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

NHSE director ‘shocked’ by lack of weekend working

The national director for mental health has said she was shocked to discover how many ward managers do not work at weekends, adding this could contribute to abuse and poor care going undetected.
Asked at the NHS Providers conference about recent reports into care scandals, NHS England’s director for mental health Claire Murdoch said it was crucial to listen to frontline staff, such as healthcare assistants, who spend most of their time with patients.

But she added: “[It’s also] making sure your ward managers do work of a night and at the weekend.
“I’ve been a bit shocked to hear that we’ve moved with agenda for change and quite often ward managers are Monday to Friday people.”
Her comments come amid a string of high-profile care scandals, such as at the Edenfield Centre in Greater Manchester, as well as an ongoing debate around seven-day working across the NHS.
It is understood Ms Murdoch is concerned managers are spending too much time on bureaucratic tasks, which typically happen during Monday to Friday shifts, meaning they are then not working night or weekend shifts.
In September, the national director ordered all trusts to carry out safety reviews, warning in a letter they should leave “no stone unturned” in seeking to eradicate and prevent poor care. She also urged all boards to urgently review safeguarding of care in their organisations, and identify any immediate issues requiring action now.
Read full story (paywalled)
Source: HSJ, 15 November 2022
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All GPs to receive direct access to cancer tests

All GP practices in England will be able to book cancer tests directly for their patients from later this month, NHS bosses say.
The option of GPs booking CT scans, ultrasounds and MRIs has been gradually rolled out in recent years, as community testing centres have opened.
NHS England chief executive Amanda Pritchard will announce later all GPs will now be able to do this. 
GPs have previously relied on referring on to specialist hospital doctors. Before referring, they have to identify clear symptoms the patient may have a specific type of cancer.
But only one out of every five cancer cases is diagnosed through these urgent GP referrals. Patients with less clear symptoms face long waits for check-ups or are diagnosed only after presenting at an accident-and-emergency (A&E) unit or being referred to hospital for something else.
And Ms Pritchard will tell delegates at the NHS Providers annual conference of health managers, in Liverpool, today, she hopes the new initiative will lead to tens of thousands of cancer cases every year being detected sooner.
Read full story
Source: BBC News, 16 November 2022
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NHS England: Pelvic floor physiotherapy will see improved services by March 2024

Far too many women were rushed into mesh sling surgery for stress incontinence after birth when pelvic floor physiotherapy could have fixed or eased the problem.
In France, women are offered pelvic floor physiotherapy after childbirth as standard.
A recent question to the Secretary of State for Health and Social Care asked what assessment the Department has made of the potential benefits of offering new mothers pelvic floor physiotherapy.
This question was answered on 15 November 2022:
"The National Institute for Health and Care Excellence’s guidance recognises that physiotherapy is important for the prevention and treatment of pelvic floor problems relating to pregnancy and birth. The NHS Long Term Plan committed to ensure that women have access to multidisciplinary pelvic health clinics and pathways in England.
NHS England is deploying perinatal pelvic health services to improve the prevention, identification and access to physiotherapy for pelvic health issues antenatally and postnatally. Two-thirds of local maternity and neonatal systems are expected to establish these services by the end of March 2023, with full deployment in England expected by March 2024."
Source: Parallel Parliament, 15 November 2022
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Mental health patients sent miles due to bed shortage

Hundreds of mental health patients in England are sent to hospitals miles from home each month because of local bed shortages - more than a year after the NHS aimed to end the practice.
NHS data shows that 630 patients were in inappropriate out of area placements (OAPs) at the end of August 2022. 
An inappropriate OAP is when someone is sent to a hospital in a different area because no beds are free locally. Of the 630 patients in inappropriate OAPs in August 2022, more than half were sent away that month.
In 2019, Kelly was sectioned and - because no local bed was free - sent to a hospital 23 miles from her home.
"I didn't have anything on me", she says, "I only had my phone and the clothes that I was in."
With family members too far away to bring her possessions, the hospital provided basics: pyjamas, trousers, a T-shirt, one pair of socks and two pieces of underwear.
"All I could wear were the pyjamas and the same top and trousers every day for three weeks," says Kelly.
"It was just awful. When you're stuck in a strange place as it is... It's even more distressing not having your own familiar things to take comfort in."
Shortly after her discharge, Kelly was sectioned again - this time closer to home. She says this made a "massive difference", adding: "When you're closer to home you've got your friends and your family coming to visit you and take you out for a walk."
Paul Spencer, the charity Mind's head of health, policy & campaigns, describes OAPs as traumatic, isolating and costly to the NHS. He says that "people are cut off from their support networks right at the very moment they need them most".
Read full story
Source: BBC News, 16 November 2022
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GMC launches 'hub' to tackle racism after recent criticism

