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

'A&E is absolute chaos - I spent 15 hours on a trolley'

Lying on a trolley in a hospital corridor in pain from a broken hip, Anne Whitfield-Ray could not believe she was in the care of the NHS.
"It was absolute chaos - like something out of a third world country," said the 77-year-old from Worcestershire.
"The staff were rushed off their feet, paint was peeling off the walls and patients were being squeezed in everywhere they could - in makeshift bays, in corridors and side rooms. It was horrific."
Anne spent 15 hours in that position until a bed could be found for her.
Such delays used to be the exception, something that happened on the odd occasion in the depths of winter.
Now they are commonplace. Latest figures show nearly 40% of A&E patients who need admitting face what is called a trolley wait - a delay of four hours or more waiting for a bed to be found.
These are the sickest and frailest patients - the ones who cannot be sent home immediately after treatment. Research has linked delays like this with longer hospital stays and even a higher risk of death.
By the time patients get to this point, they may have already faced hours of waiting in A&E or, increasingly, stuck outside A&E in the back of an ambulance, as was the case for Anne.
She is now back home recovering after surgery, a few days after her fall in October.
She said that despite her experience she cannot fault the staff: "They are doing the best they can. But this is not what should be happening in the NHS".
Read full story
Source: BBC News, 8 December 2022
Patient Safety Learning

Private hospitals could ease NHS backlog

Patients will be encouraged to choose private hospitals for NHS care under plans to help clear backlogs of routine operations through outsourcing more treatment.
A task force of private healthcare bosses and NHS chiefs met in Downing Street for the first time yesterday in an effort to find more capacity for hip replacements, cataracts and other routine procedures in the independent sector. NHS bosses are hopeful of meeting a target to eliminate waits of more than 18 months by April, but there is increasing concern in government about whether one-year waits can be eliminated by 2025 as planned.
Private hospitals say they have spare capacity that could help bring down waits but NHS bosses have been sceptical. Patients have long had a legal right to choose where they are treated but ministers are planning a fresh push for GPs to offer them the choice of having NHS treatment in private hospitals, in a revival of a Blair-era scheme.
Steve Barclay, the health secretary, said he wanted to “turbocharge our current plans to bust the backlog and help patients get the treatment they need”.
Read full story (paywalled)
Source: The Times, 8 December 2022
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Clinicians who raised patient safety risks claim Berkshire NHS trust deleted email evidence

Two clinicians who say they lost their jobs at Berkshire Healthcare NHS Foundation Trust after raising patient safety concerns claim the trust’s legal team brought a five-figure costs threat against them to prevent witnesses from giving evidence in a tribunal.
The threat of costs liability, intended to bring the case to a halt, was made halfway through the hearing – less than 48 hours before witnesses for the trust were due to give evidence.
One of the claims put forward at the tribunal hearing was that the trust had destroyed crucial evidence by deleting the email account of a former staff member.
The clinicians – Samir Lalitcumar and Ahmed Ghedri – brought allegations of poor practice against current and former staff at the trust. Berkshire NHS trust claimed their allegations, including claims that the trust had deleted email evidence, were “without merit”.
A fortnight into the tribunal hearing, both out-of-work medics were threatened with costs liability, known as a “drop-hands offer”, totalling more than £300,000, had they opted to proceed with their case and lost.
Lalitcumar and Ghedri had brought claims of whistleblowing detriment against their former employer, Berkshire Healthcare Trust. They say they were “victimised” and unfairly dismissed as a result of having blown the whistle on dangerous care within the trust’s geriatrics services – potentially affecting upwards of 2,000 patients.
Read full story
Source: Computer Weekly, 7 December 2022
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GPs say parents need clearer strep A advice

