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

Annual breast cancer checks could save 1,000 lives a year, says women’s health tsar

Offering women annual breast cancer checks could save 1,000 lives a year, the Government’s women’s health tsar has said.
Dame Lesley Regan said that the current system of screening women aged 50 to 70 once every three years was “not based on scientific evidence”.
The UK’s breast screening programme has the longest gap between screens in the world. In the US, it is every one or two years, and in Europe, it is every two years.
Dame Lesley, who is also a professor of obstetrics and gynaecology at Imperial College London, claimed that the decision to give women mammograms once every three years had been based on the budgets available in the Eighties, when checks were introduced. 
However, she said that more recent studies showed annual mammograms could save significant numbers of lives. 
On Tuesday, she told the launch of the Hologic Global Women’s Health Index in London: “If [someone] has a mammogram which is reported as normal today and she developed, for example, a precancerous lesion next month, she will then be waiting [until her next check], when it may well have become invasive, in the belief that she’s fine.
“If you have yearly mammography – and I appreciate that’s an expensive resource – there are very good studies demonstrating how many lives you save.”
Read full story (paywalled)
Source: The Telegraph, 25 January 2023
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Coroner says student might be alive if GP had seen him

A law student who died after four remote GP consultations might have lived had he been given a face-to-face appointment, a coroner ruled.
David Nash, 26, died in November 2020 from a bone infection behind his ear that caused an abscess on the brain.
Over a 19-day period leading up to his death, he had four phone consultations with his GP.
The coroner, Abigail Combes, said the failure to see him meant he underwent surgery ten hours later than it could have been.
Andrew and Anne Nash fought for more than two years to find out whether their son would have lived if he had been seen in person by clinical staff at Burley Park Medical Centre in Leeds.
Yesterday they said they were “both saddened and vindicated by the findings that the simple and obvious, necessary step of seeing him in person would have saved his life” and wanted to make sure “others don’t die as David did”.
Read full story (paywalled)
Source: The Times, 21 January 2023
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Hospital patient discharges putting strain on Devon's care sector

Devon care homes say they are being asked to accept patients with Covid-19, flu and other infectious diseases to ease the pressure on local hospitals.
One owner said it felt like the start of the pandemic again, as the safety of care homes was being "compromised".
Devon has some of the longest waits for emergency care in the country, according to NHS figures.
Simon Spiller, owner of The Croft Residential Care Home in Newton Abbot, said since the start of winter the home was being asked to shortcut its assessment process to help ease the blockages in Devon's hospitals.
He said other local care homes have told him they were facing the same pressure.
Mr Spiller said: "We're being encouraged, or really asked, to shortcut our assessment process. Normally, one of our team would go to the hospital to assess people, to really understand their care needs, to ensure they're an appropriate fit for our care home, which specialises in dementia.
"Increasingly, because of the speed they're trying to achieve a discharge, we're being asked to accept people at kind of face value, as presented by the NHS."
Read full story
Source: BBC News, 26 January 2023
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Women’s healthcare in Britain ‘worse than in China and Saudi Arabia’

Women’s healthcare in the UK is worse than that of China and Saudi Arabia, according to a global tracker. 
Poor efforts at prevention, diagnosis and treatment of health problems left the UK ranked lower than several countries with a troubling record on women’s rights.
The research, which compared a wealth of data, found Britain fared worse than most comparable Western countries, including the United States, Australia, New Zealand, France and Germany.
The UK was placed 30th out of 122 countries, in the 2021 Hologic Global Women’s Health Index published on Tuesday.
The score – three points lower than when a similar exercise was carried out last year – places it on a par with Kazakhstan, Slovenia, Kosovo and Poland for women’s healthcare provision.
Read full story
Source: The Telegraph, 24 January 2023
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‘Risk averse’ NHS 111 algorithm sends too many patients to A&E

NHS 111 sends too many people to accident and emergency departments because its computer algorithm is “too risk averse”, the country’s top emergency doctor has warned.
Dr Adrian Boyle, president of the Royal College of Emergency Medicine (RCEM), said that December was the “worst ever” in A&E with 9 in 10 emergency care leaders reporting to the RCEM that patients were waiting more than 24 hours in their departments.
Asked what measures could help improve pressures in emergency care, Dr Boyle said more clinical input was needed in NHS 111 calls.
“In terms of how we manage people who could be looked after elsewhere, the key thing to do is to improve NHS 111,” Dr Boyle told MPs.
“There is a lack of clinical validation and a lack of clinical access within NHS 111 - 50 per cent of calls have some form of clinical input, there’s an awful lot which are just people following an algorithm.”
Dr Boyle added where clinical input is lacking “it necessarily becomes risk averse and sends too many people to their GP, ambulance or emergency department”.
Read full story (paywalled)
Source: The Telegraph, 24 January 2023
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Thousands exposed to severe harm due to ambulance wait times last month

Record numbers of patients suffered severe harm last month because they spent so long in the back of ambulances waiting to get into A&E, new NHS figures reveal.
An estimated 57,000 people in England “experienced potential harm”, of whom 6,000 were exposed to “severe harm”, in December – both the largest numbers on record – because they had to wait at least an hour to be handed over to hospital staff, according to NHS ambulance service bosses.
The health union Unison, which represents many ambulance staff, said the data showed that the ambulance service “is barely coping” with the huge number of calls it is receiving.
A senior ambulance service official said the high volume of patients being put at risk because they had to wait outside A&E so long before receiving medical attention, and paramedics being prevented from answering other 999 calls, was “horrific” and “astronomical”.
He added: “These figures also show that whatever NHS England say they are doing to try to resolve this huge problem, it clearly isn’t working.”
Martin Flaherty, Association of Ambulance Chief Executives (AACE) managing director, said: “Our December 2022 data for handover delays at hospital emergency departments shows some of the worst figures we have recorded to date and clearly underlines that not enough is being done to reduce and eradicate these dangerous, unsafe and harmful occurrences.”
Read full story
Source: The Guardian, 25 January 2023
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We need to tell the public that hospitals are ‘horrible places’, urges trust CEO