Following the blistering verdict last week of the independent review into the General Medical Council's (GMC) handling of the notorious 'laptop' case, which highlighted the "worrying trend" of ethnic minority doctors facing disproportionate regulatory action, the GMC has launched a new resource 'hub' to support doctors facing racism at work. 
A new dedicated area on the GMC website offers advice on how to address racism in the workplace, and sits alongside its existing dedicated whistleblowing webpage as the latest of 12 areas in an 'ethical hub' that brings together resources on how to apply GMC guidance in practice, focussing on areas doctors often query or find most challenging, and helping to address important ethical issues.
Announcing the launch, the GMC said: "Tackling discrimination and inequality continues to be an urgent priority for health services."
It added: "The GMC has committed to working with organisations to drive forward change, setting targets on tackling inequality." Its equality, diversity, and inclusion targets set last year aimed, inter alia, "to eliminate disproportionate complaints from employers about ethnic minority doctors, by 2026, and to eradicate disadvantage and discrimination in medical education and training by 2031". In March this year it published its first progress report, which showed that the gap between employer referral rates for ethnic minority doctors and international medical graduates, compared with white doctors, had "reduced slightly".
Read full story
Source: Medscape UK, 15 November 2022
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Orthodontist advised treatment with risk of harm to children, tribunal told

An orthodontist whose methods around shaping the jawline have gone viral advised treatment to young children that “carried a risk of harm”, a tribunal has heard. Dr Mike Mew, whose “mewing” techniques have racked up nearly 2 biillion views on TikTok, faces a misconduct hearing at the General Dental Council (GDC).
Opening the hearing in central London on Monday, Lydia Barnfather, representing the GDC, said comments made by Mew, who claims to help “alter the cranial facial structure” on his YouTube channel, were “pejorative” about orthodontists.
Barnfather told the professional conduct committee that Mew seeks to treat children with “head and neck gear” and “lower and upper arch expansion appliances” to help align teeth and shape the jawline.
“The GDC alleges this is not only very protracted, expensive, uncomfortable and highly demanding of the child, but it carries the risk of harm", Barnfather said.
It was heard that between September 2013 and May 2019, advice and treatment were provided to two children, referred to as Patient A and Patient B.
Mew was accused of failing to “carry out appropriate monitoring” of their treatment and “ought to have known” this was liable to cause harm.
Barnfather said: “The GDC allege you are not to have treated patients the way you did.”
She argued that both children had “perfectly normal cranial facial development for their age” before treatment took place. She added that the treatment was “not clinically indicated” and that Mew “had no adequate objective evidence” it would achieve its aims.
Read full story
Source: The Guardian, 14 November 2022
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FDA warns of rise in reports of child poisonings linked to cough medicine

Poison control centres in the USA have seen an increase in reports of children ingesting a type of prescription cough medicine, a study published by the Food and Drug Administration (FDA)found.
From 2010 through 2018, reports of paediatric poisonings involving the drug, benzonatate, increased each year, the study found. Benzonatate, sold under the brand name Tessalon, is prescribed to treat coughs caused by colds or the flu. It is not approved for children younger than 10 years old.
The findings, published in the journal Pediatrics, were based on more than 4,600 cases reported to poison control centres. 
The reports included children who were unintentionally exposed to the drug, as well as children who abused or misused it intentionally. 
The proportion of cases with serious adverse effects was low. However, accidental or inappropriate use of benzonatate, which comes in gel capsules, can lead to serious health problems in children, including convulsions, cardiac arrest and death.
The findings should galvanise doctors to be more careful when they prescribe these kinds of medications, said study author Dr. Ivone Kim, a pediatrician and senior medical officer at the FDA.
Cough medications "should be treated like any other medication that can have serious side effects," Ameenuddin said, "which means not giving it to children without specific medical direction."
Read full story
Source: NBC News, 15 November 2022
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Royal Sussex Hospital: Doctors warn of unsafe maternity services

Doctors have warned of "unsafe" maternity services at a Sussex hospital in emails seen by the BBC.
In the email chain between senior staff at the Royal Sussex County Hospital in Brighton, consultants wrote of "compromises" to patient care.
One doctor said during a birth "we were one step away from a potential disaster".
One senior doctor wrote in the exchange that "increasing workforce issues" had contributed to making the situation in the maternity unit "almost unmanageable at times". They added: "We are making compromises to patient care every day as a result."
Another wrote that their workload was often "unmanageable, and obviously impacted by the staffing issues".
A senior member of maternity staff said "we are delivering suboptimal care" and "we are one step away from potential disaster".
A doctor also said staff were being "stretched", and that there were delays to women's care.
Another consultant wrote: "We have an unsafe service and we have to strive for better than that."
Read full story
Source: BBC News, 16 November 2022
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ICSs may be breaching patient confidentiality, watchdog warns

