. Every single day I was more and more worried and my mental health was worse and worse, and my family was having to deal with me crying over stupid things. been talking about going private. But I’d been resistant – we’re both very leftwing and believe passionately in the NHS.
However, in the Dee made an appointment with a private clinic. She was seen immediately.
“After the scan, the doctor told me that the lumps were glandular tissue. The swelling, the pain and itching – were all stress related. As soon as he said, ‘You’re not going to die,’ they stopped.
“The NHS is the only thing I’m truly proud of in the UK. What worries me is I can see it disappearing, if not in my lifetime then in my children’s lifetime. That’s one of the reasons I didn’t want to go private. It felt absolutely awful to have to make the choice I did.
“On the one hand, I knew I would have an answer. But on the other, I knew there were so many women who wouldn’t be able to do what I was doing. I felt guilty, I felt I’d put my own life above my principles."
Read full story
Source: The Guardian, 11 September 2022
Patient Safety Learning

Johnson & Johnson reaches $300m settlement over pelvic mesh implants

Pelvic mesh implant manufacturer Johnson & Johnson group has reached a $300m settlement in two class actions, after thousands of women worldwide reported complications from the mesh products including chronic pain, painful sexual intercourse and incontinence.
It marks the largest settlement in a product liability class action in Australian history, and is subject to federal court approval.
Shine Lawyers led the Australian class actions and alleged Johnson & Johnson failed to properly test the devices and played down their risk to both surgeons and patients. Women have suffered complications including mesh exposure and erosion – when the mesh pokes through the vaginal wall or cuts through internal tissue – vaginal scarring, fistula formation, painful sex, and pelvic, back and leg pains. Some of these complications may occur years after surgery and can be difficult to treat.
Shine Lawyers’ Rebecca Jancauskas said the settlement would help support women’s ongoing treatment needs.
“We welcome this settlement which brings the litigation to an end,” she said. “If the federal court approves the settlement our focus will shift to the important task of distributing the settlement to group members.”
Read full story
Source: The Guardian, 12 September 2022
Patient Safety Learning

World Sepsis Day: 12,000 Irish people treated for condition last year, with one in five dying

At least 12,000 people were treated for sepsis in hospitals in Ireland last year, with one in five of those dying from the life-threatening condition.
However, the HSE said the total number of cases is likely to be much higher.
Marking World Sepsis Day, it said the condition kills more people each year than heart attacks, stroke or almost any cancer.
The illness usually starts as a simple infection which leads to an “abnormal immune response” that can “overwhelm the patient and impair or destroy the function of any of the organs in the body”.
Dr Michael O’Dwyer, the HSE’s sepsis clinical lead, said: “The most effective way to reduce deaths from sepsis is by prevention.
“A healthy lifestyle with moderate exercise, good personal hygiene, good sanitation, breastfeeding when possible, avoiding unnecessary antibiotics and being vaccinated for preventable infections all play a role in preventing sepsis.
“Early recognition and then seeking prompt treatment is key to survival. Recognising sepsis is notoriously difficult and the condition can progress rapidly over hours or sometimes evolve slowly over days.”
Read full story
Source: Independent Ireland, 13 September 2022
hub resources on sepsis
RCNi: Sepsis resource collection NSW Clinical Excellence Commission - Sepsis toolkit Dr Ron Daniels video: Recognising sepsis Introducing the Suspicion of Sepsis Insights Dashboard
Patient Safety Learning

Trust 'hiding serious harm and death' report

There was a fair bit of press coverage last week about an employment tribunal case against the Care Quality Commission – in which the regulator was found to have sacked an inspector for making a series of whistleblowing disclosures.
However, many of the key details were either skirted over, or missed altogether, in the coverage.
The disclosures made by Shyam Kumar related not just to his role as a special adviser for the CQC, but also to his full-time employer, University Hospitals of Morecambe Bay FT, and to understand the case fully, they need to be separated out.
The important context (also skirted over) was that Dr Kumar had raised a series of legitimate concerns about another orthopaedic surgeon at UHMB, both internally within the trust, and externally with the CQC, in 2018.
This caused major tensions within UHMB, to the extent that Dr Kumar started to be targeted for criticism by a different surgeon, being labelled a ‘traitor’ to Indian doctors in a group email.
When challenged by Dr Kumar, the colleague complained to the CQC that Dr Kumar had sought to threaten and intimidate him, along with other accusations.
Read full story (paywalled)
Source: HSJ, 12 September 2022
Patient Safety Learning

