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

Nurses to vote on strikes in Royal College of Nursing’s first ever UK-wide ballot

Nurses will start voting on Thursday on whether to strike over pay amid warnings that record numbers are leaving the profession.
Around 300,000 members of the Royal College of Nursing (RCN) are being asked if they want to mount a campaign of industrial action in the union’s first UK-wide ballot.
The RCN said new analysis by London Economics to coincide with the ballot launch showed that pay for nurses has declined at twice the rate of the private sector in the last decade.
It is the first time in its 106-year history that the RCN has balloted members across the UK on strike action and it is urging them to vote in favour. 
RCN general secretary Pat Cullen said in a message to those being balloted: “This is a once-in-a-generation chance to improve your pay and combat the staff shortages that put patients at risk.
“Governments have repeatedly neglected the NHS and the value of nursing. We can change this if together we say ‘enough is enough’.
“Record numbers are feeling no alternative but to quit and patients pay a heavy price. We are doing this for them too."
Read full story
Source: The Independent, 6 October 2022
Sam

How 175 British children were infected with HIV

At least 175 children with the blood disorder haemophilia were infected with HIV in the 1980s, according to documents from the national archives seen by BBC News. Some of the families affected are giving evidence at a public inquiry into what has been called the worst treatment disaster in the history of the NHS.
It was almost 36 years ago - in late October 1986 - but Linda will never forget the day she was told her son had been infected.
She had been called into a consulting room in Birmingham Children's Hospital, with 16-year-old Michael.
As a toddler, he had been diagnosed with haemophilia, a genetic disorder that stopped his blood clotting properly.
Linda assumed the meeting was to discuss moving his care to the main Queen Elizabeth Hospital in the city.
"It was so routine that my husband stayed in the car outside," she says.
"Then, all of a sudden, the doctor said, 'Of course, Michael is HIV positive,' and he came out with it like he was talking about the weather outside. My stomach just fell."
Between 1970 and 1991, 1,250 people with blood disorders were infected with HIV in the UK after taking Factor VIII - a new treatment that replaced the clotting protein missing from their blood.
About half of those infected with HIV died of an Aids-related illness before life-saving antiretroviral drugs became available.
Almost three decades later, Linda is giving evidence to the long-running public inquiry into the treatment disaster.
She will appear alongside other parents, in a special session about the experiences of families whose children were infected in the 1970s and 80s.
"I felt as though I needed to do it because I want to help get to the bottom of it," she says. "We all want to know why it was allowed to happen and to keep on happening as well."
Read full story
Source: BBC News, 6 October 2022
Patient Safety Learning

Coroner warns of lack of change since man's death

A coroner has raised concerns about a mental heath trust where staff falsified records made on the night a man died.
Eliot Harris, 48, died in the Northgate Hospital in Great Yarmouth, run by the Norfolk and Suffolk Foundation Trust (NSFT), in April 2020.
Norfolk coroner Jacqueline Lake said that, two years on, staff were still not recording observations properly.
The 48-year-old, who had schizophrenia, had been sectioned under the Mental Health Act after he became agitated at his care home and refused to take medication. He was taken to Northgate Hospital and, after a period in a seclusion room, was transferred to a private room on the ward.
Mr Harris was discovered unresponsive in bed during the early hours of 10 April and pronounced dead half an hour later.
In a Prevention of Future Deaths Report (PFDR), Ms Lake said: "Quality audits undertaken following Eliot Harris's death, show that observations are still not being carried out and recorded in accordance with NSFT's most recent policy - more than two years following Eliot's death."
She said that on the night Mr Harris died there was no nurse in charge and instead of being allocated specific tasks, staff were told to "muck in", causing confusion about job responsibilities.
These issues were not resolved at the time of the inquest, she said, with no evidence provided about whether specific tasks were allocated on the night shift.
Not all staff had been trained in recording observations, there was a lack of evidence about procedures for entering a patient's room over concerns for their welfare, and there was "still some way to go to make sure care plans are completed", Ms Lake said.
Read full story
Source: BBC News, 6 October 2022
Patient Safety Learning

