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

‘Rubbish’ government Strep A comms blamed for flooding services

‘Rubbish’ communications on Group A Strep from government agencies made A&Es more ‘risky’ over the weekend, after services were flooded with the ‘worried well’, several senior provider sources have told HSJ.
On Friday the UK Health Security Agency, successor to Public Health England, issued a warning on a higher than usual number of cases after the deaths of five children under 10 in a week.
Several senior sources in hospital, 111/ambulance, urgent care and primary care providers, told HSJ they were not warned UKHSA were making an announcement that would also see services flooded by the worried well.
NHS England’s clinical lead for integrated urgent care issued a letter, seen by HSJ, saying a “considerable increase” in 111 demand over the weekend was “in part due to Group A Strep concerns”. Sources in the sector said the increase in demand was “heavily” Strep-related.
One senior accident and emergency leader told HSJ that when parents could not get through on 111 they brought their children to emergency departments. “The media messaging has been handled terribly”, they added.
They added: “Huge numbers of ‘worried well’ makes the A&E a much more dangerous place. We are just not equipped to deal with the volume of patients. [There is a] much greater chance we would miss one seriously unwell child when we are wading through a six-hour queue of viral, but otherwise well, kids.”
Read full story (paywalled)
Source: HSJ, 6 December 2022
Patient Safety Learning

More than 10,000 patients given faulty knee replacements

More than 10,000 patients have been given a faulty knee replacement which doubles the risk of joint failure, The Telegraph has disclosed.
The implant, which has been in use since 2003, was withdrawn from the market by its manufacturer in October.
The Telegraph has learnt that UK health regulator the Medicines and Healthcare products Regulatory Agency (MHRA) is now preparing to issue a field safety notice, prohibiting its use.
Available across multiple NHS trusts, the implant, manufactured by Zimmer Biomet, a US firm, has been shown to fail in up to 7% of patients after ten years - twice the accepted failure rate of 3.5% set by the National Joint Registry. 
One study found the failure rate to be much higher at 17.6% - more than five times as high as the accepted level.
This can have catastrophic consequences for patients, many of whom are elderly, as undergoing a second knee replacement operation poses a much greater risk. 
The knee replacement, called the Nexgen, is part of a family of Zimmer Biomet implant devices with 88 possible variants. In total, these have been given to over 183,000 people in England, Wales and Northern Ireland, and more than five million worldwide. Of these variants, three combinations have been proven to place patients at a dangerously high risk of joint failure.
Read full story (paywalled)
Source: The Telegraph, 5 December 2022
Patient Safety Learning

High cost of infant formula putting babies in danger, UK charities warn

Vulnerable parents may be forced to resort to unsafe practices to feed their babies because of sharp increase in the cost of infant formula, charities have warned.
The price of the cheapest brand of baby formula has leapt by 22%, according to analysis by the British Pregnancy Advisory Service (BPAS).
BPAS said the cost of infant formula needed to safely feed a baby in the first six months of their life was no longer covered by Healthy Start vouchers, which are worth £8.50 a week and provided to women in England, Wales and Northern Ireland who are pregnant or have young children.
The charity Feed said families that were unable to afford enough infant formula had resorted to watering down the product or feeding their babies unsuitable food such as porridge.
BPAS’s chief executive, Clare Murphy, said: “We know that families experiencing food poverty resort to unsafe feeding methods, such as stretching out time between feeds and watering down formula. The government cannot stand by as babies are placed at risk of malnutrition and serious illness due to the cost of living crisis and the soaring price of infant formula.
“The government must increase the value of Healthy Start vouchers to protect the health of the youngest and most vulnerable members of our society.”
Read full story
Source: The Guardian, 6 December 2022
Patient Safety Learning

