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

Victims and families call for prosecutions as contaminated blood inquiry nears end

Victims and family members affected by the contaminated blood scandal are calling for criminal charges to be considered as the public inquiry into the tragedy draws to a close.
While the inquiry, which will begin to hear closing submissions on Tuesday, cannot determine civil or criminal liability, people affected by the scandal are keen for the mass of documents and evidence accumulated over more than four years to be handed over to prosecutors to see whether charges can be brought.
About 3,000 people are believed to have died and thousands more were infected in what has been described as the biggest treatment disaster in the history of the NHS. The inquiry has heard evidence that civil servants, the government and senior doctors knew of the problem long before action was taken to address it and that the scandal was avoidable. But no one has ever faced prosecution.
Eileen Burkert, whose father, Edward, died aged 54 in 1992 after – like thousands of others – contracting HIV and hepatitis C through factor VIII blood products used to treat his haemophilia, said the inquiry had shown there was a “massive cover-up”.
She said: “In my eyes it’s corporate manslaughter. You can’t go giving people something that you know is dangerous, and they just carried on doing it. As far as my family’s concerned, they killed our dad and they killed thousands of other people and there’s been no recognition for him since he died, there’s been nothing.
Read full story
Source: The Guardian, 16 January 2023
See UK Infected Blood Inquiry website for further details on the inquiry.
Patient Safety Learning

MP says NHS ‘shambles’ is fault of ‘utterly useless senior managers’

A Conservative MP has blamed “far too many overpaid and utterly useless senior managers” for what he described as the “shambles of the NHS.”
Philip Davies, MP for Shipley in Yorkshire, said in an email that the NHS is “appallingly run”, with many senior managers “who wouldn’t be able to get a similar job in the private sector.”
He claimed the NHS “shambles” “is not a problem created by the government,” as “the government’s job is to fund that NHS,” while running the services is done by NHS England and individual trusts.
However, recent analysis indicates that managers make up just 2 per cent of the NHS workforce, compared with 9.5 per cent of the UK workforce. NHS Confederation has said the NHS is “as a whole under, not over, managed,” despite “persistent and misleading media headlines.”
Read full story (paywalled)
Source: HSJ, 16 January 2023
Patient-Safety-Learning

A&E nurse: Most challenging I've seen in 30 years

There are 10 patients in the corridor and the nurses are about to go out to assess two more waiting in an ambulance outside.
The senior sister, Susan Beswick, who has worked in the hectic and often stressful world of NHS accident and emergency for 30 years, says she has never seen anything like it.
"The last six to 12 months have been more challenging than I have ever known," she says.
"We have been exceptionally busy for quite a number of weeks now. We're running two to three times above our capacity continually and often more than that."
Susan's whole nursing career has been at Royal Bolton Hospital, which, like many in the country, is facing overwhelming demand from a growing as well as ageing population and has out-of-date buildings that are not fit for purpose.
A policy of cohorting, adopted by many hospitals, has been agreed between emergency-department staff and paramedics. One member of an ambulance team will be left to look after two or three patients in a corridor, allowing others to get back on the road more quickly.
The problem is space. There are simply too many patients coming in to be accommodated, even with all the streaming initiatives.
Read full story
Source: BBC News, 13 January 2023
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NHS ‘bed-blocking’ fuelled by 50 steps needed to discharge fit patients

Hospital staff have to complete 50 separate steps on average to discharge a patient, it has emerged, as the NHS grapples with a bed-blocking crisis.
On average, around 14,000 patients deemed fit to leave hospital are stuck in beds every day, according to the latest official figures. The congestion is helping to fuel the backlog in accident and emergency (A&E) departments, where more than 55,000 patients waited 12 hours or longer last month.
Steve Barclay, Health Secretary, announced an additional £250 million in funding last week to buy up care beds to help discharge thousands of patients.
But doctors, social care experts and families have warned discharges are being delayed by NHS “bureaucracy” and excessive form filling.
Dr Matt Kneale, co-chair of the Doctors’ Association UK and a junior doctor in Manchester, said patients are held up by “numerous bottlenecks” before being sent home.
“While social care shortages are the predominant issue, smaller factors stack up to create a big problem,” he told The Telegraph.
Many hospitals have limits on the times their pharmacies are open, he explained, meaning patients can often be stuck on the ward all day, or an extra night, waiting for their medication.
Read full story (paywalled)
Source: The Telegraph, 15 January 2023
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Wales coroner rules nurses’ Covid deaths as industrial disease