‘Sack poor NHS managers’, says new government adviser

An MP who has just become a ministerial assistant in the Department of Health and Social Care has called for ‘underperforming’ NHS managers to be ‘sacked’, claiming some executives in the health service earn up to £500,000 per year.
James Sunderland, who was made a Department of Health and Social Care parliamentary private secretary just days ago, told a Conservative party conference fringe event that money spent on executives should be reinvested into the coal face.
Mr Sunderland, MP for Bracknell since 2019, also said the NHS is “better funded now than at any time in its history”.
He said: “The solution is not more money, it’s better managers. We need to get to grips with the senior management of the NHS. People not performing need to be sacked.
“We need to reinvest money spent on executives and management into the coalface. It’s about efficiency in how we do business.”
Read full story
Source: HSJ, 3 October 2022
Patient Safety Learning

WHO alert over India-made cough syrups after deaths in The Gambia

A global alert has been issued over four cough syrups after the World Health Organization (WHO) warned they could be linked to the deaths of 66 children in The Gambia.
The syrups have been "potentially linked with acute kidney injuries and 66 deaths among children", it said.
The products were manufactured by an Indian company, Maiden Pharmaceuticals, which had failed to provide guarantees about their safety, the WHO added.
The WHO identified the medicines as Promethazine Oral Solution, Kofexmalin Baby Cough Syrup, Makoff Baby Cough Syrup and Magrip N Cold Syrup.
The four products had been identified in The Gambia, but "may have been distributed, through informal markets, to other countries or regions", the WHO added, in the alert published on its website.
It warned that their use may result in serious injury or death, especially among children.
Read full story
Source: BBC News, 6 October 2022
Patient Safety Learning

Four of UK’s top countries for nurse recruitment on WHO ‘red list’

Three of the top seven countries from which the UK recruits overseas nurses are on the World Health Organization’s (WHO) ‘red list’ where active recruitment should not be used.
Nigeria, Ghana and Nepal are the third, fifth and seventh highest respectively in the list of countries that provided the largest number of overseas staff joining the Nursing and Midwifery Council (NMC) register between April 2021 and March 2022.
All three were on the red list during this period, which is derived by the WHO and identifies countries facing the most pressing health workforce shortages, meaning they should not be targeted for systematic recruitment by international employers.
Nepal has since moved off the red list following of a government-to-government agreement between the Department of Health and Social Care (DHSC) and the Government of Nepal in the summer.
But the agreement has raised concerns among health leaders, including those reported in The Observer which suggested Nepali recruitment agencies carried out abusive practices, such as charging illegal fees.
Royal College of Nursing general secretary and chief executive Pat Cullen said the “overreliance” on international recruitment showed that the government had “no grip on the nursing workforce crisis”.
“It’s deeply concerning that four ‘red list’ countries appear amongst the top 20 most recruited from countries,” she said.
“This approach is unsustainable. Ministers must invest in growing the domestic nursing workforce.
“They need to give nursing staff the pay rise they deserve to retain experienced nurses and attract new people to the profession.”
Read full story
Source: Nursing Times, 4 October 2022
Patient Safety Learning

We must challenge 'doctor knows best' attitude, bereaved mother says

Merope Mills, an editor at the Guardian, has questioned doctors' attitudes after her 13-year-old daughter Martha's preventable death in hospital.
Martha had sustained a rare pancreatic trauma after falling off a bike on a family holiday, and spent weeks in a specialist unit where she developed sepsis.
An inquest concluded that her death was preventable, and the hospital apologised.
Ms Mills said her daughter would be alive today if doctors had not kept information from the parents about her condition, because they would have demanded a second opinion.
She added that doctors' attitudes "reeked of misogyny", citing a moment when her "anxiety" was used as an argument to not send critical care to Martha.
In a statement, Prof Clive Kay, chief executive of King’s College Hospital NHS Foundation Trust said he was "deeply sorry that we failed Martha when she needed us most".
"Our focus now is on ensuring the specific learnings from her case are used to improve the care our teams provide - and that is what we are committed to doing."
Watch video
Source: BBC News, 6 October 2022
Further reading on the hub 
‘We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death (The Guardian) “Are you questioning my clinical judgement?” Suppressing parents’ concerns is a serious patient safety risk
Patient Safety Learning

