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

Ministers may order inquiry or review over English mental health care failings

Ministers may order a public inquiry into mental health care and patient deaths across England because of the number of scandals that are emerging involving poor treatment.
Maria Caulfield, the minister for mental health, told MPs on Thursday that she and the health secretary, Steve Barclay, were considering whether to launch an inquiry because the same failings were occurring so often in so many different parts of the country.
They would make a final decision “in the coming days”, she said in the House of Commons, responding to an urgent question tabled by her Labour shadow, Dr Rosena Allin-Khan.
An independent investigation found this week that that three teenage girls – Christie Harnett, 17, Nadia Sharif, 17, and Emily Moore, 18 – took their own lives within the space of eight months after receiving inadequate care from the Tees, Esk and Wear Valleys (TEWV) NHS mental health trust in north-east England.
They died after “multifaceted and systemic failings” by the trust, especially at its West Lane hospital in Middlesbrough, the inquiry found.
Allin-Khan pointed to a series of scandals that have come to light, often through media investigations, about dangerously substandard mental health care being provided by NHS services and also private firms in England, including in Essex and in Greater Manchester.
“Patients are dying, being bullied, dehumanised, abused and their medical records are being falsified, a scandalous breach of patient safety,” Allin-Khan said. “The government has failed to learn from past failings.”
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Source: The Guardian, 3 November 2022
Patient Safety Learning

GPs giving antidepressants to children against guidelines

GPs are breaching medical guidelines by prescribing antidepressants for children as young as 11 who cannot get other help for their mental health problems, NHS-funded research reveals.
Official guidance says that under-18s should only be given the drugs in conjunction with talking therapies and after being assessed by a psychiatrist.
But family doctors in England are “often” writing prescriptions for antidepressants for that age group even though such youngsters have not yet seen a psychiatrist, according to a report by the National Institute for Health and Care Research (NIHR), the NHS research body.
The report linked the prescriptions to the long wait many young people, some self-harming or suicidal, face before starting treatment with NHS child and adolescent mental health services (CAMHS). Under-18s are prescribed the drugs for anxiety, depression, pain and bedwetting.
The guidance on antidepressants has been issued by the National Institute for Health and Care Excellence (NICE), which advises the NHS on which treatments are effective.
Referencing NICE’s recommendation of a two-step approval process, the NIHR study said “this often” did not happen. “No antidepressants are licensed in the UK for anxiety in children and teenagers under 18 years, except for obsessive compulsive disorder. Yet both specialists [psychiatrists] and GPs prescribe them. Thousands of children and teenagers in the UK are taking antidepressants for depression and anxiety. The numbers continue to rise and many have not seen a specialist.”
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Source: The Guardian, 4 November 2022
Patient Safety Learning

Trusts should seek extra funding to be ready for major incidents, says inquiry

Ambulance trusts should review their ability to respond to mass casualty incidents and press commissioners for any additional resources they need, the report into the Manchester Arena bombing has said.
Only 7 of the 319 North West Ambulance Service Trust vehicles available on the night of the attack, in 2017, were able to deploy immediately, the report said. It said experts believed that “such a situation would almost inevitably be replicated if a similar incident were to occur again anywhere in the country”, given current resources and demand.
Ambulance trusts are now hugely more stretched than in 2017, with response times having significantly lengthened due to lack of resources.
The second volume of the report from the inquiry, chaired by Sir John Saunders, published today, is critical of the emergency services’ response to the bombing which killed 22 people. NWAS “failed to send sufficient paramedics into the City Room [an area adjoining the Arena]” and did not use available stretchers to remove casualties in a safe way, it says. A key role for managing the incident – that of ambulance intervention team commander – was not allocated for half an hour.
But it also raised issues of ambulance capacity and availability for major incidents involving mass casualties. “Around the UK, ambulance services are always ’playing catch up,’” it said, with no spare frontline capacity.
With demand doubling over the last 10 years, the inability to respond to such incidents is only going to get worse – and lives will be lost if they do not attend the scene quickly and in sufficient numbers, the report said.
Read full story (paywalled)
Source: HSJ, 3 November 2022
Patient Safety Learning