It is crucial that doctors listen to patients – and their families

Merope Mills’s recent article in the Guardian should be mandatory reading for all medical and nursing students. All of us who are senior doctors or nurses will recognise only too well the dangerous conditions that Merope describes: the senior doctors with overinflated egos; the internecine warfare between departments; the nursing staff and junior doctors who are rendered impotent by repeated attempts to galvanise action from off-site but know-it-all seniors; the lack of integrated thinking that results when there is no consistent lead clinician; and, most dangerous, not listening to the patient or their relatives, and not directly examining the patient.
Candour and co-production are terms much used in healthcare, but for some staff these aspects of care are a million miles away from the ego-driven practice in which they engage. This is why Merope’s advice is so important. Do not have blind faith in your clinician. Do not leave all the thinking to them. Do equip yourself with knowledge and, most of all, do demand to be treated as an equal partner in the care of your body or your loved one.
Current and former healthcare professionals respond to Merope Mills’s account of losing her daughter after a series of catastrophic medical errors.
Read full story
Source: The Guardian, 11 September 2022
Patient Safety Learning

Dr Hardeep Singh earns prestigious John M. Eisenberg Award for lifetime work improving patient safety

Hardeep Singh, an informatics leader, patient safety advocate and innovator, and friend of the Jewish Healthcare Foundation (JHF), has been awarded the Individual Achievement Award in the 20th John M. Eisenberg Patient Safety and Quality Awards for demonstrating exceptional leadership and scholarship in patient safety and healthcare quality through his substantive lifetime body of work.
The Joint Commission and National Quality Forum present Eisenberg Awards annually to recognise major achievements to improve patient safety and healthcare quality.
Dr Singh, chief of the Health Policy, Quality & Informatics Program in the Center for Innovations in Quality, Effectiveness and Safety at Michael E. DeBakey VA Medical Center and professor at Baylor College of Medicine, was recognised for his pioneering career in diagnostic and health IT safety and his commitment to translating his research into pragmatic tools, strategies, and innovations for improving patient safety.
His commitment to improving patient safety began while pursuing his Master of Public Health at the Medical College of Wisconsin in 2002 when he first learned the field of patient safety existed. That commitment was galvanised early in his medical career, as he found himself treating patients who had been misdiagnosed, received unsafe care, or experienced poor outcomes.
The breadth and depth of Dr Singh's research work is remarkable, but what is most notable is the extent to which he has succeeded in translating it into pragmatic strategies and innovations for improving patient safety. Dr. Singh emphasised that while the Eisenberg Award recognizes an individual for their achievements, his work in patient safety has been successful because of its multi-disciplinary and collaborative approach with psychologists, human factors engineers, social scientists, informaticians, patients, and more.
That work has led to the development of several tools to improve patient safety, including The Safer Dx Checklist, which helps organizations perform proactive self-assessment on where they stand in terms of diagnostic safety.
"As an immigrant and an international medical graduate, I have had a lifelong dream to make an impact on health care. I saw every scientific project as an opportunity to change health care. So, I made a personal commitment that my research must use a pragmatic, real-world improvement lens and challenge the status quo in quality and safety," Dr. Singh said.
Read full story
Source: Jewish Healthcare Foundation News, 31 August 2022
Patient Safety Learning

GPs allowed to close on day of Queen's funeral

NHS bosses have been told to make sure patients can access care if GPs close on the day of the Queen's funeral.
NHS England has written to local bosses saying while GP services will be able to close on the bank holiday there needs to be enough out-of-hours care. The letter also asked for scheduled Covid booster care home visits to be carried out as planned.
In another letter to hospitals NHS England said it expected a rise in patients not turning up for clinics.
There have been reports of some hospitals in England and other parts of the UK cancelling routine treatments due to take place on the day of the funeral too.
The letter addressing GP access, signed by NHS England's director of primary care Dr Ursula Montgomery, said GP practices would be contractually able to close their core services on Monday as its a confirmed bank holiday.
But it added local health boards would need to "urgently work to ensure sufficient out-of-hours services capacity is in place".
The letter also said areas must make up for cancelled appointments by offering patients another appointment within two weeks and make sure patients can pick up prescriptions in advance.
Read full story
Source: BBC News, 12 September 2022
Patient Safety Learning

US medical groups warn of 'irreparable harm' to patients In confusing post-Roe era