Parents of man left to die in prison say care failures will haunt them for ever

The parents of a 25-year-old man left to die in a cell by a negligent prison nurse given responsibility for 800 inmates have told how the conditions in which their son died will haunt them for ever.
The case – the 27th death in just five years at HMP Nottingham – was said to illustrate the desperate state of Britain’s understaffed and increasingly dangerous prison system.
Alex Braund was being held on remand awaiting trial when he fell ill in his cell with the first signs of pneumonia on 6 March 2020.
Four days later, on the morning of 10 March, after a series of ill-fated attempts by Braund’s cellmate to get prison staff to take the situation seriously, the young man collapsed.
Prison staff responded to an emergency bell rung by Braund’s cellmate at 6.55am, but they initially only looked through the cell hatch, taking five minutes to enter the cell in order to give CPR.
Braund was subsequently taken to Queen’s medical centre in Nottingham, where he was pronounced dead at 11.44am of cardiac arrest caused by pneumonia.
The jury at an inquest at Nottinghamshire coroner’s court found there had been a “continuous failure to provide adequate healthcare”, with a prison officer told by a nurse a few hours before Braund’s death that there was “nothing to be done at this time of night”.
Questioning during the hearing revealed that the nurse, who has since lost her job and been reported to the nursing and midwifery council, had amended her records on the morning of Braund’s death.
Read full story
Source: The Guardian, 6 December 2022
Patient Safety Learning

Five million missed out on GP appointments in one month, says Labour

Five million people were unable to book a GP appointment in October, analysis of NHS data suggests.
The Labour party, which studied figures from the GP Patient Survey, warned the struggle to see a doctor will mean many patients will not have serious medical conditions diagnosed until it is “too late”.
According to the survey, some 13.8% of patients, or around one in seven, did not get an appointment the last time they tried to book one.
With almost 32 million GP appointments reported in England in October, the party said it means that more than 5 million people could have been unable to book a GP appointment when they tried to make one that month.
October saw GP surgeries carry out the highest number of appointments since records began in 2017, despite a depleted work force.
Labour’s shadow health secretary Wes Streeting told Labour List: “Patients are finding it impossible to get a GP appointment when they need one. I’m really worried that among those millions of patients unable to get an appointment, there could be serious conditions going undiagnosed until it’s too late". 
Professor Kamila Hawthorne, chair of the Royal College of General Practitioners, said in a statement: “GPs and their teams are working flat out to deliver the care and services our patients need. GPs want our patients to receive timely and appropriate care, and we share their frustrations when this isn’t happening. But difficulties accessing our services isn’t the fault of GP teams, it’s a consequence of an under-resourced, underfunded, and understaffed service working under unsustainable pressures.”
Read full story
Source: The Independent, 6 December 2022
Patient Safety Learning

Coroner calls for UK anaphylaxis register after Pret a Manger deaths

The families of two Pret a Manger customers who died after experiencing severe allergic reactions have welcomed a report from a senior coroner suggesting hospitals should be obliged to report fatal and near-fatal anaphylaxis.
Maria Voisin, the senior coroner for Avon, said a robust system of capturing and recording serious cases of anaphylaxis could provide an early warning of the risk posed to allergic individual byproducts with an undeclared allergen content.
She said the system could involve mandatory reporting by hospitals to local health protection officials of anaphylaxis similar to the current system for notifiable diseases.
Voisin sent her recommendations in a prevention of future deaths report to bodies including the UK health department and the Food Standards Agency (FSA) after the case of Celia Marsh, a Wiltshire dental nurse with a severe dairy allergy who died after eating a “vegan” Pret a Manger wrap contaminated with milk protein.
Marsh’s family said: “We welcome the prevention of future deaths report as the next step in our fight to make the world a safe place for allergy sufferers like our beloved mum and wife.
“Above all, we hope that the FSA, UK Health Security Agency and the Department of Health and Social Care will now start working together to put in place a system for mandatory reporting of fatal and near-fatal anaphylactic reactions to allow the public to be alerted of unsafe allergen products and provide an accurate record of such incidents. This will ensure important lessons can be learned with the appropriate enforcement action being taken.”
Tanya Ednan-Laperouse, whose 15-year-old daughter, Natasha, died in 2016 after eating a Pret baguette containing sesame seeds, said: “The coroner’s clear and concise recommendations should herald a transformation of the way anaphylaxis cases are dealt with in this country and mean that Celia’s death was not in vain.
Read full story
Source: The Guardian 5 December 2022
Other hub posts you may be interested in:
Why allergies are the Cinderella service of the NHS – a blog by Tim McLachlan AllergyWise: Free course for parents and carers of children with severe allergies
Patient Safety Learning