Poorer areas in England suffer most from GP shortage, study finds

The gap between the number of GPs per patient in richer and poorer parts of England is widening, according to analysis by University of Cambridge.
The study for BBC Newsnight saw "stark inequalities" in GPs' distribution.
Separate BBC research also found patient satisfaction on measures such as how easy a practice is to reach by phone is lower in deprived areas.
The Department of Health and Social Care said it was focusing support on those who need it most.
Earlier this year, public satisfaction with GP care - as measured by the British Social Attitudes poll - fell to its lowest level across England since the survey began in 1983. The fall was widespread across all income groups.
The finding chimes with a Health Foundation analysis of official checks on the quality of services carried out by the Care Quality Commission (CQC).
It found practices serving patients living in the most deprived areas are more likely to receive CQC ratings of "inadequate" and "requires improvement" than those serving patients who live in the most affluent areas.
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Source: BBC News, 4 November 2022
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East Kent maternity deaths: Trust has lost confidence of patients

A boss at a trust which was heavily criticised in a damning report says patients have lost confidence in the care they provide.
Raymond Anakwe, executive director of East Kent Hospitals Trust, said regaining patient trust would be "possibly the largest challenge".
He was speaking at a board meeting two weeks after a review found a "clear pattern" of "sub-optimal" care.
Mr Anakwe said: "The reality is we have lost the confidence of our patients."
He also said the trust has lost the confidence "of our local community and sadly also many staff".
The trust's chief executive, Tracey Fletcher, told the meeting that she believed many staff thought "enough is enough", and that the trust has to be "brave" if it's to move forward.
Stewart Baird, a non-executive director, said: "I think it's clear the buck stops here with the people sat round this table, and where there are bad behaviours in the trust, it's because we have allowed it.
"Where people don't feel able to speak up, it's because we have not provided an environment for them to do that."
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Source: BBC News, 3 November 2022
Patient Safety Learning

'Distressing' 999 wait highlights South West Ambulance delays

South West Ambulance has the longest waits in the country for people to get through to the operator. It takes almost a minute on average for ambulance control to answer 999 calls compared with just five seconds for the West Midlands service.
Jean and Claire Iles called 999 six times to request an ambulance for Steven Iles' internal bleeding and two of their calls were unanswered for 10 minutes
"He just looked at me and he just passed away before they could even get to him," 41-year-old Claire Iles said.
"I rang about 4pm and said he has gone grey, and I said if you don't come now he is going to die, and it was still 20 minutes before the ambulance turned up."
She was at home with her parents in Yate, near Bristol, when her father, Steve, 63, fell ill.
It took 11 hours for a South West Ambulance crew to arrive, but Jean said by that time it was too late.
Mr Iles died at 17:10 GMT on 19 March from a strangulated hernia that cut off the blood supply to his heart.
The trust has apologised for the distress and anxiety caused but said it remained under "enormous pressure".
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Source: 4 November 2022
Patient Safety Learning

Regulator investigates lawyers acting for NHS trust over ‘gagging’ clauses

Lawyers acting for an NHS trust are being investigated over “gagging” clauses proposed in a settlement agreement with a whistleblower who raised concerns that mistakes by paramedics in the deaths of patients were being covered up.
In June, the then health secretary, Sajid Javid, announced an NHS review into “tragic failings” by North East Ambulance Service after Paul Calvert went public with claims that reports into deaths were doctored to cover up failings by staff.
The Guardian has learned that NEAS’s lawyers, Ward Hadaway, are also under scrutiny – by the Solicitors Regulation Authority (SRA) – over the terms proposed by the trust for his exit agreement. The agreement, offering him £41,000 in compensation, initially included confidentiality clauses relating to future disclosures.
A SRA investigation does not mean there has been wrongdoing and it does not confirm or deny whether it is examining a solicitor. However, the Guardian understands that the regulator has been in contact with Calvert about the proposed agreement.
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Source: The Guardian, 3 November 2022
Patient Safety Learning

