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

Record 7 million people awaiting hospital treatment, says NHS England

The number of people waiting for hospital treatment with the NHS in England has topped 7 million for the first time in August.
Other unwelcome records were recorded elsewhere, with just 56.9% of patients attending major A&Es in September seen within four hours – a record low.
Just 72.9% of patients received their first treatment for cancer within two months after seeing a consultant while one-month waits for radiotherapy also reached a new low at 90.5% of patients against a target of 94%. The service failed to meet seven out of eight of its stated cancer targets.
The number of patients waiting more than a year for treatment grew to 387,257 by the end of August, up from 377,689 the month before, equivalent to one in every 18 patients on the waiting list. Eighteen-month waits fell from the high of 123,969 in September 2021 but still affect 50,888.
The latest data, covering August or September depending on the metric, shows that the NHS is under increasing pressure even before winter begins. There are currently 10,522 patients in hospital with Covid, double the number seen last month (4,630 on 13 September). On Wednesday, the NHS warned that hospitals in England may be forced to cancel operations to protect their stocks because of staff shortages.
The service pointed to successes elsewhere, saying the number of people waiting 18 months for treatment continues to fall and was almost 60% lower in August as compared with the same month last year (121,711) and noting that 255,055 people received an NHS cancer check following an urgent GP referral in August – the highest number since records began.
Read full story
Source: The Guardian, 13 October 2022
Patient Safety Learning

‘Obfuscations and failures’ in trust’s handling of death, damning review finds

There were ’obfuscations, difficulties and failures’ in a scandal-hit trust’s handling of a baby’s death, a damning review has found, although it cleared the organisation’s former chair of ’serious mismanagement’.
A fit and proper person review into the conduct of former Shrewsbury and Telford Hospital Trust chair Ben Reid, who left in August 2020, has been published by the board.
The report follows complaints about Mr Reid’s conduct from the family of baby Kate Stanton-Davies, who died in the trust’s care and whose case – alongside that of Pippa Griffiths – sparked the original Ockenden inquiry.
In March 2022, the final Ockenden report into maternity services at Shrewsbury found poor maternity care had resulted in almost 300 avoidable baby deaths or brain damage cases in the most damning review of maternity services in the NHS’s history.
Report author Fiona Scolding KC said she does not believe Mr Reid “lied” or acted unethically in his handling of complaints from the family and therefore this does not disqualify him from holding office within the terms of such a review.
However, the report is highly critical of the trust, with Ms Scolding concluding it is “undoubtedly true” the provider had not dealt with Kate’s father Richard Stanton and her mother Rhiannon Davies in an “open and honest” way in respect of their daughter’s death.
Read full story (paywalled)
Source: HSJ, 13 October 2022
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Drug shortages linked with medication errors, study results suggest

A French study of adverse drug reactions has a highlighted a link between drug shortages and medication error.
Data from the French Pharmacovigilance Database show that medication errors were identified in 11% of the 462 cases mentioning a drug shortage.
The researchers found that medication errors usually occurred at the administration step and involved a human factor.
“A drug shortage may lead to a replacement of the unavailable product by an alternative,” the researchers wrote. “However, this alternative may have different packaging, labelling, dosage and sometimes a different route of administration that may increase the risk of a medication error.”
Read full story (paywalled)
Source: The Pharmaceutical Journal, 11 October 2022
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Secret footage reveals abuse of woman with dementia at luxury UK care home

An 88-year-old woman with dementia was physically and mentally abused at a luxury care home charging residents close to £100,000 a year, the Guardian can reveal.
Staff misconduct was exposed by secret filming inside the home run by Signature Senior Lifestyle, which operates 36 luxury facilities mostly in the south of England.
It has admitted that Ann King was mistreated at Reigate Grange in Surrey earlier this year.
Distressing footage from a covert camera inside her room shows:
 Care staff handling King roughly, causing her to cry out in distress. On one occasion she was left on the floor for 50 minutes.  King being taunted, mocked and sworn at when she was confused and frightened.  The retired nurse being assaulted by a cleaner, who hits her with a rag used to clean a toilet while she is lying in bed.  The cleaner threatening to empty a bin on the pensioner’s head and making indecent sexual gestures in her face. The abuse was exposed by King’s children, Richard Last and Clare Miller. They became so concerned about her wellbeing at the care home, where she lived from January 2021 to March 2022, that they installed a hidden camera on her bedside table.
They have shared the footage because they fear what happened to their mother may not be an isolated incident, and because: “She has always been horrified by this type of thing and we felt she would have wanted us to show this is going on.”
Read full story
Source: The Guardian, 13 October 2022
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Why are hospitals still using Covid rules to keep fathers out of maternity wards?

