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

NHS 111 failures led to early Covid deaths, investigation finds

Multiple failures by the NHS 111 telephone advice service early in the pandemic left Covid patients struggling to get care and led directly to some people dying, an investigation has found.
The Healthcare Safety Investigation Branch (HSIB) looked into the help that NHS 111 gave people with Covid in the weeks before and after the UK entered its first lockdown on 23 March 2020.
It identified a series of weaknesses with the helpline, including misjudgment of how seriously ill some people with Covid were, a failure to tell some people to seek urgent help, and a lack of capacity to deal with a sudden spike in calls.
It also raised concerns that the government’s advice to citizens to “stay at home” to protect NHS services deterred people who needed immediate medical attention from seeking it from GPs and hospitals, sometimes with fatal consequences.
Mistakes identified by HSIB included that:
The CRS algorithm did not allow for the assessment of any life-threatening illness a caller had – such as obesity, cancer or lung disease – to establish whether they should undergo a clinical assessment. When many callers reached the core 111 service, there was no way to divert them as intended to the CRS, which was operationally independent of 111. Although patients who had Covid-19 symptoms as well as underlying health conditions, such as diabetes, were meant to be assessed when they spoke to the core 111 service, some were not. The number of extra calls to 111 in March 2020 meant that only half were answered. Read full story
Source: The Guardian, 29 September 2022
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Mother given substantial damages over baby's care

A mother from County Down will receive "substantial" undisclosed damages over alleged hospital treatment failures and care given to her daughter.
Christina Campbell from Ballygowan brought medical negligence lawsuits over treatment she received at the Ulster Hospital in Dundonald after her daughter, Jessica, died in 2017 with a rare genetic disorder.
The claim said that failure to test Ms Campbell during her pregnancy meant the condition went undetected. Damages were also sought for an alleged "ineffective" end of life care plan for the four month old.
Jessica was diagnosed with trisomy 13 shortly after her birth in December 2016. She experienced feeding and respiratory difficulties, as well as a congenital heart defect and a bilateral cleft lip and palate.
She was discharged from hospital with a home-based end-of-life care plan, including community and respite referral to the hospice, but a few months later.
The claims said a failure to provide Ms Campbell with a amniocentesis test, which checks for genetic or chromosomal conditions, meant Jessica's condition was not discovered sooner.
The lawsuit also highlighted concerns about Jessica's hospice treatment. It includes alleged uncertainty about the provision of humidified oxygen, a defective feeding pump and delays in a specific feeding plan and saline nebuliser being provided for the family.
The family's solicitor said the awarding of damages "signifies the importance of lessons learned" as a result of Ms Campbell's campaign.
"It is hoped that lessons can now be learned to ensure no other family has to go through a similar experience," he said.
Read full story
Source: BBC News, 29 September 2022
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Hospital’s ‘consistently high’ mortality rate under investigation

NHS England and local system leaders are investigating “consistently high” mortality rates over the last two years at an acute hospital after previous reviews failed to find an explanation, an integrated care board meeting was told this week.
A Lincolnshire integrated care board member said previous work had “never got to the bottom” of what is happening at Peterborough City Hospital, which sits outside Lincolnshire but provides services to the county’s residents.
Gerry McSorley, who chaired the predecessor clinical commissioning group and is now a non executive director on the ICB, said the problems at Peterborough were “masked” by better mortality rates at Hinchingbrooke Hospital, which is run by the same trust. He added that the concerns around the hospital’s summary hospital-level mortality indicator ration were also being looked into by NHS England.
However, after publication of the story, NWAFT told HSJ: “Following an internal review we found the variance in mortality rates between our two main acute sites… is down to clinical coding variation and in no way reflects the safety or quality of care provided to patients”.
Read full story (paywalled)
Source: HSJ, 29 September 2022
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‘Appalled’ NHSE director orders safety review at all providers