Antibiotics could be given to children at schools affected by Strep A infections, schools minister Nick Gibb says

Antibiotics could be given to children at schools affected by Strep A to stop the spread of the infection, schools minister Nick Gibb has said.
Mr Gibb told Sky News that the UK Health and Security Agency (UKHSA) is "working closely with the schools involved and giving very specific advice to those schools which may involve the use of penicillin".
He added that health officials will "have more to say about that".
"They're providing more general advice to parents, which is to look out for the symptoms - so, sore throat, fever, high temperature and also a red or raised rash on the skin are symptoms of this invasive Strep A outbreak."
His comments came after the ninth death of a child from the infection.
Read full story
Source: Sky News, 6 December 2022
Patient Safety Learning

Prolific surgeon ‘harmed more than 100 patients’

A consultant orthopaedic surgeon who carried out double the average number of knee and hip operations over a three year-period is facing a tribunal over alleged misconduct and more than 100 legal cases lodged by former patients, HSJ has been told.
Jeremy Parker, who performed hundreds of operations at Colchester Hospital and the private Oaks Hospital until his suspension in 2019, is currently appearing before a misconduct hearing.
The tribunal is investigating allegations that between August 2015 and November 2018, Mr Parker failed to provide good clinical care to six patients. It has also been alleged that Mr Parker performed surgery in breach of restrictions on his clinical practice between October 2018 and January 2019 and that his actions were dishonest.
The trauma and orthopaedic surgeon is also facing allegations that he added pre-typed operation notes to approximately 14 patients’ records ahead of an invited review into his clinical practice by the Royal College of Surgeons, without indicating they had been made retrospectively.
Read full story (paywalled)
Source: HSJ, 5 December 2022
 
Patient Safety Learning

Special measures label ‘hurts people’, says trust CEO

The ‘special measures’ label unquestionably hurts staff morale, according to the chief executive of a trust that is hoping to move out of the highest level of oversight for the first time in five years.
Peter Reading, CEO of Northern Lincolnshire and Goole Foundation trust, told HSJ that targeted support from NHS England had brought “strong benefits” but said: “The label of special measures is one that hurts people, and so we are very keen to shed that label. I think I speak on behalf of all of our staff in that respect.
“It doesn’t help morale and there’s no question about it, if you give people a bad name, even when they’re actually delivering generally very good care, and they’re working their socks off, and the label does not help.”
Read full story
Source: HSJ, 5 December 2022
Patient Safety Learning

Overcrowding at Forth Valley Royal Infirmary ‘risked harming patients’

NHS managers will be held accountable for failings at an overcrowded hospital where patients were put at risk of “serious harm” and some were left waiting up to 25 hours for a bed, ministers have warned.
Forth Valley Royal Infirmary’s A&E was operating at two and a half times capacity during a visit by Healthcare Improvement Scotland (HIS) in September. Inspectors said that patients were at risk because of poor handling of medicines and unsafe working conditions at the hospital, which was placed in special measures by the Scottish government last month.
The Times reported last month that the hospital had been declared “unsafe” by staff after five consultants resigned following severe criticism of the hospital’s leadership. They described it as a “war zone” and told of fire-fighting to cope with patient numbers while working in a “toxic” environment.
Read full story (paywalled)
Source: The Times, 6 December 2022
Patient Safety Learning

More diagnostic hubs to tackle NHS waiting lists in England

The government is setting up 19 more diagnostic centres in communities across England to help tackle the Covid backlog.
Ninety one are already open and have delivered more than 2.4 million tests, checks and scans since last summer, ministers say.
It is hoped the centres will speed up access to services for patients, thereby reducing waiting times.
Seven million people in England are now waiting for hospital treatment.
GPs can refer patients to community diagnostic centres so that they can access life-saving checks and scans, and be diagnosed for a range of conditions, without travelling to hospital.
Some are located in football stadiums and shopping centres and can offer MRI and CT scans, as well as x-rays.
In September, according to the government, the hubs delivered 11% of all diagnostic activity - and its ambition is for 40% to be achieved by 2025.
Read full story
Source: BBC News, 7 December 2022
Sam

