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

Covid inquiry first preliminary hearing to begin

The first preliminary hearing of the UK Covid public inquiry will begin today.
The session, in London, will focus on the UK's pandemic preparedness before 2020. It will be largely procedural, involving lawyers and an announcement about who will be giving evidence. Public hearings where witnesses are called will not start until the spring.
The inquiry formally started in the summer, with a listening exercise.
But this first preliminary hearing is still being seen as an important milestone for the families who lost loved ones.
Lindsay Jackson's mother, Sylvia, 87, died from Covid during the first lockdown, after contracting it at a care home.
Ms Jackson, of the Covid-19 Bereaved Families for Justice campaign group, said it was essential lessons were learned.
She was "really pleased" the inquiry was finally starting but it had taken too long to reach this stage. 
"It's two-and-a-half years since the pandemic started," she said.
"We lost so many people. If people have done things wrong, they need to be held accountable.
"For me, my family and the others who lost loved ones, it's important that answers are found to the questions that we have."
Read full story
Source: BBC News, 4 October 2022
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Hundreds of thousands more women than men prescribed powerful anti-anxiety drugs ‘harder to come off than heroin’

Hundreds of thousands more women than men have been prescribed powerful anti-anxiety drugs which experts warn are harder to come off than heroin, The Independent can reveal.
New information obtained under freedom of information (FOI) laws shows women in England were 59% more likely to be prescribed benzodiazepines – better known by the brand names of Valium, Xanax and Temazapam – than men between January 2017 and December 2021.
Benzodiazepines are commonly prescribed for anxiety and insomnia, with the drug’s withdrawal symptoms including depression, acute anxiety, insomnia, vivid nightmares, headaches, vomiting, shakes, cramps and, in the worst cases, seizures which can cause death.
Many countries explicitly state benzodiazepines should not be taken for more than four weeks, while research has found benzodiazepines can cause memory loss and Alzheimer’s.
In September 2020, the US Food and Drug Administration announced its “black box warning” must be placed on all benzodiazepines to inform patients withdrawal from the drugs can be life-threatening.
Stephen Buckley, head of information at Mind, a leading UK mental health charity, told The Independent it was difficult to “know the exact reasons behind why women are more likely to be prescribed benzodiazepines than men” but said the FOI “findings support others which show gender discrepancies in prescribing have been occurring for a long time”.
“Previous research in some parts of the world has found that male prescribers were more likely to prescribe benzodiazepines to female patients than male patients. Research into the reasons behind gender differences in prescribing psychiatric medication is important.”
Read full story
Source: The Independent, 3 October 2022
Related reading:
Medicines, research and female hormones: a dangerous knowledge gap Gender bias: A threat to women’s health
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Record number of NHS staff hand in resignation

The latest NHS workforce figures have shown that a record number of staff voluntarily resigned from their jobs during the first quarter of this financial year.
According to the data, almost 35,000 NHS workers resigned voluntarily, which was up from 28,105 during the same period in 2021, and 19,380 in 2020. It is also higher than in any equivalent first quarter over the last 10 years.
The most common reason for leaving during quarter one of 2021-22 was ‘work-life balance’, with almost 7,000 NHS workers citing this as their reason for leaving their jobs.
Close to 2,000 NHS workers also left in the same period in search of a ‘better reward package’, with almost 1,000 reporting ‘incompatible working relationships’. In it unclear from the NHS digital data whether they left the NHS altogether.
Read full story (paywalled)
Source: HSJ, 3 October 2022
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Tribunal told of 'failure' over girl's blood tests

If doctors had tested a nine-year-old girl's blood sooner they may have changed the treatment she received before her death, an expert witness has confirmed to a medical tribunal.
The hearing was told this was a "significant failure" in the care of Claire Roberts.
Claire died at the Royal Belfast Hospital for Sick Children in 1996. In 2018 a public inquiry concluded she died from an overdose of fluids and medication caused by negligent care. At the time, her parents were told a viral infection had spread from her stomach to her brain.
The General Medical Council (GMC) said one of the doctors involved in Claire's care, Dr Heather Steen, acted dishonestly in trying to conceal the circumstances of her death.
Dr Steen denied allegations that she acted dishonestly and engaged in a cover-up.
The Medical Practitioners Tribunal Service (MPTS) heard from a defence expert witness on Monday who said doctors not checking the sodium levels in Claire's blood earlier was a "significant failure" in her care.
Dr Nicholas Mann told the tribunal he would have ordered more blood tests on Claire on the morning after she was admitted to hospital but he said he did not know if this would have prevented her death.
"There should have been more attention to her fluids and electrolytes on the day after admission. Whether that would have altered the final outcome I don't know but certainly it would have been sensible to do that," he said.
The tribunal also heard that Claire's death was not referred to a coroner, despite this being something all of the doctors caring for her would have had a duty to do.
It was also told that a letter sent to Claire's parents from the hospital in 2005 contained inaccuracies.
During questioning of Dr Mann, a barrister for the GMC highlighted the involvement of Dr Steen in compiling the letter which was signed by another doctor. Tom Forster KC said it was the GMC's case that Claire's family were given incorrect information about potential causes of her death despite these not being definitively diagnosed.
Read full story
Source: BBC News, 3 October 2022
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Lung cancer tests urged for ex-smokers over 55