The NHS’ mental health director has branded abuse exposed at a city inpatient unit as “heartbreaking and shameful” and ordered a national review of safety across all providers.
In a letter to all leaders of mental health, learning disability and autism providers, shared with HSJ, Claire Murdoch responded to BBC Panorama’s exposure of patient abuse at the Edenfield Centre run by Greater Manchester Mental Health FT by warning trusts they should leave “no stone unturned” in seeking to eradicate and prevent poor care.
An investigation by the programme found a “toxic culture of humiliation, verbal abuse and bullying” at the medium-secure inpatient unit in Prestwich near Manchester.
In response, Ms Murdoch said the mindset that “it could happen here” must be at the front and centre of national and local approaches, adding that trusts which already adopt this outlook are most likely to identify and prevent toxic and closed cultures.
She also urged all boards to urgently review safeguarding of care in their organisations and identify any immediate issues requiring action now, such as freedom to speak up arrangements, complaints, and care and treatment reviews. A separate national probe into the quality of inpatient care is due to launch imminently.
Read full story (paywalled)
Source: HSJ, 30 September 2022
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Thérèse Coffey scraps promised paper on health inequality

Thérèse Coffey is ditching the government’s long-promised white paper on health inequalities, despite the 19-year gap in life expectancy between rich and poor, the Guardian has been told.
The health secretary has decided to not publish a document that was due to set out plans to address the stark inequalities in health that the Covid-19 pandemic exposed.
It was meant to appear by last spring and be a key part of then prime minister Boris Johnson’s declared mission to level up Britain. It was due to set out “bold action” to narrow the wide inequalities in health outcomes that exist between deprived and well-off areas, between white and BAME populations, and between the north and south of England.
"It’s dead. It’s never going to appear. The white paper is being canned,” said one source familiar with the situation.
Health experts reacted with dismay to reports of the paper being scrapped. “We expect the government to keep its commitment to addressing health disparities in an upcoming white paper and would have grave concerns if this long-planned paper were delayed or shelved,” said Dr Habib Naqvi, director of the NHS Race and Health Observatory.
“We need to see priorities and an action plan set out to address a number of serious and longstanding health inequalities. This should be a priority, particularly given the cost of living crisis and the impact this is having on diverse communities.”
Read full story
Source: The Guardian, 29 September 2022
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Paramedics pilot plan to reduce huge ambulance queues at A&E

Hannah Rusby reassures her patient he’s in good hands. He is in his eighties, skeletal, confused and struggling to answer basic questions. His breathing is rapid.
After a few minutes of probing questions and basic tests, Rusby knows this is serious — after months of decline while living alone, the man is critically ill and needs to go to hospital urgently.
With more than 500,000 people waiting for social care assessments across England, emergency calls such as this are increasingly common. 
“We are becoming a middleman for all the other services,” said Rusby, who qualified as a paramedic seven years ago and works for the London Ambulance Service (LAS). She said the job increasingly involves responding to people who fall through society’s cracks.
Daniel Elkeles, 49, chief executive of the LAS, agrees: “There are lots of patients who, if something else were available, we wouldn’t need to take them to hospital. As the population has got older and frailer, it’s unsurprising that an increasing number of the calls are not traditional emergencies.”
He believes paramedics can be the link between GPs, community nursing and social care.
From next week, the LAS will pilot having three cars covering six boroughs in southwest London. Each will have a paramedic and a community nurse and will respond to 999 calls from elderly people who have fallen at home.
They’re going to see every frail elderly person who has fallen [and] hasn’t broken a bone, and our aim is to keep all of those patients at home. The community nurse will assess the house to make sure it’s safe then refer the patient to their GP and an urgent community response team,” said Elkeles.
The service hopes this will mean as many as 1,000 fewer people going to A&E a year.
Read full story (paywalled)
Source: Sunday Times, 2 September 2022
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England skin and breast cancer patients have worst waiting time to see specialist