The deaths of two nurses from Covid-19 in the early days of the pandemic have been ruled as industrial disease.
Gareth Roberts, 65, of Aberdare, and Domingo David, 63, of Penarth, were found to have been most likely to have contracted the virus from colleagues or patients while working for hospitals under the Cardiff and Vale University Health Board.
The senior coroner Graeme Hughes concluded on Friday that although they were given appropriate personal protective equipment (PPE), Roberts and David were “exposed to Covid-19 infection at work, became infected and that infection caused” their deaths. He made a finding of industrial disease.
Roberts’ family had argued for a conclusion of industrial disease, while the health board had made the case for ruling that both deaths were from natural causes.
Unions are campaigning for Covid-19 to be considered an industrial disease by the UK government so workers affected by it would receive greater financial support.
Read full story
Source: The Guardian, 13 January 2023
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Surgical mesh: "I wish I could go back in time and not have my operation"

Complications after a procedure to treat IBS left Jennifer Hill in pain – and fighting for compensation.
Earlier this year, an NHS inquiry found surgeon Anthony Dixon had caused women to “suffer harm” as a result of the mesh operations he carried out between 2007 and 2017. Dixon, who is now banned from practising in the UK, carried out hundreds of laparoscopic ventral mesh rectopexy (LVMR) operations for both the North Bristol NHS Trust and privately at Bristol’s Spire Hospital. Mesh is used to repair the pelvic floor, but the inquiry concluded that women should have been offered alternative treatments first. 
Jennifer Hill, from Herefordshire, is one of those women. She wishes she could go back in time and not have her mesh operation, which took place in May 2012. “I was totally unaware of the controversy surrounding mesh,” she says. “I still kick myself that I didn’t get a second opinion or ask more questions.”
Read full story (paywalled)
Source: The Telegraph, 11 January 2023
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Child mortality from trauma and sudden death rising in England, study shows

Child mortality from trauma and sudden unexpected death increased last year, according to figures highlighting the stark impact of poverty on child health.
The analysis, which tracked all child deaths in England between 2019 and 2022, found overall mortality dipped during the pandemic due to a decrease in infectious illnesses, but that numbers of deaths have since returned to pre-pandemic levels. This included a 32% increase in trauma deaths and a 13% rise in sudden unexpected death in infancy or childhood (Sudic) last year compared with pre-pandemic rates.
Prof Karen Luyt, the programme lead for the National Child Mortality Database, based at the University of Bristol, said the figures could be “the first mortality signal” from families struggling with the cost of living crisis.
“This is worrying and I think we’re likely to see things getting worse,” she said. “Certainly for childhood illness and mortality, we know there’s a strong social gradient and we know that more families are now living in poverty.”
Sudic deaths are defined as being unexplained and unexpected at the point death is registered, but may be subsequently found to be due to cardiac arrest after infection or an asthma attack, for instance. It is a broader category than sudden infant death syndrome (Sids), where the cause of death often remains a mystery even after postmortem examination.
Read full story
Source: The Guardian, 16 January 2023
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NHS trust declined care for vulnerable Black patient days before he died in police custody

An NHS trust declined to provide care for a vulnerable Black man days before he died in police custody while having a psychotic episode, The Independent has learnt.
Godrick Osei, 35, died after being restrained by up to seven Devon and Cornwall Police officers in the early hours of 3 July 2022, after fleeing his flat and hiding in the cupboard of a care home in Truro.
His family said he had been expressing “paranoid thoughts” and had called the police himself for help. He was arrested and died within an hour.
Mr Osei had been diagnosed with anxiety and depression, had suspected post-traumatic stress disorder (PTSD) and was prescribed various medications to treat these conditions. He also intermittently used illicit drugs and had suffered alleged sexual assault in prison around 2013, according to a medical report from North East London NHS Foundation Trust (NELFT).
In the days before his death, Mr Osei was in the care of NELFT’s community mental health team, whose caseworkers were concerned that he was exhibiting signs of a further severe illness – emotionally unstable personality disorder (EUPD) – and was a high risk to himself.
However, Mr Osei was based outside the team’s catchment area, and NELFT asked the neighbouring Cornwall Partnership NHS Foundation Trust (CPT) to assess him instead.
CPT refused without explaining why, according to a medical report seen by The Independent.
Following Mr Osei’s death, an investigating officer from NELFT made multiple attempts to contact CPT to explore the possibility of a joint investigation into the matter, but didn’t receive a response.
Read full story
Source: The Independent, 16 January 2023
Patient Safety Learning