GP leaders have urged the government to put out clearer advice for parents about when to seek help over potential strep A infections.
Prof Kamila Hawthorne, of the Royal College of GPs, said many surgeries were struggling with the extra demand on top of existing pressures.
The government should consider "overspill" services for surgeries unable to cope, she said.
Since September, 15 UK children have died after invasive strep A infections.
This includes the death of one child in Wales, and one in Northern Ireland. There have been no deaths confirmed in Scotland.
The UK Health Security Agency figures (UKHSA) show there have also been 47 deaths from strep A in adults in England.
Most strep A infections are mild, but more severe invasive cases - while still rare - are rising.
Prof Hawthorne, said: "We do not want to discourage patients who are worried about their children to seek medical attention, particularly given the current circumstances.
"But we do want to see good public health messaging across the UK, making it clear to parents when they should seek help and the different care options available to them - as well as when they don't need to seek medical attention."
Read full story
Source: BBC News, 8 December 2022
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Nurses bitten and screens smashed - life in A&E

Busy, noisy, highly stressful - and sometimes violent. This is the reality of A&E as the NHS gears up for what will be an incredibly difficult winter.
That much is clear from the experience of staff and patients at Royal Berkshire Hospital's emergency department.
Like all units, it is struggling to see patients quickly - more than a third of patients wait more than four hours.
The stress and frustration means tempers can easily boil over.
Receptionist Tahj Chrichlow says it can get so busy patients end up "packed like sardines".
"Sometimes people can be not as nice to us as we like," he adds, explaining how earlier this week the window of the reception office had been smashed by one angry person.
The Royal College of Emergency Medicine is warning delays are putting patients at risk.
Vice president Dr Ian Higginson says hospitals are "full to bursting".
"When our hospitals are full, we can't get patients out of our emergency departments.
"That means emergency departments become overcrowded and we see patients waiting for long periods on uncomfortable trollies in corridors or other rubbish places."
Dr Higginson says his colleagues are "very worried" and unable to deliver the care they would like to give to patients.
Read full story
Source: BBC News, 8 December 2022
 
Patient Safety Learning

Stubborn cancer backlog at record high

The number of people waiting more than two months to start cancer treatment remained over 30,000 — double the pre-covid level — for three months to the end of October, according to new data published.
NHS England previously committed to bringing the number of people waiting longer than 62 days to be diagnosed and begin treatment, after referral for suspected cancer, to pre-pandemic levels – roughly 14,000 – by March 2023.
But the number has been generally growing since the spring, and remained above 30,000 from August through to the end of October, the latest figures available. September and October’s monthly totals were higher than the previous monthly peak in May 2020, after services were disrupted in the first covid wave.
The increase in waiters this year has been caused by diagnostic and treatment capacity falling short of an increased number of referrals. 
Matt Sample, policy development manager at Cancer Research UK, said: “While it’s good to see significant numbers of people coming forward with potential cancer symptoms, performance against key targets are among the worst on record, continuing a trend that existed long before the pandemic hit, with one target having been missed for almost seven years.”
Read full story (paywalled)
Source: HSJ, 8 December 2022
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Our job is to keep people out of A&E

As the pressures of winter and the Covid treatment backlog grow, the NHS is struggling. In Manchester, one organisation is pioneering a new way to care for people that tries to reduce the burden on the health service.
It's the first call-out of the day for nurse Manju and pharmacist Kara in north Manchester. They are on their way to see Steven, who has been diagnosed with Parkinson's disease and had a fall the previous night.
This might have led to a call-out for an ambulance crew and a visit to A&E. But instead the Manchester Local Care Organisation (LCO) stepped in.
Once at Steven's house, Manju makes sure he hasn't been harmed by his fall, while Kara checks his medication.
Manju notes that Steven's tablets could have contributed to his fall.
Manju asks Steven how he copes going up and down the stairs.
"I'm OK, just about," he says. But when he has a go at coming down the stairs, Manju spots he could use an extra grab rail and says she will sort one out.
This intervention by the team has not only avoided Steven ending up in A&E, but also ensures he can continue to live independently in his own home.
That's a key part of the LCO mission, according to Lana McEwan, one of the team leaders in north Manchester.
"We would consider ourselves to be an admission-avoidance service, so we're trying to prevent ambulances being called in the first instance.
"When an ambulance has been called, we're taking referrals directly from the ambulance service and responding within a one or two-hour response depending on need, and that's an alternative to A&E."
Local neighbourhood teams are made up of nurses, social workers, pharmacists and doctors, all working together to keep people out of hospital.
Read full story
Source: BBC News, 9 December 2022
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Racism poses public health threat to millions worldwide, finds report