At 9.16am Florence Wilkinson gave birth to a healthy baby boy by planned caesarean section. The team of NHS doctors and midwives worked like a well-oiled machine, performing what to them was a standard operation, while also showing real kindness. After a short stint in a close observation bay, Florence was moved onto the postnatal ward. Still anaesthetised, Florence was completely reliant on her partner Ben to help her recover from the birth and feed her son in his first hours of life.
Yet just a few hours later, the scene was very different. Due to Covid protocol, Ben was not able to stay overnight. 
At 8pm, midwives bustled around briskly ejecting fathers and birth partners from the ward – and what followed was one of the hardest, most frightening nights of Florence's life. She was alone with a newborn, yet during the course of that night she only saw a midwife once. She was still recovering from my operation and unable to pick up her baby. An exhausted healthcare assistant told Florence she didn’t have time to help and the newborn didn’t feed for seven hours. There simply weren’t enough staff to look after the mothers, but no partner to advocate for them either.
A review of the maternity policies listed on the websites of 90 hospital trusts in England reveals that 54% still restrict partners from staying overnight after birth. While a few trusts have always limited access at night, many admit to bringing in restrictions during the pandemic which they continue to implement to this day. 
“It is deeply concerning to hear that some Trusts are continuing to implement restrictions on visiting, such as limited postnatal visiting overnight, under the premise of Covid, particularly at this stage in the pandemic,” says Francesca Treadaway, director of engagement at the charity Birthrights. “There is overwhelming evidence, built up since March 2020, of the impact Covid restrictions in maternity had on women giving birth. It must be remembered that blanket policies are rarely lawful and any policies implemented should explicitly consider people’s individual circumstances.”
Read full story (paywalled)
Source: The Telegraph, 13 October 2022
 
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Public responds to NHS amber alert over donor blood stocks

The blood-donation service has been inundated with offers of help after putting out an alert, on Wednesday, warning NHS stocks were running critically low in England.
More than 10,000 appointments to donate blood over the next few weeks have been booked in the past 24 hours.
The NHS usually has six days' worth of blood to use for operations and transfusions but levels are currently due to fall below two.
Type-O blood is in particular demand. O positive is the most common and anyone can receive O negative in an emergency or if their blood type is unknown.
Blood supplies have been challenging since the Covid pandemic, because of staff shortages and sickness, and a change in people's behaviour means they are less likely to visit donation centres in towns and cities, according to NHSBT.
Individual hospitals must decide how to manage the shortage - for example, by postponing some non-urgent operations.
"This is an amazing response from the public and we have been reminded in the last 24 hours of the incredible goodwill and spirit of the public towards helping patients in times of great difficulty," an NHSBT official said.
Read full story
Source: BBC News, 13 October 2022
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Government’s obesity campaign called out for being 'ineffective' and 'irresponsible'