The health service’s independent data watchdog has issued a warning to local NHS bodies over concerns confidential patient information is being shared unlawfully with third parties, including for ‘population health’ analysis.
In a letter to integrated care systems (ICSs), National Data Guardian Nicola Byrne and UK Caldicott Guardian Council chair Arjun Dhillon said they had both “been made aware that within some local record sharing programmes, organisations could be processing confidential patient information without ensuring that the processing does not breach confidentiality”.
They added among the four areas of concern health and care staff had raised with them was that confidential patient information may be being transferred from local record sharing programmes to third party hosted secure data environments. Secure Data Environments are data storage and access platforms where organisations can apply to access data for planning and research purposes.
It is not clear what kind of patient data may have been unlawfully shared.
Read full story (paywalled)
Source: HSJ, 17 November 2022
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NHS care backlog push at serious risk - National Audit Office

The plan to tackle long waits in hospital treatment and cancer care in England by 2025 is at serious risk, the spending watchdog says.
The National Audit Office report warned inflation and other pressures on the NHS could undermine the push. These included a lack of staff and hospital beds, which was affecting productivity, the watchdog said.
But NHS bosses said they could overcome the challenges and the health service was on track to hit its targets.
NHS England and the government have set a series of targets over the next three years.
They include:
returning performance on the 62-day target for cancer treatment to pre-pandemic levels by March 2023 ending waits of over a year and a half for planned treatment, such as knee and hip operations, by April 2023 ending waits of over a year for planned treatment by March 2025 The NAO report comes as the chancellor prepares to set out his tax and spending plans in his Autumn Statement on Thursday. Cuts to public spending are likely but Health Secretary Steve Barclay has strongly hinted the NHS will receive more money.
Read full story
Source: BBC News, 17 November 2022
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New mothers more likely to die in UK than Scandinavia

Women are four times as likely to die after childbirth in Britain as in Scandinavian countries, a study published in the BMJ has found.
Researchers analysed data on the number of women who die because of complications during pregnancy in eight high-income European countries.
They found that Britain had the second-highest death rate, with one in 10,000 mothers dying within six weeks of giving birth, only slightly less than in Slovakia, the worst performing.
The study found that rates of “late” maternal death — when women die between six weeks and a year after giving birth — were nearly twice as high in Britain as in France, the only other country for which data was available. Heart problems and suicide were the main causes of death.
Professor Andrew Shennan, an obstetrician at King’s College London, said: “Any death relating to pregnancy is devastating. Equally shocking are the avoidable discrepancies in worldwide maternal mortality.
“Causes of [maternal] death are relatively consistent across the world, and largely avoidable. Most deaths are due to haemorrhage, sepsis and hypertensive disorders of pregnancy.
“In Europe, non-obstetric causes of death have become proportionately more common than obstetric causes, including deaths from cardiovascular disease (23%) and suicide (13%); these should be prioritised.”
Read full story (paywalled)
Source: The Times. 17 November 2022
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Families blame ‘chaotic, splenetic mess of a government’ for compensation hold-up

Families whose loved ones’ bodies were sexually abused in a hospital mortuary have yet to receive any compensation, because the Department of Health and Social Care has not signed off a proposed framework.
A family member involved in the case claimed the delay was due to a “chaotic, splenetic mess of a government… [which] can’t get an arse on a seat long enough to approve it”.
Former hospital maintenance supervisor David Fuller is serving life sentences for the murder of two women, committed two decades before he went on to commit sexual offences against 101 dead women and girls in hospital mortuaries in Kent.
He was given a total of 12 years, to run concurrently, for 51 sex offences when he was sentenced last December but recently pleaded guilty to 16 additional charges involving 23 bodies and will be sentenced for these next month.
But the families of the women and girls involved have waited more than a year to receive any compensation for the emotional distress his actions caused. 
Read full story (paywalled)
Source: HSJ, 16 November 2022
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US Senate investigates ‘catastrophic failure’ to protect female migrant detainees