Ambulance staff to strike on 21 December

Ambulance staff across most of England and Wales will go on strike on 21 December in a dispute over pay.
The coordinated walkout by the three main ambulance unions - Unison, GMB and Unite - will affect non-life threatening calls only.
But it could mean people who have had trips and falls not being responded to.
Members of GMB, which represents nearly a third of the 50,000-strong workforce, will then follow that up with another walkout on 28 December.
It comes as Royal College of Nursing members are also preparing to go on strike on 15 and 20 December in parts of England, Wales and Northern Ireland.
The walkouts will involve paramedics as well as control room staff and support workers, with the military on standby to help out.
The only service which will be completely unaffected, however, is the East of England.
Under trade union rules, life-preserving care has to be provided so the two highest category calls - covering everything from heart attacks and strokes to major trauma - will still be responded to.
But Matthew Taylor, of the NHS Confederation, which represents health managers, said he was worried the action would "undoubtedly" affect patient care and how quickly ambulance services could respond and may even deter people from seeking help.
"The prospect of industrial action over Christmas is very concerning," he added.
Read full story
Source: BBC News, 6 December 2022
Patient Safety Learning

US putting on a full-court press to secure support for hospitals and patients

As the US Congress convenes, the American Hospital Association are turning up the pressure to secure additional support for hospitals and the patients and communities they serve.
Specifically, they are asking Congress to:
Prevent any further damaging cuts to health programmes, including stopping the forthcoming 4% Statutory Pay-As-You-Go (PAYGO) sequester. Establish a temporary per diem payment targeted to hospitals to address the issue of hospitals not being able to discharge patients to post-acute care or behavioural facilities because of staffing shortages. Increase the number of Medicare-funded graduate medical education positions to address the workforce need for additional physicians in the USA. Extend or make permanent the Low-volume Adjustment and the Medicare-dependent Hospital programmes — critical rural programmes that are due to expire on 16 December. Make permanent the expansion of telehealth services and extend the hospital-at-home programme. Finalize Senate passage of the Improving Seniors’ Timely Access to Care Act, which streamlines prior authorisation requirements under Medicare Advantage plans. Create a special statutory designation for certain hospitals that serve marginalised urban communities. Read full story
Source: American Hospital Association, 2 December 2022
Patient Safety Learning

Scarlet fever cases rise tenfold as parents struggle to find Strep A antibiotics

Scarlet fever cases have surged by tenfold in a year, official data shows, as pharmacists grapple with a shortage of antibiotics during a Strep A outbreak. Strep A bacteria usually only causes mild illness, including scarlet fever and strep throat, which is treated with antibiotics. But in rare cases, it can progress into a potentially life-threatening disease if it gets into the bloodstream.
Infections are higher than normal for this time of year, and at least nine children have died after contracting the bacteria in recent weeks. Pharmacists say they are struggling to get their hands on antibiotics to treat Strep A infections – despite the government insisting there is no shortage.
“We are worried because we are having to turn patients away,” said Dr Leyla Hannbeck, the head of the Association of Multiple Pharmacies (AIMP).
Read more
Source: The Independent, 8 December 2022
Patient-Safety-Learning

NHSE cuts £1bn from cancer, maternity and primary care funds

NHS England is raiding a national fund earmarked for improvements in cancer, maternity care and other priority services by up to £1bn this year, to pay for deficits elsewhere, and will cut it by a similar amount in 2023-24, HSJ has learned.
The “service development fund” is allocated at the beginning of the year for priority service areas also including primary care, community health, mental health, learning disabilities and health inequalities.
Several NHSE directors said it was being tightly squeezed this year, amid major cost pressures from inflation, a pay deal unfunded by government, and higher than expected covid-related costs.
One well-placed source said the fund this year was required to underspend by about £1bn against what had been planned, which will help balance overspends elsewhere in the NHS. 
The cuts are likely to be linked to ministers’ view that the NHS should focus on “core” priorities and cut other activities, including reducing NHSE national programme work which is typically linked to SDF budgets.  Patricia Hewitt is looking into giving integrated care systems more “autonomy” from NHSE to set their own priorities. 
Read full story (paywalled)
Source: HSJ, 8 December 2022
Patient Safety Learning