The American Medical Association and three other major health groups have warned that patients across the nation could suffer “irreparable harm” due to the shattered legal landscape left in the wake of the Supreme Court’s decision to overturn Roe v. Wade.
In a statement, co-authored with the American Pharmacists Association, the American Society of Health-Systems Pharmacists and the National Community Pharmacists Association, the groups said they were deeply concerned by state efforts to limit access to medically necessary medicine. Ongoing questions about state laws are already impacting patients, and language in newly enacted rules is “vague,” “unclear” and “disrupting care,” they said.
“Physicians, pharmacists, and other health care professionals face a confusing legal landscape due to state laws’ lack of clarity, confusing language, and unknown implementation by regulatory and enforcement bodies,” the statement reads. “Without such guidance, we are deeply concerned that our patients will lose access to care and suffer irreparable harm.”
The groups pointed to reports that some hospitals had prioritised caution over healthcare, others that have removed emergency contraceptives from kits for victims of sexual assault and pharmacies that have imposed “burdensome” steps for prescriptions.
Read full story
Source: HuffPost, 9 September 2022
Patient Safety Learning

What’s behind the mystery of thousands of excess deaths this summer?

Over the past couple of months, deaths in England and Wales have been higher than would be expected for a typical summer. In July and August, there were several weeks with deaths 10% to 13% above the five-year average, meaning that in England about 900 extra people a week were dying compared with the past few years.
The leading causes of death are within the typical range (the five-year average): heart and lung diseases, cancers, dementia and Alzheimer’s disease. Covid-19 deaths could account for half of the excess mortality, but the other half is puzzling, as there’s no one clear reason that jumps out.
It’s likely to be a mix of factors: Covid is making us sicker and more vulnerable to other diseases (research suggests it may contribute to delayed heart attacks, strokes, and dementia); an ageing population; an extremely hot summer; and an overloaded health service meaning that people are dying from lack of timely medical care.
The excess mortality puzzle has been weaponised by some to argue that this is a delayed consequence of lockdown. In essence, this is to say that mandatory restrictions on mixing and stay-at-home legal orders, as well as turning the NHS into a Covid health service during the first and second waves of infection, prevented people from being diagnosed or treated for other conditions such as cancer, heart disease, or even depression – and that those long-hidden conditions are now killing people.
Read full story
Source: The Guardian, 13 September 2022
Patient Safety Learning

Largest private-sector nurses strike in U.S. history begins in Minnesota

About 15,000 nurses in Minnesota walked off the job Monday to protest understaffing and overwork — marking the largest strike of private-sector nurses in U.S. history.
Slated to last three days, the strike spotlights nationwide nursing shortages exacerbated by the coronavirus pandemic that often result in patients not receiving adequate care. 
Minnesota nurses charge that some units go without a lead nurse on duty and that nurses fresh out of school are delegated assignments typically held by more experienced nurses, across some 16 hospitals where strikes are expected.
The nurses are demanding a role in staffing plans, changes to shift scheduling practices and higher wages.
“I can’t give my patients the care they deserve,” said Chris Rubesch, the vice president of the Minnesota Nurses Association and a nurse at Essentia Health in Duluth. “Call lights go unanswered. Patients should only be waiting for a few seconds or minutes if they’ve soiled themselves or their oxygen came unplugged or they need to go to the bathroom, but that can take 10 minutes or more. Those are things that can’t wait.”
Read full story (paywalled)
Source: Washington Post, 12 September 2022
Patient Safety Learning

Health groups call for global fossil fuel non-proliferation treaty

The World Health Organization (WHO) and almost 200 other health associations have made an unprecedented call for a global fossil fuel non-proliferation treaty.
A call to action published on Wednesday, urges governments to agree a legally binding plan to phase out fossil fuel exploration and production, similar to the framework convention on tobacco, which was negotiated under the WHO’s auspices in 2003.
“The modern addiction to fossil fuels is not just an act of environmental vandalism. From the health perspective, it is an act of self-sabotage,” said the WHO president, Dr Tedros Adhanom Ghebreyesus.
Diarmid Campbell-Lendrum, the head of the WHO’s climate change department, said the letter was a watershed moment. “This is the first time the health sector has come together to issue such a statement explicitly about fossil fuels,” he told the Guardian. “The current burden of death and disease from air pollution is comparable to that of tobacco use, while the long-term effects of fossil fuels on the Earth’s climate present an existential threat to humanity – as do nuclear weapons.”
Read full story
Source: The Guardian, 14 September 2022
Further reading
Climate change: why it needs to be on every Trust's agenda
Patient Safety Learning