Patients with suspected skin and breast cancer have experienced the largest increase in waiting times of everyone urgently referred to a cancer specialist, with 1 in 20 patients now facing the longest waits, analysis of NHS England data shows.
Almost 10,000 patients referred by a GP to a cancer specialist had to wait for more than 28 days in July – double the supposed maximum 14-day waiting time. Three-quarters of them were suspected of having skin, breast or lower gastrointestinal cancer, a Guardian analysis has revealed.
In total, 53,000 people in England waited more than two weeks to see a cancer specialist. That is 22% of all the patients urgently referred for a cancer appointment by their GPs.
Minesh Patel, head of policy at Macmillan Cancer Support, said people were waiting “far too long for diagnosis or vital treatment”. Patients “are worried about the impact of these delays on their prognosis and quality of care”.
“The NHS has never worked harder,” said Matt Sample, the policy manager at Cancer Research UK, but patients dealing with long waits “reflects a broader picture of some of the worst waits for tests and treatments on record”.
“When just a matter of weeks can be enough for some cancers to progress, this is unacceptable.”
Read full story
Source: The Guardian, 2 October 2022
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NHS blunders rise by 60% in five years as op bungles hit 14,000 and severe cases soar

Surgical blunders have soared 60% in five years – and extreme mistakes are now a daily occurrence in the NHS.
Some 13,921 people were treated for damage caused by botched operations in the year to March 31 – up from 8,695 in England in 2016/17.
Cases involved an “unintentional cut, puncture, perforation or haemorrhage”.
Separately, a report from NHS England shows 134 patients fell victim to so-called Never Events from April 1 to July 31.
Extreme errors included two women left infertile after their ovaries were wrongly removed. Injections and invasive tests were given to the wrong patients and in 39 cases foreign objects, such as drill bits and wires, were left inside bodies.
There were 57 cases of surgery on the wrong body part and 12 instances of patients being given the wrong implant or prosthesis.
The Royal College of Surgeons in England said: “If the system is overstretched, there is a risk that mistakes will happen.”
Rachel Power, chief executive of the Patients Association, said: “When Never Events occur, the physical and psychological effects can stay with a patient for life.”
Read full story
Source: The Mirror, 1 October 2022
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‘Perilous’ shortage of homecare workers leaves patients trapped in hospitals

A “perilous” shortage of homecare workers is the biggest reason thousands of people are languishing longer in hospital than needed, driving up waiting lists and making people sicker, figures reveal.
Almost one in four people unable to be discharged – sometimes for weeks – were trapped in hospital because they were waiting for home care, as agencies hand back contracts because staff are quitting owing to low pay, leaving 15% of jobs vacant.
A fifth of people unable to be discharged were also waiting for short-term rehabilitation and 15% were waiting for a bed in a care home, according to analysis of data obtained using freedom of information requests and public records by Nuffield Trust and the Health Foundation.
It estimated that in April this year, one in six patients were in hospital because of delayed discharge, and the discharge of patients with a hospital stay of more than three weeks was delayed by 14 days on average.
“People are ending up in hospital for malnutrition and dehydration, problems which, even if you supported people a little bit at home, would stop,” said Jane Townson, the director of the Homecare Association.
“More providers are having to turn down work than usual and some are having to hand back people because they can’t do it.”
Read full story
Source: The Guardian, 3 October 2022
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Scottish Government orders review as neonatal deaths higher than expected

Healthcare Improvement Scotland have been commissioned to lead a review into the neonatal death rates.
It follows the higher than expected deaths in both March 2022 and September last year, as published by Public Health Scotland.
At least 18 babies under four weeks old died in March – a rate of 4.6 per 1,000 births.
The wider inquiry is understood to have been triggered because the mortality rate passed an "upper control" threshold of 4.4 per 1,000 births. The average mortality rate among newborns is just over 2 per 1,000 births.
The Scottish Government said the investigation is expected to take no longer than six to nine months once the review team is formed.
Public health minister Maree Todd said: “Every death is a tragedy for the families involved. That is why earlier this year I committed to this review to find out if there is a reason for the increase.
“I appreciate how difficult this time is for anyone affected and I would encourage them to access support if they wish to do so. There is information about organisations and help available on the National Bereavement Care Pathways Scotland as well as the Scottish Government website.”
Read full story
Source: The Scotsman, 30 September 2022
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Hospital accused of ‘cover up’ after review finds failings in delivery of baby born with brain damage