The Government’s national obesity campaign risked turning fat-shaming into "wilful political strategy", said two humanities researchers in a new paper published in Sociology of Health and Illness. The Tackling Obesity campaign, launched by the Government "to improve health and protect the NHS during the COVID-19 pandemic", was "unproductive", "ineffective", "irresponsible", and could have led to "fat-shaming", they said. Moreover, the Government "perpetuated the neoliberal view that good health is essentially a matter of individual achievement earned through lifestyle choices and behaviour" - ignoring "the multiple structural and socioeconomic factors that contribute to obesity".
Co-authors Dr Tanisha Spratt, lecturer in sociology in the School of Humanities and Social Sciences at the University of Greenwich, London, and Luna Dolezal, associate professor in philosophy and medical humanities at the University of Exeter, said they were using the Tackling Obesity campaign "as an illustration" to explore "the dynamics between fat shaming, neoliberalism, ideological constructions of health and the 'obesity epidemic' within the UK".
They said that fat shaming was a practice that "encourages open disdain for those living with excess weight [and] operates as a moralising tool to regulate and manage those who are viewed as 'bad' citizens". They regarded this as an example of "how the ideological underpinnings of 'health' have been transformed under neoliberalism". Fat shaming discourses that are often used as tools to promote 'healthy' lifestyle choices are "problematic", they said.
Prof Dolezal, a principal investigator on the Wellcome-funded Shame and Medicine project, also co-authored a paper published earlier this month saying that the health and care system "should be more sensitive to people's 'shame'".
Read full story
Source: Medscape, 13 October 2022
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University of Leicester team finds more stillbirths in deprived areas

Research suggests there are higher rates of stillbirth and neonatal death for those living in deprived areas and minority ethnic groups.
A report from a team at the University of Leicester shows that while overall stillbirth and neonatal mortality rates have reduced, inequalities persist.
MBRRACE-UK, the team that carried out the research, said it had looked at outcomes for specific ethnic groups. The report showed the stillbirth rate in the UK had reduced by 21% over the period 2013 to 2020 to 3.33 per 1,000 total births. Over the same period the neonatal mortality rate has reduced by 17% to 1.53 per 1,000 births.
However despite these improvements, the authors found inequalities persisted, with those living in the most deprived areas, minority ethnic groups and twin pregnancies all experiencing higher rates of stillbirth.
Elizabeth Draper, professor of perinatal and paediatric epidemiology at the university, said: "In this report we have carried out a deeper dive into the impact of deprivation and ethnicity on stillbirth and neonatal death rates.
"For the first time, we report on outcomes for babies of Indian, Pakistani, Bangladeshi, Black Caribbean and Black African, rather than reporting on broader Asian and black ethnic groups, who have diverse backgrounds, culture and experiences.
"This additional information will help in the targeting of intervention and support programmes to try to reduce stillbirth and neonatal death."
Read full story
Source: BBC News, 14 October 2022
Patient Safety Learning

Over £800 million to boost innovation, growth and improve patient safety

Patients up and down the country are set to benefit from innovative new treatments and improved delivery of health and care services following significant funding to support ground-breaking experimental medicine research and advance the UK’s response to patient safety challenges.
£790 million to support breakthroughs in new treatments, diagnostics and medical technology to improve patients’ lives and bolster the economy. £25 million for research on patient safety to improve the safe delivery of health and care and better address health challenges, such as cancer treatment and reducing medication error. Exceeds funding commitments to boost research across all areas of the country, levelling up innovation and addressing health inequalities. The government has announced that over £800 million of funding, to be allocated by the National Institute for Health and Care Research (NIHR), will go to support specialist research facilities bringing together scientists to create an environment where experimental medicine and patient safety research can thrive.
This boost to the country’s research infrastructure will see further investment in scientific expertise which supports access to innovative technology and novel research projects. As well as this, it will improve regional economic growth through employment opportunities, giving private sector organisations confidence to continue to invest in research across the country.
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Source: GOV.UK, 14 October 2022
Patient Safety Learning

NHS logging baby deaths as stillbirths ‘to avoid scrutiny’

NHS hospitals have claimed that babies born alive were stillborn, a Telegraph investigation has found, prompting accusations they were trying to avoid scrutiny.
Six children who died before they left hospital were wrongly described as stillborn. Several of the children lived for minutes and one lived for five days.
Coroners are not able to carry out inquests into stillbirths, leaving some families unable to get answers until the error was corrected. In one case, an obstetrician told a coroner in Stockport that he had been pressured by an NHS manager to say a baby he had delivered had definitely been stillborn, in order to be “loyal” to the trust. 
His comments are likely to raise fears that some NHS trusts in England have used the stillbirth label to avoid having coroners examine any errors that may have been made by staff. 
The revelations raise questions over transparency at some NHS trusts.
The babies identified by The Telegraph should have been recorded as neonatal deaths, but staff claimed they were stillbirths – babies that never had any signs of life outside the mother’s body, even for a single moment. 
All the NHS trusts that wrongly classified neonatal deaths as stillbirths have apologised to the babies’ parents, and say they have changed their practices. 
Read full story (paywalled)
Source: The Telegraph, 16 October 2022
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MRI blunders: Hundreds of patients with metallic implants narrowly avoid death or serious injury after being wrongly referred for scans