Lung cancer screening should be offered to over-55s who have smoked, government advisers have said.
New guidance from the UK National Screening Committee has called for a mass introduction of checks for all present and former smokers between the ages of 55 and 74. While the NHS offers routine screening for other types of cancer, including breast, bowel and cervical, there is no lung cancer screening programme.
Lung cancer is the UK’s deadliest form and every year 48,000 people are diagnosed, with 35,000 deaths. The death rate is so high because it is often spotted when symptoms develop and it is too late for treatment. Only 5% of those diagnosed with lung cancer at the latest stage survive for five years, but when picked up early more than half survive.
Officials have recommended targeted screening to cut death rates. It involves a CT scan which takes a detailed picture of the lungs to look for abnormalities.
The National Screening Committee said that targeting all of those who have smoked would reduce deaths because 70% of lung cancer cases are caused by smoking.
Read full story (paywalled)
Source: The Times, 30 September 2022
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Failing NHS hospitals to be boosted by Cobra-style meetings

Underperforming hospitals face special measures before what ministers warn will be one of the worst winters in the history of the NHS.
Thérèse Coffey, the health secretary, told a fringe event at the Conservative Party conference that there was too much “variation in what patients experience” as her department plans to impose closer control on failing hospitals.
Robert Jenrick, the NHS minister, said that the government “shouldn’t be tolerant of those parts of the NHS which are underperforming” and had demanded quicker improvement from more than a dozen hospitals.
He acknowledged that NHS staff were overstretched in the aftermath of the pandemic, saying that he wanted to “put boosterism to one side” and accept that the shortage of doctors and nurses was the biggest problem facing the health service.
However, he also questioned why some hospitals were doing so poorly when other nearby hospitals with similar problems were seeing much shorter waits.
“A very striking dynamic is the variability that we see within the NHS and I think this is where we as Conservatives have a message, which is that we shouldn’t be tolerant of those parts of the NHS which are underperforming.”
Read full story (paywalled)
Source: The Times, 4 October 2022
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Teen held in hospital for months due to lack of secure children’s home place

A young teenager with complex needs in local authority care has been deprived of their liberty and held in hospital for several months because no secure placement could be found anywhere in England, a family court has heard.
General hospitals are not registered to provide secure accommodation for children in this situation, and do not have the specialist staff required to provide the care and therapeutic input needed.
High court judges have repeatedly raised concerns that children in urgent need of secure accommodation are waiting months to find a place, to the detriment of their mental health.
England has an acute shortage of secure therapeutic placements for children with severe emotional and psychological needs. Government figures published in March show there are just 132 spaces in secure homes for children with urgent and complex needs.
On any given day, about 50 children – twice as many as in the previous 12 months – were seeking a placement. About 30 children – an increase of a third on the previous 12-month period – end up placed hundreds of miles from home in Scotland due to the lack of available secure units in England.
A Department for Education spokesperson said: “All children and young people deserve to grow up in stable, loving homes, and local authorities have a statutory duty to ensure that there are enough places for their looked-after children.
“We are supporting local authorities through providing £259m to maintain capacity and expand provision in secure and open children’s homes.
“This will provide high quality, safe homes for some of our most vulnerable children. It will mean children can live closer to their families, schools, and health services, in settings that meet their needs.”
Read full story
Source: The Guardian, 4 October 2022
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Woman died from sepsis 'as doctors argued for hours over which ward to treat her on'

Tina Hughes, 59, died from sepsis after doctors allegedly delayed treating the condition for 12 hours while they argued over which ward to treat her on.
Ms Hughes was rushed to A&E after developing symptoms of the life-threatening illness on September 8 last year. Despite paramedics flagging to staff they suspected sepsis, it was not mentioned on her initial assessment at Sandwell General Hospital, in West Bromwich.
A second assessment six hours later also failed to mention sepsis while medics disagreed over whether to treat her on a surgical ward or a high dependency unit.
The grandmother-of-five was eventually transferred to the acute medical unit at 3am the next morning where sepsis was finally diagnosed, but she continued to deteriorate and was admitted to intensive care four hours later and put on a ventilator.
She died the following morning.
A serious incident investigation report by Sandwell and West Birmingham Hospitals NHS Trust has since found there was "a delay in explicit recognition of sepsis".
Read full story (paywalled)
Source: The Telegraph, 4 October 2022
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Hospital merger confusion blamed for cancer deaths