Patients declining two dates could be struck from waiting lists

Patients face being removed from the NHS waiting list if they decline two dates offered to them for their treatment, new internal guidance seen by HSJ reveals.
The “interim operational guidance” from NHS England says if patients decline two proposed dates for treatment, they should be moved on to “active monitoring” and removed from the NHS’s main elective waiting list.
Waiting list consultant Rob Findlay said the guidance was an “abuse of national waiting times statistics”, and that “the menacing of patients [proposed in the strategies outlined in the guidance] is appalling”.
The Royal College of Surgeons of England told HSJ  it had not been consulted on the guidance, as it would have expected. The college said the guidance could be positive if used “sensibly” but it warned that “used poorly, it could see patients lost in the system, or banished to waiting list purgatory”.
NHSE elective recovery adviser Sir Jim Mackey told HSJ the guidance was to support trusts to manage “a small number of patients who… continue to decline treatment date offers [and] to fill appointment slots so patients get seen as soon as possible”.
He said there were long-waiting patients who have “refused offers of treatment alternative, sometimes multiple offers. This is absolutely their choice, but it does make access for other patients more difficult when slots are held for them”.
Read full story (paywalled)
Source: HSJ, 6 October 2022
Patient Safety Learning

UK power cut warning prompts fear for people using life-saving machines

Rolling power cuts enforced this winter if gas supplies run extremely low could endanger thousands of people who use life-saving machines at home, health leaders have warned.
They spoke out after National Grid warned on Thursday that households could experience a series of three-hour electricity outages this winter to manage extreme gas shortages, for example if Vladimir Putin shuts off supplies from Russia and cold weather sends demand soaring.
Such an event would mean consumers in different parts of the country being notified a day in advance of three-hour blocks of time during which their power would be cut off.
The prospect of rolling power outages caused alarm among some health groups, with particular concerns for the thousands of vulnerable patients who rely on electrical devices to keep themselves alive and healthy.
Laurie Cuthbert, a director of Kidney Care UK, a health charity, said thousands of adults and children depended on a constant source of power to provide life-saving dialysis at home.
Andy Fletcher, the chief executive of Together for Short Lives, which advocates for the UK’s 99,000 seriously ill children and their families, said: “For seriously ill children a three-hour blackout could deprive them of vital life-saving equipment such as ventilators, oxygen and temperature control. Families would be forced to decide whether to admit their child to hospital, which would be extremely disruptive and distressing.”
Read full story
Source: The Guardian, 6 October 2022
Patient Safety Learning

Social care: 'Jo's care will cost £1.5k a week - the system is broken'

It was only a year ago that Boris Johnson stood up in Parliament and said he was going to fix the long-term problems in social care. He announced a new tax - to raise about £12bn a year - would be spent on health and social care costs only. But the UK's new prime minister, Liz Truss, has already scrapped the plan. Families, carers and care providers have been left asking where the funding will now come from to fix a system, which they say is broken.
Dr Jo Wilson was a high-flying international executive before she was diagnosed with dementia two years ago, aged 66. Her husband, Bill, insists he's her husband, not her carer. But he now sees to Jo's every need. 
Bill has had to find fight and persistence to navigate the world of dementia care. "It took me two years to get a care package in place for Jo," he explains. "And I only got that because Jo had a collapse at home and was taken into hospital."
Even after it was confirmed Jo could have carers come to their home to help, Bill found the variety of staff, unreliable time keeping, and a lack of understanding of dementia, left him questioning whether it was worth it.
He's now permanently exhausted, and frustrated.
Professor Martin Green, chief executive of Care England, says without a complete restructure of the social care system "thousands, if not millions, will be left without support, and the NHS will be on its knees". It is a warning heeded by others.
A new poll by Ipsos Mori for BBC News, suggests more than 70% of those over 55 are not confident that social care services will provide care to those in need. More than half of responses cited staff shortages and limited public funding as their main concerns.
Care providers say it's these issues that are putting them under extreme pressure. "We know currently that three in five people with dementia do not get the support that they need once they have that diagnosis. And that leads to crisis in care", says Fiona Carragher, director of policy at the Alzheimer's Society."
Read full story
Source: BBC News, 7 October 2022
Patient Safety Learning