Hundreds of patients with metallic implants narrowly avoided death or serious injury after being wrongly referred for MRI scans, an investigation revealed yesterday.
The powerful magnets used in the machines can displace and damage metallic items such as pacemakers, ear implants and aneurysm clips.
Doctors should question patients and check medical records before requesting a scan because of the risk of injury. But hospitals in England recorded 315 near-misses from April 2020 to March 2022 involving patients sent for an MRI.
An MRI scan at Mid Yorkshire Hospitals Trust was ditched after staff confirmed the skin over the patient’s pacemaker had begun heating up. Another patient – at Wrightington, Wigan and Leigh Trust – told staff about a metal plug implanted in their nose only after the scan had begun. Many of the incidents involved forms being filled out incorrectly on behalf of elderly and disoriented patients.
At East Kent Hospitals University Trust, a patient described as ‘not compos mentis’ was given the all-clear by a care home nurse and again by a clinician for MRI – only for staff to realise at the last moment that metal clips were implanted in their chest. Information about the incidents was obtained using freedom of information requests.
Helen Hughes of Patient Safety Learning, said: "It is vital that near-misses are regularly reported, their causes understood, and that this learning is acted on to prevent future avoidable harm."
Read full story
Source: MailOnline, 15 October 2022
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Staff at Kent NHS trust warned of 'harrowing report' into preventable baby deaths

The chief executive of an NHS trust at the centre of a maternity scandal where there were at least seven preventable baby deaths has warned staff to prepare for a "harrowing report" into what happened.
In an email seen by Sky News, East Kent Hospitals University NHS Foundation Trust chief executive Tracey Fletcher told her staff to expect a "harrowing report which will have a profound and significant impact on families and colleagues, particularly those working in maternity services".
An independent investigation into the trust, stretching back over a decade, will be published this week and is expected to expose a catalogue of serious failings.
It is also expected to say the avoidable baby deaths happened because recommendations that were made following reports into other NHS maternity scandals were not implemented.
The East Kent review is led by obstetrician Dr Bill Kirkup, who also chaired the investigation into mother and baby deaths in Morecambe in 2015.
Dawn Powell's newborn son Archie died in February 2019 aged four days.
In an emotional interview, Mrs Powell told Sky News she will never get over the loss of her son, who would be alive today if she or Archie had been given a routine antibiotic.
"For families like us, where your child has been taken away, you have forever got that hole in your life that you will never heal," Mrs Powell said.
Read full story
Source: Sky News, 16 October 2022
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NHS boss Amanda Pritchard vows that victims of falls won’t wait hours in agony

Elderly people who call for help after a fall at home will no longer be left waiting for hours on the floor, the head of the NHS has said, as she bids to keep patients out of hospital and stop the service being overwhelmed this winter.
Amanda Pritchard said she would start a new national service within weeks under which community teams would offer immediate help to people who had had an accident but had avoided serious injury.
Pritchard, who took over as chief executive of NHS England last year, said a quarter of less severe 999 calls in January involved falls. The new teams could stop 55,000 elderly people a year being taken to hospital, she said.
All NHS areas will be told this week to establish the service before a “very, very, very challenging winter” for the health service.
Read full story (paywalled)
Source: The Times, 16 October 2022
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Whistleblower Peter Duffy calls for oversight of NHS records to prevent evidence tampering

Peter Duffy warned that there is a growing risk of electronic patient records and NHS staff communications being exposed to tampering efforts in disputes with managers and executives.