Racism is a “profound” and “insidious” driver of health inequalities worldwide and poses a public health threat to millions of people, according to a global review.
Racism, xenophobia and discrimination are “fundamental influences” on health globally but have been overlooked by health researchers, policymakers and practitioners, the series published in the Lancet suggests.
Inaccurate and unfounded assumptions about genetic differences between races also continue to shape health outcomes through research, policy and practice, the review of evidence and studies found.
“Racism and xenophobia exist in every modern society and have profound effects on the health of disadvantaged people,” said the lead author, Prof Delan Devakumar of University College London.
“Until racism and xenophobia are universally recognised as significant drivers of determinants of health, the root causes of discrimination will remain in the shadows and continue to cause and exacerbate health inequities.”
Read full story
Source: The Guardian, 8 December 2022
Patient Safety Learning

USA: House Bill establishes Federal Agency dedicated to patient safety

Nanette Barragán, US representative for California’s 44th Congressional District, has announced the introduction of new legislation intended to establish a National Patient Safety Board (NPSB) as a non-punitive, collaborative, independent agency to address safety in healthcare. This landmark legislation is a critical step to improve safety for patients and healthcare providers by coordinating existing efforts within a single independent agency solely focused on addressing safety in health care through data-driven solutions.
Prior to the COVID-19 pandemic, medical error was the third leading cause of death in the United States, with conservative estimates of more than 250,000 patients dying annually from preventable medical harm and costs of more than $17 billion to the U.S. healthcare system. Recent data from the Centers for Medicare and Medicaid Services and Centers for Disease Control and Prevention indicate that patient safety worsened during the pandemic.
The NPSB’s solutions would focus on problems like medication errors, wrong-site surgeries, hospital-acquired infections, errors in pathology labs, and issues in transition from acute to long-term care. By leveraging interdisciplinary teams of researchers and new technology, including automated systems with AI algorithms, the NPSB’s solutions would help relieve the burden of data collection at the frontline, while also detecting precursors to harm.
A coalition of leaders in health care, technology, business, academia, and other industries has united to call for the establishment of an NPSB. 
“We have seen many valiant efforts to reduce the problem of preventable medical error, but most of these have relied on the frontline workforce to do the work or take extraordinary precautions,” said Karen Wolk Feinstein, PhD, president and CEO of the Pittsburgh Regional Health Initiative and spokesperson for the NPSB Advocacy Coalition. “The pandemic has now made things worse as weary, frustrated, and stressed nurses, doctors, and technicians leave clinical care, resulting in a cycle where harm becomes more prevalent. Many organizations have united to advance a national home for patient safety to promote substantive solutions, including those that deploy modern technologies to make safety as autonomous as possible.”
Read full story
Source: Business Wire, 8 December 2022
Patient Safety Learning

Three investigations launched into trust beset by bullying and safety scandals

Three “major” reviews are being launched into a struggling teaching trust in response to growing concerns over bullying and poor workplace culture.
Birmingham and Solihull integrated care board has begun a series of investigations into University Hospitals Birmingham, whose chief executive announced he was standing down last month.
The first review will get under way immediately and will focus on specific allegations made recently on BBC Newsnight. These include patient safety concerns, the “bullying” of clinicians and the issues raised by a review of 12 patient deaths undertaken by former consultant Dr Manos Nikolousis in 2017.
It will be led by an “experienced senior independent clinician” from outside the local health system who is expected to report by the end of January. 
The second and third investigations will review the trust’s leadership and broader cultural issues respectively. The probes will be carried out with UHB and NHS England. Both are expected to report in the first half of 2023. 
Read full story (paywalled)
Source: HSJ, 9 December 2022
 