More than 1m people report Long Covid in UK a year after infection

More than 1 million people in the UK have long Covid at least one year after they were first infected, new figures reveal.
The data, released by the Office for National Statistics (ONS) on Thursday, comes as other figures suggest the number of Covid patients admitted to hospital in England is continuing to rise amid a new wave of the virus.
As of 3 September, an estimated 2.3 million people living in private households in the UK – 3.5% of the population – had Long Covid, equivalent to one in every 28 people.
Ondine Sherwood, a co-founder of the advocacy group and charity Long Covid SOS, says the number of people now reporting long Covid – 342,000 of whose lives are “severely impacted” as result – illustrates that this is “not just a personal tragedy but a societal, health and workforce problem”.
Danny Altmann, professor of immunology at Imperial College London and expert on long Covid, described the situation as deeply disappointing, noting that while the number of people with long Covid appeared to dip over the summer, it is now clear there is a definite, ongoing, upwards trend.
“This reinforces the message that it’s really foolhardy to imagine we can laugh off a massive, growing BA.5 wave as ‘living with the virus’ and ‘no worse than flu’,” he said. “Long Covid and even long Covid from the 2022 Omicron waves continues to wreck lives in people of all ages. I do wish we could just remind everyone to take this seriously – get boosted, keep indoor meetings well ventilated, wear masks indoors and for travel.”
Read full story
Source: The Guardian, 6 October 2022
Patient Safety Learning

Number of NHSE whistleblowers tripled in 2021-22

The number of concerns reported by NHS England staff through the freedom to speak up process almost tripled last year, the organisation’s latest board papers have revealed.
There were 152 cases received by the internal freedom to speak up guardians in 2021-22 compared to 56 in 2020-21. This year 54 cases were received in quarter three alone.
The most common concerns are related to allegations of bullying and harassment. These accounted for nearly 40% of the total. People and team management concerns accounted for a third of FTSU cases. Within the latter, there were sub-themes of breakdown in relationships, failure to offer role models and sanctioning or ignoring poor culture.
This week’s report also set out the NHSE FTSU guardian’s next steps. These include appointing a lead guardian, finalising a strategy and continuing to engage with Health Education England and NHS Digital staff as they are brought into NHSE next year.
Read full story (paywalled)
Source: HSJ, 7 October 2022
Patient Safety Learning

Remote monitoring service to be expanded in Norfolk following success

Norfolk Community Health and Care it is using a remote monitoring service from Inhealthcare which allows patients to monitor their vital signs at home and relay readings via a choice of communication channels to clinicians who monitor trends and intervene if readings provide any cause for concern.
Analysis of the six months before and after introduction showed a significant reduction in hospital bed days, A&E attendances, GP visits and out-of-hours appointments.
Lead heart failure nurse at the trust, Rhona Macpherson, spoke to Digital Health News about the impact of the services on patients and nurses. For Macpherson, the service has helped promote self-management.
“We give each of the patients a set of scales, blood pressure monitor and pulse oximeter and we get them to do their observations,” she said.
“So we’re promoting self-management and looking at things but also it means that we can get accurate information on what’s happening with their observations.
“We then set parameters to alert if they go outside of the parameters, and it just means we can intervene much more quickly than we would do, and we can see what’s going on between our visits as well as what’s happening when we’re actually there.”
The service has transformed working practices for nurses, increasing efficiency and saving valuable time.
Macpherson said: “We’re using the technology to try and make ourselves a little bit more efficient, so it’s saving on the travel time and face to face visits.
“We can do a lot more with telephone. We’ve got the option of using video, but telephone is actually quite useful. So it’s less face to face visits, less travel and also, we’re trying to empower the patients to do their own observations and monitor themselves, rather than us just doing it for them.”
Patient Safety Learning