Hospital issues ‘full capacity’ alert days before move to smaller building

A major acute site has issued a ‘full capacity’ alert to staff, just days before the services are due to move into a replacement hospital with fewer beds.
In an email seen by HSJ, medical leaders at the Royal Liverpool Hospital alerted staff to extreme pressures on the site, with ambulances being held outside and “no space” in resuscitation areas.
The RLH currently has around 685 beds, but at the end of this month the services are due to start transferring to the long-awaited new Royal Liverpool, on an adjacent site.
The new hospital has 640 beds, and several frontline staff have told HSJ this is causing significant concern, with the current services under so much pressure.
One senior source at the trust said there has been a push since 2017 to reduce inpatients beds at the current hospital, to try and match the capacity of the new build, but this hasn’t been achieved.
They added: “Surgeons are concerned that their beds will get filled with medical outliers. The whole issue is all the patients who are waiting for social care. It was supposed to have been sorted by now.”
Read full story (paywalled)
Source: HSJ, 13 September 2022
Patient Safety Learning

Thousands of patients face cancelled NHS appointments or operations due to Queen’s funeral

Thousands of hospital and GP appointments have been cancelled due to the public holiday surrounding the Queen's funeral on Monday.
Many hospitals are to postpone outpatient appointments and planned operations because of reduced staffing, while most GP surgeries will also close.
NHS hospitals in England have been urged to contact patients who could be affected, whether or not their appointment has been postponed.
Some hospitals have said they will be operating as usual, while others have said that they will postpone some non-urgent appointments.
Some patients and doctors have expressed concern about their appointments being postponed.
One doctor told The Independent: “I have the greatest respect for the Queen ... but when patients are waiting up to two years to be seen ... really?
One GP leader in London said practice staff were now getting “abuse” over the bank holiday closures.
Read full story
Source: The Independent, 14 September 2022
Patient Safety Learning

The career, accomplishments and impact of Richard I. Cook

Multiple professional and research communities feel a profound loss at the death of Richard I. Cook. Richard died peacefully at home on August 31, 2022 in the loving care of his wife Karen and his family.
Dr Richard Cook was a polymath who excelled in multiple careers, usually simultaneously. A physician and anaesthesiologist, he was committed to providing personal, safe, and superb care to his patients.
Richard was a Clinical Practitioner, Professor, Field Researcher, Human Factors specialist, Cognitive Systems Engineer, Designer of human-automation systems, Patient Safety Advocate, Change Agent, Teacher, Author, Innovator, Software Engineer, Pioneer of new fields such as Resilience Engineering. As a polymath, he was all of these, because by doing each, he learned more about all. Because he was committed to learning by doing, learning by detailed study of work as done, learning through interdisciplinary inquiry, and learning at the intersections, he was able to build unique expertise that broke traditional categories. This rare form of expertise mattered because he used it to create safety in health care and elsewhere, to lead R&D in unexplored directions, reject intellectual superficiality, and inspire a new generation of researchers, faculty and designers.
Read the full obituary
Source: Adaptive Creative Labs, 12 September 2022
Patient Safety Learning

Nottingham review scope 'wider than UK's biggest maternity scandal'

The midwife leading a review into failings by Nottingham's maternity services said the scope was wider than the UK's biggest maternity scandal.
Donna Ockenden previously led the review at Shrewsbury and Telford NHS Trust that found failings led to the deaths of more than 200 babies.
The terms of reference for the review in Nottingham were set out on Tuesday. A category of severe maternal harm has been added to include cases that did not lead to a death or injury.
Earlier this year Ms Ockenden completed her inquiry into the UK's biggest maternity scandal at Shrewsbury and Telford NHS Trust.
She said the scope of the review in Nottingham was wider because an additional category had been added to the investigation. It aims to identify cases of severe maternal harm, like an unexpected admission to intensive care or a major obstetric haemorrhage.
Ms Ockenden said: "We felt adding in the category of severe maternal harm would help us to understand women's experiences and help us to learn and help the trust to learn from those cases as well.
"So actually there's been a widening of the scope which our review team felt was important and when we tested it out with some families they felt it was important too.
"Perhaps there's a mum out there saying 'well I'm ok, and my baby's ok, but x,w,z of my maternity experience really worried me or frightened me' then she can send in her experiences."
She said fathers could also send in their experiences.
Read full story
Source: BBC News, 14 September 2022
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