A US Senate investigation into allegations that unwanted medical procedures were performed on detained female immigrants in Georgia has uncovered “a catastrophic failure by the federal government” to protect the detainees.
A Senate hearing on Tuesday by the bipartisan permanent subcommittee on investigations (PSI), chaired by the Georgia senator Jon Ossoff, announced its findings on conditions and practices at the Irwin county detention center (ICDC).
The ICDC, located in Ocilla, Georgia, housed detainees who shared accounts of poor treatment including gynaecological procedures that were “excessive, invasive and often unnecessary”. An account of what was occurring at the ICDC first came to light when Dawn Wooten, a nurse at the facility, acted as a whistleblower.
Ossoff called the alleged unnecessary and sometimes non-consensual medical treatment and procedures disclosed in the 18-month investigation “nightmarish and disgraceful”.
Ossoff said: “This is an extraordinarily disturbing finding, and in my view represents a catastrophic failure by the federal government to respect basic human rights.”
The report detailed the harrowing account of an unnamed woman who was detained in the ICDC in 2020. The detainee describes how Dr Mahendra Amin allegedly removed a portion of her fallopian tube, a result of a dilation and curettage procedure she was not made aware of, and how Amin told her “she would never be able to have children naturally again”.
Read full story
Source: The Guardian, 15 November 2022
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Extra funding announced for NHS only half of what is needed, experts warn

The NHS will receive an extra £3.3bn in each of the next two years, the chancellor has announced, but experts warn the cash is probably only half of what is needed to keep the health service afloat.
Jeremy Hunt told the Commons during his autumn statement he had been assured the funding would mean the NHS can hit its “key priorities”. Its chief executive, Amanda Pritchard, later issued a statement welcoming the funding, saying it showed that “the government has been serious about its commitment to prioritise the NHS”.
However, it was only last month that NHS England, the organisation Pritchard leads, had forecast a £7bn shortfall in its funding next year, which it warned it could not plug with efficiency measures alone.
“The NHS warned it needed more money to cope with the impact of inflation on its costs,” said Nigel Edwards, the chief executive of the independent thinktank Nuffield Trust. “Today’s autumn statement has provided much-needed extra cash from April over the next two years, but this is only around half of what the NHS had warned last month would likely be needed.”
Hunt pledged to grow the NHS budget in 2023-24 and 2024-25 by £3.3bn in each year.
But Edwards warned that would not account for the £2.5bn worth of inflation and other unexpected cost pressures the NHS has faced in the current financial year.
“The impact of today’s funding announcement is that real terms health spending per head after adjusting for age will increase by less than 1% for the next two years,” Edwards added. “This is compared to the long-term average of 2.6% and comes at a time when the NHS cannot afford to stand still and is desperately trying to increase the work it can do to clear record waiting times.”
Read full story
Source: The Guardian, 17 November 2022
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Harrowing ‘systemic abuse’ at children’s hospitals revealed

Children say they were “treated like animals” and left traumatised as part of a decade of “systemic abuse” by a group of mental health hospitals, an investigation by The Independent and Sky News has found.
The Department of Health and Social Care has now launched a probe into the allegations of 22 young women who were patients in units run by The Huntercombe Group, which has run at least six children’s mental health hospitals, between 2012 and this year.
They say they suffered treatment including the use of “painful” restraints and being held down for hours by male nurses, being stopped from going outside for months and living in wards with blood-stained walls. They also allege they were given so much medication they had become “zombies” and were force-fed.
Through witness testimony, documents obtained by Freedom of Information request and leaked reports, the investigation has uncovered:
The CQC has received more than 700 whistleblowing and safeguarding reports, including “incidents of concern” and several “sexual safety” concerns. NHS England was notified of 195 safeguarding reports between 2020 and 2021. A 2018 internal report at Meadow Lodge hospital in Newton Abbot (now closed) found staff members using sexually inappropriate language in front of patients. 160 reports investigated by Staffordshire police about Huntercombe Staffordshire between 2015 and 2022. Between March 2021 and 2022, the CQC gave permission for 29 patients to be admitted to Maidenhead hospital after it was placed in special measures. Read full story
Source: The Independent, 17 November 2022
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Ambulance waits quadruple in handover hotspots

Ambulance waiting times for stroke and suspected heart attacks have quadrupled in four parts of England since before Covid-19 – whereas others have only grown by half – underlining the severe impact of long accident and emergency handovers.
Response times have leapt across England over the past two years, particularly for category 2 and 3 incidents, but the data makes clear that the steepest increases are in areas where hospitals have the biggest handover delay problems.
Of the 10 patches with the largest increases in average category 2 performance between 2018-19 and 2021-22, four are served by major hospitals which make up NHS England’s “cohort one” of trusts selected for the worst handover problems; and four more are on government’s list of 15 which accounted for the most long handover delays last winter. 
The increase in handover delays – in turn linked to delayed discharge, staffing, lack of community services and social care’s collapse – are the stand-out reason for areas with a steep rise in response times.
Read full story (paywalled)
Source: HSJ, 18 November 2022
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