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Hospital apologises after hiding surgeon's error for seven years

A hospital trust has apologised to a woman for failing to admit a surgeon had been responsible for a massive haemorrhage that almost killed her after a Caesarean section.
For seven years, East Kent Hospitals Trust maintained the size of Louise Dempster's baby was to blame.
"It was just continuous lies," the 34-year-old told BBC News.
East Kent Hospitals chief executive Tracy Fletcher promised "to ensure lessons are learned".
Louise Dempster gave birth in May 2015 but the surgeon's error only emerged during an inquiry into poor maternity care at East Kent Hospitals Trust which reported this year.
Read full story
Source: BBC News, 9 December 2022
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Over 1000 'adverse events' in women and infants' care in Scotland

More than 1000 investigations have been launched in Scotland over the past decade into adverse events affecting women and infants' healthcare.
Figures obtained by the Herald show that at least 1,032 Significant Adverse Event Reviews (Saers) have been initiated by health boards since 2012 following "near misses" or instances of unexpected harm or death in relation to obstetrics, maternity, gynaecology or neonatal services.
The true figure will be higher as two health boards - Grampian and Orkney - have yet to respond to the freedom of information request, and a number of health boards reported the totals per year as "less than five" to protect patient confidentiality.
Saers are internal health board investigations which are carried out following events that could have, or did, result in major harm or death for a patient.
Major harm is generally classified as long-term disability or where medical intervention was required to save the patient's life. They are intended as learning exercises to establish what went wrong and whether it could have been avoided. Not all Saers find fault with the patient's care, but the objective is to improve safety.
NHS Lanarkshire was only able to provide data from April 2015 onwards, but this revealed a total of 194 Saers - of which 102 related to neonatal or maternity services, and 80 for obstetrics.
A Fatal Accident Inquiry involving NHS Lanarkshire has already been ordered into the deaths of three infants - Leo Lamont and Ellie McCormick in 2019, and Mirabelle Bosch in 2021 - because they had died in "circumstances giving rise to serious public concern".
Read full story (paywalled)
Source: The Herald, 10 December 2022
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Hospitals in England pay £5,200 for one agency doctor's shift

Hospitals in England have paid out as much as £5,200 for a shift by a doctor through an agency, according to figures obtained by Labour through Freedom of Information requests.
That is the latest in an intensifying debate over workforce shortages in the NHS in England.
Labour blamed the high agency fees on Conservatives, arguing they had failed to train enough doctors and nurses. A Conservative spokesperson said "record numbers" had been recruited.
The most expensive reported shift was £5,234 - paid by a trust in northern England. This covers the agency fee and other employer costs as well as the money going to the doctor.
The NHS Confederation said the "staffing crisis" was so "desperate" that NHS trusts were being forced to pay large fees to make sure rotas were "staffed safely".
Matthew Taylor, chief executive of the NHS Confederation, said: "Trusts are having to breach the caps on how much they pay for agency doctors because of the extremely high levels of demand they are facing for their services.
"The staffing crisis is so desperate that they either pay these fees or find that their rotas cannot be staffed safely, leading to reduced services for patients. This is particularly true in parts of the country where the NHS can struggle to recruit new staff."
Read full story
Source: BBC News, 12 December 2022
Patient Safety Learning

Six NHS workers reported ‘every week’ for sexually harassing patient or colleague