NHS England considers substantive return to ‘payment by results’

NHS England is considering a substantive shift to a ‘payment by results’ model from April, in a bid to drive up elective activity.
Under rules for this financial year, elective care is paid for through block contracts, with additional payments for areas that treat more patients, and supposed penalties for those that fall short.
One well-placed source told HSJ there was “strong momentum” towards reviving PbR for elective care, which could mean trusts being paid purely for each unit of activity delivered, without a block contract element.
There is a belief this could help drive up activity levels, which have remained below the levels recorded before the  pandemic.
Returning to PbR would be a controversial move, as many believe it drives competitive behaviour between providers and goes against the grain of collaboration within health systems.
Other options for changes to the payment system being considered include increasing the rate of incentives and penalties.
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Source: HSJ, 4 November 2022
Patient Safety Learning

Horror as women are facing major medical procedures without anaesthetic, warn experts

Hysteroscopy Action says thousands of women are in extreme pain during and following the invasive procedures to treat problems in the womb, with many suffering for days.
It says some are left with symptoms of post-traumatic stress and subsequently feel unable to have intimate relationships with partners. Others avoid important examinations such as smear tests.
The group has written to Women’s Minister, Maria Caulfield, to raise its concerns.
In its letter, it claims women are not always given the choice of intravenous sedation or general anaesthetic to reduce pain because of an NHS drive to cut costs. 
Some are given local anaesthetic which is often painful and doesn’t work. Others are given no drugs at all and expected to cope with distraction techniques  - known as “vocal locals.”
Hysteroscopy Action has urged Ms Caulfield to open more theatre space for women to have procedures under general anaesthetic as well as offering women the choice of intravenous sedation. 
Yet Hysteroscopy Action, which has been in touch with thousands of patients who have undergone such examinations, says women are not made aware of this.
Last week RCOG President Dr Edward Morris, said it was “working to improve clinical practice around outpatient hysteroscopy”.
He added: “No patient should experience excruciating pain and no doctor should be going ahead with outpatient hysteroscopy without informed consent.”
"Hysteroscopy Action has collated more than 3,000 accounts of “brutal pain, fainting and trauma during outpatient hysteroscopy.”  
Hysteroscopy Action's spokeswoman, Katharine Tylko said: “We are counselling hundreds of patients with PTSD, who for various medical reasons find the procedure extremely painful, some even find it torturous."
“This does not happen for other invasive procedures such as colonoscopy. We urge the Women’s Minister to act and are demanding an end to this gender pain-gap.”
The letter, which has over 20 signatories, including Helen Hughes, Chief Executive of the Patient Safety Learning charity, Baroness Shaista Gohir, civil rights campaigner, and women’s rights activist, Charlotte Kneer MBE, calls for women to be given informed consent and choice about whether and what type of sedation they want.
Read full story
Source: Express, 6 November 2022
Read hub members experiences of having a hysteroscopy in the Community thread and Patient Safety Learning's blog on improving hysteroscopy safety.
Patient Safety Learning

West Lane Hospital: Staff concerns 'ignored' at Middlesbrough site

A whistleblower at a mental health trust criticised over the deaths of three teenagers has said bosses ignored workers when they raised concerns.
Christie Harnett and Nadia Sharif, both 17, and Emily Moore, 18, who were friends, all took their own lives within eight months of each other.
The whistleblower said agency workers fell asleep on duty at Middlesbrough's West Lane Hospital and staff struggled "to keep children alive".
The trust has apologised for failings.
Reports into the women's care found 120 failings at Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV), which ran the hospital, and other agencies.
Speaking after the reports were published, the health trust worker, who did not wish to be identified, told the BBC staff were "ignored" when they tried to warn bosses about conditions in the hospital.
"Staff repeatedly raised concerns with managers, some of the time we just didn't have enough staff to keep the children safe," the worker said.
"We warned them something serious was going to happen, but they just ignored us.
"Senior managers looked at numbers, rather than the skillset that staff actually had.
"The agency staff would sometimes fall asleep on duty or watch the telly rather than engage with patients."
Read full story
Source: BBC News, 4 November 2022
Patient Safety Learning