Hospital authorities in Wales have been accused of attempting to cover up failings in the delivery of a baby born with significant brain damage.
Gethin Channon, who was born on 25 March 2019 at Singleton Hospital, in Swansea, suffers from quadriplegic cerebral palsy, a severe disability that requires 24/7 care.
There were complications during his birth, due to him being in an abnormal position that prevented normal delivery, and he was eventually born via caesarean section.
An independent review commissioned by Swansea Bay University Health Board (SBUHB), which manages Singleton Hospital, found “several adverse features” surrounding Gethin’s delivery that were omitted from or “inaccurately specified” in the hospital’s internal report.
The investigation, carried out by obstetrician Dr Bill Kirkup, said SBUHB had “significantly” downplayed the “suboptimal” care received by Gethin and his mother, Sian, and had erroneously attributed his condition to a blocked windpipe.
It also suggests that amendments were retrospectively made to examination notes taken by staff during the course of Ms Channon’s labour.
The family said that SBUHB, which was flagged by national inspectors in the months after Gethin’s birth due to “concerns” over its ability to deliver “safe and effective” maternity care, had “covered up” the failings in their case.
SBUHB said it had been “working tirelessly” with the family to investigate and address their concerns, and that it would be inappropriate to comment on specific allegations as the process was ongoing.
Read full story
Source: The Independent, 2 September 2022
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Trusts ‘rationing’ crisis support as only seven ICSs achieve service expansion

Only a handful of integrated care systems have so far managed to implement a key expansion in their support for patients in mental health crisis.
Internal NHS England documents, seen by HSJ, suggest that only 7 out of 42 health systems have begun offering enhanced mental health crisis support through the 111 helpline.
This was a key target set out by the NHS long term plan in 2019, to be fully rolled out by next year. Some areas of the country have implemented the expansion, but others are lagging well behind, the document suggests.
Currently, all areas offer separate 24/7 all-age crisis lines run by individual mental health trusts, offering brief psychological interventions and advice.
But HSJ has been told of national problems affecting the existing helplines, with callers facing long waits. In a recent review, Healthwatch England said the services are having to “pick and choose” who to help because of high demand, which in effect led to “service rationing”.
Siân Balsom manager for Healthwatch York, said: “People are overwhelmingly positive about the NHS. But there’s an acceptance that crisis support is not going to be there for people. That feels like a really bad place to be in.
“We know people in the voluntary sector feel like they are holding people they don’t have the skills and experience to support. [They] feel they are holding people in the wrong service because the right service is not there for them.
“People are trying to do a good job, but the system is more under pressure than it has ever been and there are clearly a lot of people who are experiencing significant mental illness who are not able to get support right there and then.”
Read full story (paywalled)
Source: HSJ, 3 October 2022
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Latest Covid surge a ‘heavy straw on camel’s back’ for every hospital in UK

Every hospital in the UK is under significant pressure and a new Covid surge is “a very heavy straw on the camel’s back”, health leaders have warned.
At least eight hospitals declared a critical incident, cancelled operations or asked people not to come to A&E unless they were seriously ill last week. One of Britain’s most senior emergency doctor said there were links between incidents like these and the rapid rise in hospitalisations for Covid, up nearly 37% in a week to 7,024. While the Office for National Statistics said it was too early to say if an autumn Covid wave had begun, health leaders said ministers need to urgently address staffing shortages.
Dr Adrian Boyle, the incoming president of the Royal College of Emergency Medicine told the Observer: “Our system is under-resourced. We don’t have enough beds, and we don’t have the workforce for the demand that we’re being asked to deal with.
“Covid just makes everything that much harder and it’s entirely valid to link this with critical incidents being called around the country. All hospitals are feeling significant levels of pressure at the moment. Covid is a very heavy straw on the camel’s back.”
Read full story
Source: The Guardian, 1 October 2022
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‘Know, Check, Ask’ before you take medication urges Northern Ireland's Minister