A ‘leading’ cancer service has reported a series of safety incidents which contributed to patients being severely harmed or dying, HSJ  has reported.
An internal report at Liverpool University Hospitals Foundation Trust suggests the incidents within the pancreatic cancer specialty were partly linked to patient pathways being ill-defined following the merger of its two major hospitals.
The report lists seven incidents involving severe harm or death, and five involving moderate harm. It is not clear how many of the patients died.
The trust was formed in 2019 through the merger of the Royal Liverpool and Aintree acute sites, with the consolidation of clinical services an integral part of the plans. However, there were no formal plans to change the configuration of pancreatic cancer services, which already operated under a “hub and spoke” model.
In one finding relevant to all 12 incidents, the report said: “Patient ownership and clinician accountability (local vs specialist) have not been defined following the merger of the legacy trusts and subsequent service reconfigurations.
“This has contributed to system failures in the provision of timely quality care, particularly in patients with time-critical clinical uncertainty.”
Read full story (paywalled)
Source: HSJ, 5 October 2022
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Covid inquiry ‘marginalising’ bereaved on first day of hearing

Bereaved families fear their experiences will be “diluted” in the UK Covid-19 Inquiry after it was confirmed their evidence would be submitted to a third-party company.
Instead of the usual “pen portraits” heard in the inquiry, families will submit their evidence to a private research company as part of a parallel listening exercise that will analyse the responses and feed back the findings to the inquiry chaired by Baroness Heather Hallett.
Matt Fowler, co-founder of the Covid-19 Bereaved Families for Justice campaign, said while families believe the start of the inquiry is a step in the right direction after campaigning for two years, they fear being excluded from the inquiry because of the listening exercise.
“All bereaved families want from the inquiry is the same outcome that anyone should, for lessons to be learnt from our loss that can stop the monumental scale of death that took place from happening again,” Matt said following the preliminary hearing. “As Baroness Hallett herself has acknowledged, for that to happen the experiences of the bereaved must be learnt from, so why is she leaving us out in the cold instead of working with us?”
A&E doctor Saleyah Ahsan, from east London, worked in intensive care units during the pandemic. She said she remembers holding hands with people and telling them they needed to be incubated as they desperately called their families – some died in intensive care.
“It is very important that stories jump off the page and are real because they are real,” 
She added: “If we really want to make sure we get this right there is only this inquiry, it has to be right. I am a medic, I see the numbers are rising, it’s autumn. Thankfully we’ve got a booster but hospitals are getting busy – I’m worried.”
Read full story
Source: The Independent, 4 October 2022
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Emergency care in ‘dire’ situation as performance plummets over weekend

Several ambulance trusts have moved to the highest level of alert in the wake of severe pressure on emergency services in recent days.
Internal data seen by HSJ suggests ambulance response times have deteriorated dramatically, while the average time for call handlers to answer 999 calls has increased to almost two minutes in some areas.
Staff across the country have been sounding the alarm over the pressures, with one senior source saying the situation was “really dire” again, after a period in which pressures had eased in August and September.
The internal data showed ambulance trusts in the South West, East of England, London and the West Midlands had all declared the highest level of alert, known as REAP 4. More are expected to follow.
The average response time for category 2 calls in the South West – including suspected heart attacks and strokes – was 1 hour 24 minutes, with 10% of these calls responded to in more than 3 hours 11 minutes. The target is 18 minutes.
Emergency departments have also faced severe pressure. An emergency care consultant in Plymouth tweeted that patients were facing 70-hour waits to be admitted to wards, with some waiting 18 hours to be handed over by ambulance staff. Fionna Lowe added: “I have taken to asking families to feed their relatives. It has never been this bad.”
Read full story (paywalled)
Source: HSJ, 4 October 2022
 
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AI eye checks can predict heart disease risk in less than minute, finds study

An artificial intelligence (AI) tool that scans eyes can accurately predict a person’s risk of heart disease in less than a minute, researchers say.
The breakthrough could enable ophthalmologists and other health workers to carry out cardiovascular screening on the high street using a camera – without the need for blood tests or blood pressure checks – according to the world’s largest study of its kind.
Researchers found AI-enabled imaging of the retina’s veins and arteries can specify the risk of cardiovascular disease, cardiovascular death and stroke.
They say the results could open the door to a highly effective, non-invasive test becoming available for people at medium to high risk of heart disease that does not have to be done in a clinic.
“This AI tool could let someone know in 60 seconds or less their level of risk,” the lead author of the study, Prof Alicja Rudnicka, told the Guardian. If someone learned their risk was higher than expected, they could be prescribed statins or offered another intervention, she said.
Speaking from a health conference in Copenhagen, Rudnicka, a professor of statistical epidemiology at St George’s, University of London, added: “It could end up improving cardiovascular health and save lives.”
Read full story
Source: The Guardian, 4 October 2022
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Residents 'not safe' at four-inquest care home