Nurses set to hold biggest-ever strike

The biggest ever strike by nurses looks set to go ahead.
The Royal College of Nursing is due to unveil the results of its ballot, which ended last week, in the next few days.
The final results are being counted but RCN sources say a large majority of nurses have voted in favour of action in a dispute over pay.
The RCN had recommended to its 300,000 members that they walk out. If strikes take place, they would affect non-urgent but not emergency care.
The vote has involved a series of individual workplace-based ballots across the UK and if nurses do not back action at a local level it is possible some hospitals and services will not be involved.
The government had appealed to nurses to "carefully consider" the impact on patients.
But Pat Cullen, RCN general secretary and chief executive, said: "Huge numbers of staff - both experienced and newer recruits - are deciding they cannot see a future in a nursing profession that is not valued nor treated fairly.
She added: "Our strike action will be as much for patients as it is for nurses. We have their support in doing this."
Cabinet minister Oliver Dowden said the government had "well-oiled contingencies in place" for dealing with any strike action by nurses.
Speaking on Sky News, Mr Dowden said essential services would be prioritised, "but of course there would be an impact as a result of a strike like that".
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Source: BBC News, 6 November 2022
Patient Safety Learning

Long Covid impact in Ireland highlighted in report

Almost 90% of those living with Long Covid in Ireland have not returned to their pre-Covid level of health, according to a new report.
The study of 988 participants was carried out by APC Microbiome Ireland, a research centre based at University College Cork (UCC), in conjunction with Cork University Hospital and Long Covid Advocacy Ireland.
It found that more than two-thirds of participants in the study continued to experience fatigue, memory problems, chest pain, stomach upset, and muscle pain.
Those surveyed also reported that they were suffering from new symptoms that had not been present before catching Covid.
These included tinnitus (38%), mouth ulcers (28%), new allergies (16%) and sexual dysfunction (13%).
They said these prolonged symptoms can significantly impact their quality of life, affect their ability to work and cause significant disability.
Read full story
Source: BBC News, 7 November 2022
Further reading and resources can be found in our dedicated area of the hub on Long Covid.
Patient Safety Learning

US hospital flu cases hit 10-year high as vaccinations fall

US influenza hospital admissions have hit the highest rate in a decade as vaccinations sag, US officials say.
They said adults have received five million fewer influenza jabs this year compared with the same time last year.
Health experts are worried a so-called tripledemic of flu, respiratory syncytial virus (RSV) and coronavirus could swamp hospitals this winter.
At least 730 people have died of flu this year, according to the Centers for Disease Control and Prevention (CDC).
While older people are the most vulnerable age group, at least four children are among the dead.
CDC data shows there have been at least 1.6 million flu cases overall and some 13,000 people have been taken to hospital.
This season's severity has not been matched at this point in the year since the H1N1 swine flu pandemic hit the US in 2009.
"There's no doubt we will face some challenges this winter," Dawn O'Connell, the US Department of Health and Human Services' (HHS) assistant secretary for preparedness and response, said at a media briefing on Friday.
Read full story
Source: BBC News, 5 November 2022
Patient Safety Learning