Six ICS chiefs to lead regional decision-making group

Six integrated care boards across the West Midlands are proposing to establish a joint committee of chief executives to make shared decisions on key issues impacting the region, it has emerged.
The CEOs of Shropshire, Telford and Wrekin ICS, Black Country integrated care systems, Birmingham and Solihull ICS, Herefordshire and Worcestershire ICS, Coventry and Warwickshire ICS and Staffordshire and Stoke-on-Trent ICS have each presented plans for a senior joint committee of the ICBs in their respective board papers.
Chiefs say there are several areas where it will be “beneficial or necessary” for the six ICBs to collaborate and make joint decisions, and it is intended this committee will provide such a mechanism. HSJ  understands it could also act as a forum to discuss performance.
Proposed shared areas of action include primary care and specialised services, which ICBs will be responsible for from April 2023, commissioning for 111/999 services, mutual aid on elective/cancer recovery, and urgent and emergency care, including ambulance handover delays. 
According to draft terms of reference, an executive committee of CEOs would be accountable to the six ICB boards and would be required to report all decisions, actions and progress to their respective systems.
Read full story (paywalled)
Source: HSJ, 7 October 2022
Patient Safety Learning

University Hospitals Birmingham NHS Foundation Trust pays fixed penalties of £8,000 for failures around consent

The Care Quality Commission (CQC) has issued two fixed penalty notices to University Hospitals Birmingham NHS Foundation Trust totalling £8,000 for failing to seek consent to care and treatment of someone in their care.
A 55-year-old gentleman who had diagnoses of epilepsy and autism was admitted to Good Hope Hospital in Birmingham on six occasions between 12 May 2019 and 6 October 2019. He had also been deaf since birth and communicated via British Sign Language (BSL) and lip reading.
These fixed penalty notices relate to the trust’s care and treatment of the patient at Good Hope Hospital in relation to three medical procedures, which occurred in September, October and November 2019.
CQC found that on these three occasions, the trust did not comply with Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, requiring registered persons to obtain the consent of the relevant person when providing care and treatment to them. Regulation 11 also states if someone is 16 or over and is unable to give consent because they lack capacity, the registered person must act in accordance with the Mental Capacity Act 2005.
The three procedures where CQC found consent failures, were feeding tubes, aimed at providing nutritional support to the patient, who was struggling with food.   
Read full story
Source: CQC, 7 October 2022
Patient Safety Learning

Influx of very low risk referrals sparks review of cancer services

NHS England is in talks about changing a pathway for women with breast problems after performance against the two-week target for them to be seen plummeted. 
HSJ understands discussions are ongoing between NHS England and the Association of Breast Surgery about changing the symptomatic breast pathway for some patients. This has been prompted by concerns that one stop breast clinics – which take those referred both via the symptomatic route and the standard two-week pathway for suspected cancer – are being flooded with very low risk patients, potentially meaning those at higher risk of cancer wait longer for tests and diagnosis.
The symptomatic pathway, which is for patients where cancer is not initially suspected by their GP, was introduced in 2010 because only about half of diagnosed breast cancers were being referred on the normal two-week pathway. The national target is for 93% of patients to be seen within two weeks. 
However, since 2018-19, national performance against this has reduced from 85.8% to 64.1% last year. 
There are concerns the pathway has led to too many patients being referred for diagnostic procedures which are inappropriate for their symptoms, preventing those who are more in need of such tests from accessing them in a timely manner.  
Association of Breast Surgery president Chris Holcombe said: “GPs tend to be quite cautious and send most people along even if the risk is quite small. We will get patients who are 25 and, to be honest, before they come to clinic, I could tell you with 99 per cent certainty they won’t have cancer. But they are worried as anything.”
Alternatives to the symptomatic breast pathway which could reduce pressure on one stop clinics and also offer patients a better service are now being evaluated, he said. “There are appropriate ways to see these patients other than in a very high resource clinic,” he added. “But they still need to be seen and seen quickly otherwise they will just bounce back into the one stop clinic.”
Read full story (paywalled)
Source: HSJ, 10 October 2022
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