Antidepressants ‘should be reduced in stages’ to avoid withdrawal symptoms

GPs whose patients want to stop taking antidepressants should reduce the dose of their medication in stages to lower the risk and severity of withdrawal symptoms, the medicines watchdog has said.
About one in six (16%) adult Britons experience moderate to severe depression, according to the Office for National Statistics. In England alone, 21.4m antidepressant drugs were prescribed between July and September 2022, according to the NHS Business Services Authority.
A new draft quality standard for the care of adults with depression from the National Institute for Health and Care Excellence (NICE) – the first update in 11 years – includes specific guidance to help adults come off antidepressant medication permanently.
NICE’s independent advisory committee, which includes experts in treating adults with depression, recommends the staged withdrawal of antidepressants in patients who want to stop taking the drugs.
A staggered reduction of medicine, known as tapering, helps to reduce withdrawal effects and long-term dependence on the medication, according to Nice.
The committee said primary care and mental health professionals should follow the NICE guideline recommendations on stopping antidepressant medication, including agreeing with their patient whether it is right for them to stop taking the medication and, if so, the speed and duration of withdrawal from it.
Read full story
Source: The Guardian, 17 January 2023
Patient Safety Learning

Transgender people lose NHS waiting times High Court case

A group of transgender people have lost their legal case against NHS England over waiting times to get seen by a gender specialist.
The two trans adults and two trans children had tried to get the wait times - more than four years in one of their cases - deemed illegal. But a High Court judge ruled on Monday the waiting times are lawful.
The Good Law Project - which helped to bring the legal action - said it would seek permission to appeal.
The four people brought the legal action against NHS England (NHSE) over the waiting time to get a first appointment with a gender dysphoria specialist.
The claimants argued that NHS England was failing to meet a duty to ensure 92% of patients referred for non-urgent care start treatment within 18 weeks.
They said the waiting times were discriminatory, arguing the delays faced by trans people were longer than for other types of NHS treatment.
But the judge dismissed the claim on several grounds.
Read full story
Source: BBC News, 16 January 2023
Patient Safety Learning

Nurses' strike: New dates as union escalates dispute

Two new nurses' strikes will be held on 6 and 7 February in England and Wales - unless there is movement on pay, the Royal College of Nursing says.
The walkouts will be the biggest so far, with more than a third of NHS trusts in England and all but one Welsh health board affected.
It comes as nurses prepare to walk out on Wednesday and Thursday, following the two strike days before Christmas.
As required under trade union laws, emergency care will be covered.
Most of the 73 NHS trusts involved in the new set of strike dates are hospitals.
It means the biggest disruption is likely to be in pre-booked treatment such as hernia repair, hip replacements or outpatient clinics.
Services such as chemotherapy, kidney dialysis and intensive care will be staffed, however, as part of the emergency cover.
Read full story
Source: BBC News, 16 January 2023
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BBC criticised for letting cardiologist ‘hijack’ interview with false Covid jab claim

The BBC has come under fire from scientists for interviewing a cardiologist who claimed certain Covid vaccines could be behind excess deaths from coronary artery disease.
Experts have criticised Dr Aseem Malhotra’s appearance on the BBC's news channel last Friday, accusing him of pushing “extreme fringe” views, which are “misguided”, “dangerous” and could mislead the public.
Scientists have described the doctor as “hijacking” an interview on statins to air his views, causing BBC staff to be “alarmed and embarrassed” by their booking. Malhotra recently retweeted a video by the MP Andrew Bridgen, who had the Tory whip removed on Wednesday after comparing the use of Covid vaccines to the Holocaust.
After criticising new guidance on statins, he cited British Heart Foundation (BHF) figures that suggested there had been more than 30,000 excess deaths linked to heart disease since Covid first arrived.
Malhotra, a cardiologist at ROC Private Clinic, claimed mRNA Covid vaccines play a role, saying his “own research” showed “Covid mRNA vaccines do carry a cardiovascular risk”. He added that he has called for the vaccine rollout to be suspended pending an inquiry because of the “uncertainty” behind excess deaths.
Read full story
Source: The Guardian, 13 January 2023
 
Patient Safety Learning

"Doctors discuss my daughter like she's nothing"