Both patients and healthcare staff have a central role to play in ensuring the safe use of medicines, Health Minister Robin Swann has said.
Minister for Health Robin Swann was speaking at an event to mark the roll out of the ‘Know, Check, Ask’ Campaign across all healthcare sectors in Northern Ireland. The aim of the campaign is to increase awareness and understanding about the importance of using medicine safely.
The call for action of the campaign is for:
Patients to Know Check Ask – Before you take it:
KNOW your medicines and keep an up-to-date list. CHECK that you are using your medicines in the right way. ASK your healthcare professional if you’re not sure. Health Care staff to Know Check Ask – Before you give it:
KNOW your medications. CHECK you have the right: patient, medicine, route, dose and time. ASK your patient if they understand and ask your colleagues when you are unsure. Minister Swann added “I want to encourage and help patients to be more curious about their medication, know what medication they are using, how to use it safely and feel able to ask their health care professionals questions about their medicines.  Patients should also feel able and confident to report problems with their medication early and so help reduce avoidable harm.”
Read full story
Source: Department of Health, 30 September 2022
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Cost of living: Young cancer patients 'in a desperate situation'

Charities are warning that young cancer patients facing soaring living costs are in a "desperate" situation.
Both Macmillan Cancer Support and Young Lives vs Cancer say they've seen dramatic increases in the number of people asking for emergency grants.
Research suggests tens of thousands of 18 to 39-year-olds with cancer are struggling to pay basic living costs.
Shell Rowe was among those who told BBC Newsbeat they're worried about becoming financially independent.  She was diagnosed with stage four non-Hodgkin's lymphoma at age 20 in 2019, just as she was about to study film in California for her third year of university.
"Prices have skyrocketed. I haven't been able to work and haven't been able to save and get a job," she says. "How am I ever going to be able to be financially independent? It really scares me."
More than half of the 18 to 39-year-olds with cancer surveyed by Macmillan and Virgin Money said they needed more financial support to manage the rising cost of living.
One in four young people are getting further into debt or have fallen behind paying rent and energy bills because of increased living costs, according to the survey of 2,000 people across all age groups.
More than a tenth (11%) of those surveyed say they've had to delay or cancel medical appointments due to the rising cost of petrol. Many people have to travel long distances for treatment, often in their own cars or a taxi because the risk of infection rules out taking public transport.
"It's never been as bad as this. Young people with cancer are in really desperate circumstances, because of the cost-of-living crisis," says Rachel Kirby, chief executive of Young Lives vs Cancer. "No young cancer patient should have to think about the choice of putting fuel in the car to get to treatment, or whether they can heat their homes. But those are the kinds of situations they're facing," 
Read full story
Source: BBC News, 3 October 2022
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People with recent dementia diagnosis found to have higher suicide risk

People who have recently been diagnosed with dementia, or who are diagnosed with the condition at a younger age, are among those at increased risk of suicide, researchers have found. The findings have prompted calls for greater support for those experiencing such cognitive decline.
While previous research has explored a potential link between dementia diagnosis and suicide risk, the results have been inconclusive, with some suggesting a raised risk and others a reduced risk.
Now researchers say certain groups of people with dementia are at increased risk of suicide.
“What it tells us is that period immediately after diagnosis is when people really need support from the services that provide the diagnosis,” said Dr Charles Marshall, co-author of the research and a clinical senior lecturer and honorary consultant neurologist at the Wolfson Institute of Population Health at Queen Mary University of London.
In the first three months after being told they had dementia, those diagnosed before the age of 65 had an almost seven times greater risk of suicide compared with those without dementia – although this reduced somewhat over time.
Marshall said it was unclear whether the findings were down to dementia itself causing people to feel suicidal, or factors such as people being concerned they may become a burden to their family.
Read full story
Source: The Guardian, 3 October 2022
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