The surgeon, who now practices on the Isle of Man, made the comments during talks given in September – to the Association for Perioperative Practice (AfPP) and at the Royal College of Surgeons Ireland (RCSI) in Dublin. He told audiences that “there is increasing potential for electronic tampering” of NHS IT records, holding serious implications for patient safety reporting and disputes with government and health service bodies.

The consultant medic, who says he was driven out of UHMBT in 2016 after blowing the whistle on dangerous practices and uninvestigated cases of harm within the trust’s urology services, won a constructive dismissal claim against his ex-employer in 2018.

Duffy now alleges that emails concerning the care of a patient at the centre of his whistleblowing were forged and backdated by senior UHMBT staff, several years after his employment claim against the trust had ended.
The emails were not disclosed during the tribunal – despite a court order having been issued to release all communications concerning the care of the patient in question, the late Peter Read, who died in early 2015 – and are understood to have surfaced during the course of an external review into UHMBT’s urology services carried out between late 2019 and 2021.

Niche Consult, a private firm commissioned by NHS England/Improvement (NHSE/I) to investigate Duffy’s patient safety disclosures alongside broader concerns regarding the trust’s urology department, determined that the emails in question were not fakes.

Duffy told the AfPP and RCSI audiences that, during the Niche review of UHMBT’s urology services in 2020, he was “abruptly told that two entirely new, never-seen-before emails had suddenly, unexpectedly appeared”. The emails appear to partly implicate him in the series of clinical errors and missed care opportunities that contributed to Read’s death.

Duffy described the allegedly falsified emails as being part of “an executive vendetta” waged against him in retaliation for his whistleblowing activity and negative publicity surrounding it, as UHMBT was seeking to cultivate the image of a “turnaround” trust in the years following a major maternity scandal between 2004 and 2013.
Read full story
Source: Computer Weekly, 28 September 2022
 
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Scotland's A&E crisis: Waits of 12 hours now a daily occurrence amid winter fears

Staff at accident and emergency departments across Scotland have expressed “deep concern” at the daily “excessively long waiting times” that are forcing a record number of patients to wait more than 12 hours, according to a leading NHS consultant.
Dr John-Paul Loughrey, vice-chair of the Royal College of Emergency Medicine Scotland national board, warned that while such long waits were once regarded as “never events,” they are now daily occurrences.
Amid fears the delays will spike significantly over the winter months, especially with another wave of Covid-19 expected, Dr Loughrey said staff were already “burned out,” “exhausted,” and “overwhelmed with a system facing increasing strain.”
The latest weekly data on A&E treatment shows that in the week ending 2 October, the number of patients waiting more than 12 hours had soared by 45% week-on-week.
“There is deep concern among staff around the excessively long waiting times,” Dr Loughrey said. “The weekly data that show significant increases in long waits translates to real patients on the ground or in the community who are seeking urgent and emergency care.
“The system is failing them. We know that long waiting times are associated with patient harm and even death. Staff face moral injury daily, but they are working incredibly hard and doing all they can to minimise this harm to patients.”
Read full story
Source: The Scotsman, 16 October 2022
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Sudden unexplained death in childhood: Charity hails new NHS efforts

NHS England has "never shown so much support" to stop children dying without explanation, a charity which works to prevent unexplained deaths has said.
Sudden unexplained death in childhood (SUDC) is a rare category of death in which the cause remains unknown even after thorough investigation. Currently there is very little awareness or research into its causes.
NHS England has said it will now begin a series of measures to change this, a move welcomed by the charity SUDC UK, including:
Piloting systems to improve education of health professionals and gather data to help identify modifiable factors which will go on to establish processes to help manage the deterioration of children. Improve information given to families and professionals about SUDC. Separately, data from every child whose death has been put down as SUDC since 2019 will being reviewed by the National Child Mortality Database. Dr Nikki Speed, from the charity SUDC UK, described the plans as revolutionary.
"This is such positive historic progress, a landmark moment. Never has the NHS shown such support to stop sudden unexplained death in childhood," she said.
"Never has there been such a clear statement to review public information on SUDC, optimise data collection and learn how we could prevent future tragedies.
"We finally have confidence that things will progress in our fight to stop SUDC."
Read full story
Source: BBC News, 15 October 2022
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