A doctor in Cambridge is spearheading a project to help to reform "blunt" medical language that patients and their families can find upsetting.
Ethicist Zoe Fritz said language that "casts doubt, belittles or blames patients" was long overdue for change.
Sixteen-year-old Josselin Tilley from Wiltshire has charge syndrome that reduces her life expectancy.
Her mother Karen said Josselin's death was often referred to in correspondence "like she's not a person.
"It's not person-centred at all, it's like she's just nothing."
The example she gave was an extract from a typical letter in November that she was copied in to by a community paediatrician addressed to colleagues.
"Death below 35: On discussion with Josselin's mum early death has been discussed with her, and there is plan, discussed with Josselin's mother about a wishes document being done."
Mrs Tilley, from Westbury, said she objected to the use of language that "very bluntly discusses Josselin's death like she's something going off in the fridge".
Doctor Fritz said the reason she and doctor Caitriona Cox were running the campaign at Cambridge University was because they recognised language regularly used by clinicians was often problematic for anyone outside of medical practice.
"Even just (the term) presenting [a] complaint. Patients coming into hospital with whatever's bothering them we [doctors] talk about as a complaint and I think that infantilises the patient. They're not complaining when telling us what's going on."
Read full story
Source: BBC News, 17 January 2023
Further reading on the hub: 
Presenting complaint: use of language that disempowers patients
Patient Safety Learning

Building firm to pay £5m over ‘defects’ at major cancer centre

A construction firm has been ordered to pay £5m after fire and electrical safety defects were found at one of the NHS’s largest cancer centres.
Lendlease was responsible for the design and build of the Bexley Wing at St James’s University Hospital in Leeds, under a private finance initiative deal nearly 20 years ago.
The building houses Leeds Cancer Centre, one of the largest in the country, and some other services. It is run by Leeds Teaching Hospitals Trust.
Concerns were later raised over fire and electrical safety in the plant room, where the building’s power supply is situated, according to a ruling published by the technology and construction court.
This included a lack of fire separation between the primary and secondary source of power, which risked a single incident disabling them both.
Read full story (paywalled)
Source: HSJ, 16 January 2023
Patient Safety Learning

Man waits eight years for mental health therapy as services hit by demand

A man has waited eight years to get adequate mental health care, as waiting lists for therapy grow.
Myles Cook, 47, from Essex, lives with severe depression and has been fighting to get one-to-one counselling for eight years but he has been told there are not enough therapists locally to respond to the demand.
Instead, he has been referred to group sessions, which he said were “detrimental” to his condition and manages his condition with medication but said he did not find that helpful either.
He said: “If you’re not getting help, and all you keep getting are pills and pills that don’t seem to be doing much. It might take the edge off but it doesn’t really do anything for my depression and because of the way the benefits system works, I’m not getting any therapy If I’m not on tablets, they’ll probably kick me off on my benefits because I’m not being treated.”
“I take the tablets, the psychiatric medications, I keep taking them although they’re not helpful because I need to have something to prove that I’m being treated to keep my benefits.”
At least 95% of patients needing NHS talking therapy services, called IAPT, should receive treatment within 18 weeks. But figures previously uncovered by The Independent showed that just one in five patients have their second IAPT appointment within three months.
And the NHS has failed to meet its target of having 1.6 million patients seen by IAPT services last year. Data published last year shows this was missed by 400,0000 at the end of 2021-22.
Read full story
Source: The Independent, 16 January 2023
Patient Safety Learning

Sudden unexplained death in childhood debated in Parliament

The issue of children dying unexpectedly and without any known cause has been debated in Parliament for the first time.
Sudden unexplained death in childhood (SUDC) is a rare category of death in which the cause remains unknown even after thorough investigation.
Former Chancellor Kwasi Kwarteng, who led the debate, said SUDC had not had the attention it deserved.
In his first speech as a backbencher for six years, he said it was important to not shy away from discussing "something that is incredibly difficult to deal with, emotionally very taxing, and one of the most serious medical phenomena".
He said: "Imagine a death of a child, who has all his or her life in front of them, suddenly ended. If you can imagine that and if you can imagine that for one of your own children you can get a sense of how tragic and how difficult that occurrence is."
He added: "It's such an uncomfortable issue but it is important to grasp uncomfortable issues to honour those who had died and prevent future deaths."
He added: "It's such an uncomfortable issue but it is important to grasp uncomfortable issues to honour those who had died and prevent future deaths."
The MPs were united in their call for more research to be carried out. They also called for the NHS website to be updated to include information about SUDC and for there to be more training for medical practitioners.
Read full story
Source: BBC News, 17 January 2023
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