A care home that will close after admitting "shortcomings in care" and failures in leadership has been labelled "not safe" by inspectors.
The Elms in Whittlesey, Cambridgeshire will shut later this month, and the Care Quality Commission (CQC) has found the service to be inadequate.
In May, the BBC first reported the concerns of relatives about The Elms after their loved ones died in 2019, weeks after a meeting in which worries were raised about "poor care".
Inquests into the deaths of the residents - George Lowlett, Margaret Canham and David Poole - remain ongoing. HC-One also apologised to the family of Joyce Parrott, who died in April 2020.
Inspectors found "people were not safe and were at risk of avoidable harm" and described multiple occasions when people had "not received their medicines as prescribed".
Other findings included:
Staff had not referred all potential safeguarding events to the local authority A failure to "establish systems to ensure people were effectively safeguarded from abuse" The provider had failed to learn when things went wrong "Widespread and significant shortfalls" in leadership No reliable record of the staff that had worked at the home and a reliance upon agency staff, which "resulted in people not receiving consistent care" Read full story
Source: BBC News, 5 October 2022
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Radar that checks people living with Parkinson’s in their own home

A miniature radar system that tracks a person as they walk around their home could be used to measure the effectiveness of treatments for Parkinson’s.
The disease, which affects about 145,000 people in the UK, is linked to the death of nerve cells in the brain that help to control movement.
With no quick diagnostic test available at present, doctors must usually review a patient’s medical history and look for symptoms that often develop only very slowly, such as muscle stiffness and tremors.
The device, about the size of a wi-fi router, is designed to give a more precise picture of how the severity of symptoms changes, both over the long term and hourly.
It sits in one room and emits radio signals that bounce off the body of a patient. Using artificial intelligence it is able to recognise and lock on to one individual. Over several months it will notice if their walking speed is becoming slower in a way that indicates that the disease is becoming worse. During a single day it can also recognise periods where a person’s strides quicken, which means that it could be used to monitor the effectiveness of new and existing drugs, even where the effects last a relatively short time.
“This really gives us the possibility to objectively measure how your mobility responds to your medication. Previously, this was nearly impossible to do because this medication effect could only be measured by having the patient keep a journal,” said Yingcheng Liu, a graduate student at the Massachusetts Institute of Technology (MIT) who is part of the team behind the device. 
Read full story (paywalled)
Source: The Times, 22 September 2022
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Cancer patients in England and Wales facing ‘unacceptable’ wait for support

The physical and mental health of tens of thousands of cancer patients in England and Wales is deteriorating because they are having to wait months for financial support from the government, a charity has warned.
Macmillan Cancer Support said many are waiting as long as five months to receive their personal independence payment (PIP), which is paid to people with long-term physical and mental health conditions or disability, and who have difficulty doing certain everyday tasks or getting around.
Health leaders said the “unacceptable” situation had now become critical, with thousands of cancer patients increasingly desperate for help.
Research for the charity found that among people with cancer who receive PIP, more than one in four (29%) have reported a deterioration in physical or mental health while they wait to receive it. This rises to almost half (46%) among those who wait more than 11 weeks to receive their first payment.
Macmillan is launching a “Pay PIP Now” campaign, saying it is hearing from patients going into debt, skipping meals and cancelling medical appointments due to travel costs, all because of delays to PIP. It wants ministers to cut the average wait times for PIP from 18 weeks at the moment to 12.
Research suggests most people with cancer suffer a financial impact from their diagnosis, including from being unable to work while having treatment, increased heating bills to stay warm and the cost of attending appointments.
Read full story
Source: The Guardian, 6 October 2022
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Vulnerable patients injured by 'inadequate' service

A troubled trust’s inpatient wards for people with a learning disability or autism have been rated “inadequate”, with staff criticised for resorting to restraint too readily which sometimes injured patients.
Care Quality Commission inspectors visited Lanchester Road Hospital in Durham and Bankfields Court in Middlesborough, run by Tees, Esk and Wear Valleys Foundation Trust, in May and June.
They found most people were being nursed in long-term segregation and some patients had very limited interaction with staff.
Among the CQC’s main criticisms was of high levels of restrictive practice used by staff, including seclusion, restraint and rapid tranquilisation.
Inspectors said incidents were not always recorded and staff did not learn from them to reduce levels of restrictions in place. They also warned staff were not always able to understand how to protect people from poor care and abuse.
Karen Knapton, CQC’s head of hospital inspection, said: “Three people had been injured during restraints, and 32 incidents of injury had been reported for healthcare assistants, some requiring treatment.
“This is unacceptable and measures must be put in place to keep patients and staff safe.”
Read full story (paywalled)
Source: HSJ, 5 October 2022
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