Six NHS staff workers are typically reported every week in England for sexually harassing a patient or colleague, the Telegraph can reveal.
Nearly a fifth of English trusts have recorded a rise in reports of sexual harassment within their services since 2017, while millions have been spent by the NHS on legal claims specific to sexual abuse over the same time period, according to newly obtained data.
Health secretary Steve Barclay described the findings as “worrying” and urged NHS leaders to take “robust action in response to any such incidents in their organisation”.
Patient Safety Learning said the Telegraph's “deeply troubling” revelations demonstrated an abuse of the “significant power imbalance” that exists between vulnerable patients and their care providers.
“Healthcare professionals need to recognise the power they hold over patients,” said chief executive Helen Hughes. “Inappropriate behaviours undermine trust in healthcare system and the ability to deliver safe care.”
“Clinicians, managers and healthcare leaders have both a professional and moral responsibility to patients to ensure that there is a safe culture in healthcare settings and that misconduct is not tolerated," said Ms Hughes.
As part of its investigation into sexual harassment within the NHS, the Telegraph uncovered the case of a mentally incapacitated patient who was raped by her healthcare worker and subsequently fell pregnant. The healthcare worker, who is in his 30s, was recently jailed for eight months after pleading guilty to sexual activity with a mentally disordered female. 
Joe Matchett, an expert lawyer at Irwin Mitchell who has secured settlements for survivors of abuse, said his firm continues to “represent a number of patients subjected to terrible abuse at the hands of hospital staff who have betrayed their position of trust in the worst imaginable way”.
Read full story (paywalled)
Source: The Telegraph, 11 December 2022
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Strep A home-test kits sell out after spate of UK deaths sparks panic buying

Strep A home-testing kits have sold out online as parents rush to find ways to diagnose their children’s rashes and high temperatures.
The panic-buying follows the deaths of at least 16 children from invasive strep A infections in the UK.
As infections and deaths from strep A have risen over the past few weeks, parents have turned to tests that involve a long cotton swab that is lightly passed over the back of the throat. Solutions and a strip test are then used to display results.
These tests are now being sold online for more than £100, while some retailers have reported selling out after demand soared over the past few days. Other suppliers have warned customers that they will not be able to get hold of a test until after Christmas. One online retailer told customers that they would not be able to get the products until mid-January. Others said they were awaiting deliveries but “there may be delays beyond our control”.
Strep A tests are not sold in England through the NHS because the National Institute for Health and Care Excellence (NICE) – which approves and advises on clinical care – has said their accuracy is uncertain and likely to be “highly variable”. Scotland has not approved them either, though in Wales people can buy them over the counter for £7.50.
“We’re not advising using those [tests] for the time being,” Professor Kamila Hawthorne, chair of the Royal College of GPs, said on Friday. “It is a clinical diagnosis. It is not too difficult to make. So long as the parent watches their child and brings their child in, then we are more than happy to see them.”
Read full story
Source: The Guardian, 11 December 2022
Patient Safety Learning

Mental health patients left in dilapidated wards amid £677m repairs backlog

Dilapidated mental health facilities across the country are in need of £677m worth of repairs to fix sewerage issues, collapsing roofs and wards that deprive patients of their dignity, The Independent has been told.
An NHS analysis of the government’s flagship programme to build 40 hospitals, seen by The Independent, shows ministers have failed in their promise of “parity” for mental health services as issues are not addressed.
NHS trust and psychiatry leaders warned that the out-of-date buildings are putting patients at risk and urged the government to include six mental health hospitals within its next round of improvements.
Data analysis by the Royal College of Psychiatrists, shared with The Independent, found that the cost of fixing “high and significant” risks in mental health and learning disability hospitals has rocketed from £92m in 2019-20 to £186m in 2021-22 – far higher than the 16 per cent increase in costs seen in acute hospitals. These are risks that must be fixed to avoid “catastrophic” failure or safety problems that could result in serious injury.
Saffron Cordery, interim chief executive at NHS Providers, said patients and staff are at risk because so many buildings aren’t fit for purpose, and warned that things will get worse until mental health trusts get the capital funding they need.
Read full story
Source: The Independent, 11 December 2022
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