400 excess deaths due to pulmonary embolism misdiagnoses, concludes independent investigation

Press release: London, UK, 8 December 2022
A new report published today has highlighted serious safety concerns relating to the misdiagnosis of pulmonary embolisms.[1] It states that there was a minimum of 400 deaths attributable to pulmonary embolism misdiagnosis from March 2021 to April 2022 in England and Wales, with deaths in some regions almost three times the national average.
This research has been carried out by Tim Edwards, an expert in risk management, and published by the charity Patient Safety Learning. Tim started this review following the premature death of his mother, Jenny Edwards, from a pulmonary embolism. He was concerned about the low quality of the investigation which took place following her death and the lack of assurance he received that any learning would be taken from this event.
The report highlights clear safety issues in relation to staff, training, and equipment. Concerns around resource gaps have also been expressed by the Royal College of Radiologists and its members.[2] The report also highlights evidence that the NHS is not applying pulmonary embolism guidance considered best practice in comparable European countries and sets out nine calls for action to improve pulmonary embolism care. Tim’s concerns were also highlighted in a House of Commons debate led by Halen Hayes, MP for Dulwich and West Norwood, on the 30 November 2022.[3]
Commenting on the report, Tim Edwards said:
"My research found that there are hundreds of people who, like my mother Jenny, died from pulmonary embolism following misdiagnosis. It is vital we learn from these deaths, and the errors that have occurred, so we can take action to improve pulmonary embolism care. By publishing this report, I hope to start a dialogue that leads to positive change, so others do not suffer the loss of a loved one as we have."
Helen Hughes, Chief Executive of Patient Safety Learning said:
“This new report highlights serious patient safety concerns relating to the diagnosis of pulmonary embolisms. Urgent action is now needed to ensure that guidelines and diagnostic processes are up to date and that clinicians have the resources they need to deliver safe and effective care. It is also vital that we increase awareness of the key symptoms of pulmonary embolisms among both healthcare professionals and the wider public. Patient Safety Learning are proud to be supporting Tim and his campaign for improvement in pulmonary embolism care and to reduce avoidable deaths.”
Notes to editors:
1. Independent Review of pulmonary embolism fatalities in England and Wales: Recent trends, excess deaths, their causes and risk of management concerns.
2. The Royal College of Radiologists report that 41% of clinical radiologists do not have the equipment they need, and that the UK has fewer scanners than most comparable OECD countries - 8.8 per million of population in the UK compared to 18.2 in France and 35.1 in Germany. They also raise that there is a high vacancy rate of clinical radiologists, 8%, with over 50% of vacancies unfilled for over a year. Data extracted from The Royal College of Radiologists. Clinical Radiology UK Workforce Census 2021 report. London: The Royal College of Radiologists, 2022.
3. Helen Hayes, MP for Dulwich and West Norwood, led an Adjournment Debate in the House of Commons on Wednesday 30 November 2022 highlighting patient safety concerns relating to the diagnosis of pulmonary embolisms. This was formally responded to by Helen Whately MP, Minister for Social Care at the Department of Health and Social Care. The full transcript can be found here.
4. Patient Safety Learning is a charity and independent voice for improving patient safety. We harness the knowledge, enthusiasm and commitment of healthcare organisations, professionals and patients for system-wide change and the reduction of harm. We support safety improvement through policy, influencing and campaigning and the development of ‘how to’ resources such as the hub, our free award-winning platform to share learning for patient safety.
Patient Safety Learning
Registered address: Patient Safety Learning, China Works SB203, 100 Black Prince Road Vauxhall, London, SE1 7SJ

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