NHS cyber attack hits patient care with records left in ‘chaos’ three months on

Patient care is still being undermined at NHS mental health trusts and social care providers that were hit by a major cyber attack in August, doctors have warned.
Three months after the major attack wiped out NHS systems, patients’ records are missing, safety has been compromised, and medication doses are at risk of being missed amid ongoing “chaos”, i News has been told.
Dr Andrew Molodynski, mental health lead at the British Medical Association, said the prolonged systems failure has damaged care because records are “integral to patients’ safety”.
Mental health patients’ records and safeguarding alerts have not been available in some trusts since 4 August, when NHS software provider, Advanced, was hit by a ransomware attack which targeted its Carenotes records system.
A total of 12 NHS mental health trusts have been impacted by the cyber attack, potentially impacting tens of thousands of patients as well as social care providers.
According to Advanced’s own hazard log spreadsheet, seen by i News, the risks associated with disruption to its server include “medication doses missed”, “required number of carers not met”, “basic needs not met, such as nutrition and personal care”, and “health needs not met, such as wound care and physical support”.
Advanced said: “We recognise that the restoration process has taken longer than we had initially anticipated and we have sought to communicate as clearly and transparently as we have been able.”
It said planned dates for restoring the system for each client has been communicated directly and that the “overall restoration programme remains on track”.
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Source: i News, 4 November 2022
Patient Safety Learning

MHRA launches annual patient safety campaign

The Medicines and Healthcare products Regulatory Agency (MHRA) has launched its seventh annual campaign urging clinicians and patients to report any suspected side effects or adverse incidents pertaining to medicines and medical devices. 
The global campaign involves regulators from more than 80 countries and aims to promote public and sector engagement in actively improving patient safety.
Once flagged to the MHRA’s Yellow Card scheme, any suspected adverse incidents or risks are catalogued and investigated by the regulator – since being established in the mid-sixties, the initiative has identified, and dealt with, many safety concerns related to medicines and medical technologies, improving patient safety and strengthening the clinician-user relationship in the health sector.
Phil Tregunno, MHRA Deputy Director of Patient Safety Monitoring, said: “Every report made by a patient, a healthcare professional, or a carer plays a key role in gaining knowledge about the risks of medicines and medical devices in clinical use and allows rapid, targeted action to be taken to minimise harm and ensure that the benefit-risk remains favourable.
“Reporting suspected side effects and adverse incidents to the Yellow Card website is not just about the individual involved, it helps to improve the safety of medicines and medical devices for all patients. By reporting, you are part of the solution – and you may be helping to protect the most vulnerable, at-risk groups from potential harm.
“If you, your child, or a patient in your care experiences a suspected side effect or adverse incident relating to a medicine or medical device, it is essential that you report it to us promptly. The faster you report, the likelier it is that we can intervene and prevent others from experiencing untoward, serious, life-altering, and occasionally life-threatening issues.”
You can report any potential side effects, adverse incidents or risks by visiting the Yellow Card scheme’s website.
Read full story
Source: National Health Executive, 7 November 2022

Patient Safety Learning

Sharp rise in babies missing out on timely health checks

The proportion of newborn babies receiving a timely health visitor check-in has fallen sharply, with one in five missing out in the most recent statistics available.
Official data reveals that only 82.6% of babies received a new birth visit within their first fortnight in 2021-22, as is recommended, and in the fourth quarter of the year it dropped as low as 79.3%.
This is the lowest proportion recorded in recent years in the annual dataset on health visitor service delivery metrics, published by the Office for Health Improvements and Disparities.
According to the NHS website, a health visitor new birth visit is supposed to take place between 10 and 14 days after birth and is designed to offer advice on issues including safe sleeping, vaccinations, infant feeding, infant development, and adjusting to life as a parent.
Kate Holmes, head of support and information at charity The Lullaby Trust, said: “Safer sleep saves babies’ lives and all families should be given advice on how to reduce the risk of sudden infant death syndrome for their baby. The new birth visit is a key opportunity for health visitors to talk to families about safer sleep and to provide them with information and support that takes their individual and family circumstances into account.”
Read full story (paywalled)
Source: HSJ, 7 November 2022
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