Hospitals are ‘horrible’ and unsafe places, which should be avoided ‘unless you really need to be there’, a longstanding trust chief executive has argued.
East Suffolk and North Essex Foundation Trust boss Nick Hulme also said the NHS had to be honest about the state of its acute services.
Speaking at a public meeting of the East Suffolk and North Essex Integrated Care Board, he described hospitals as “awful” and “horrible”, and said NHS leaders had “got to get that message out” to the public. 
He added: “The food’s rubbish, we don’t let you sleep, we don’t let you know what’s going on” and that although he had stayed in some “fairly dodgy” hotels, none had forced him to share a bathroom with six people.
The trust CEO told the meeting he wanted to emphasise to the public that “the worst place you can possibly be in the health system is a hospital, unless you need to be there”, according to a report in the East Anglian Daily Times.  He added that hospitals were “not safe places”.
Read full story (paywalled)
Source: HSJ, 26 January 2023
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UK facing crisis point in abortion provision, experts say

The UK is facing a “crisis point” in abortion provision, experts say, with rising demand and restricted access to care in many areas putting unprecedented pressure on struggling NHS services.
Healthcare professionals described a “terrifying” state of affairs in which women are travelling hundreds of miles for appointments or waiting several weeks before they are seen.
Dr Jonathan Lord, the director of MSI Reproductive Choices UK, a major provider of abortion services, told the Guardian’s Today in Focus podcast: “There is no doubt we are seeing absolutely unprecedented levels of demand at the moment. All providers are reporting they are busier than they have ever been.”
Lord, who is also an NHS consultant gynaecologist, said the rise was being driven by “the economic downturn, the cost of living crisis and the ability to access good quality contraception” via GPs and sexual health services, which have been affected by the wider NHS crisis.
Clare Murphy, the chief executive at the British Pregnancy Advisory Service (BPAS), previously said: “The pandemic, and the policies adopted by the government, have had a clear impact on women’s pregnancy choices.” Faced with “economic uncertainty and job insecurity”, women had been forced to make tough decisions, she said.
Read full story
Source: The Guardian, 26 January 2023
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USA: 48% of physicians are happy at work, survey finds

Physicians' happiness fell amid the pandemic and is not rebounding easily, according to Medscape's 2023 Physician Lifestyle and Happiness Report.
The report is based on survey responses from 9,175 U.S.-based physicians in 29 specialties polled last year between 28 June and 3 October.
The report found:
1. 59% of physicians said they were "somewhat" or "very happy," down from 84% before the pandemic. These figures mirror percentages seen in Medscape's same report conducted last year. 
2. The percentage of physicians who are happy at work, specifically, fell from 75% before the pandemic to 48% today.
3. Four in 10 physicians said they regularly look after their own health and wellness, up from 33% who said the same in Medscape's 2022 report. 
4. 53% said they would take a pay decrease in return for better work-life balance. 
Read full story
Source: Becker's Hospital Review, 20 January 2023
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Two thirds of GPs say ‘advice and guidance’ is blocking patients who really need a referral

Two-thirds of GPs feel ‘advice and guidance’ is preventing patients who really need a referral to secondary care from getting one, according to the findings of a snapshot survey of Pulse readers.
Advice and guidance (A&G) services, which involve GPs accessing specialist advice before making a referral, have become a major part of NHS England’s plans for clearing the pandemic backlog.
But of the 366 GP survey respondents in England who said they had used advice and guidance, 68% said they felt the pathway is blocking necessary referrals.
The survey also found that of those 366 GPs who had used A&G services:
Around half (49%) said A&G was reducing referrals; More than three-quarters (78%) said it was increasing their workload; Just over half (60%) said it was requiring them to work beyond their competence; Two-thirds (68%) said A&G was resulting in patients complaining because their wish to see a consultant had been diverted. One GP who wished to remain anonymous commented: "An increasing number of referrals are being rejected for secondary care service pressure reasons rather than clinical need. [This] often duplicates GP admin work as we need to re-refer, rewriting the referral and/or enclosing further information or tests results in order to get a referral accepted."
Read full story
Source: Pulse, 25 January 2023
Further reading on the hub:
Rejected outpatient referrals are putting patients at risk and increasing workload pressure on GPs Patient referrals and waiting lists: A ticking time bomb A child left waiting for ‘urgent’ surgery, a blog by Clare Rayner
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Surgeon admits botching surgeries that left patients with life-changing injuries

An NHS surgeon has admitted to botching patients’ surgeries which left them with life-changing injuries, a tribunal has heard.
Dr Camillo Valero, who works at Norfolk and Norwich NHS trust and is facing allegations over his conduct towards three patients, has been admitted to severing a patient’s gallbladder during an operation.
Dr Valero is facing a medical practitioner’s tribunal where he already admitted to failures during two patients’ procedures.
Allegations against him include a failure to obtain a “critical view of safety” for his patients during surgeries.
He is also accused of shouting at patients during an altercation in an allegedly “aggressive” manner.
According to a tribunal document he was accused of asking the patient “are you a doctor?” when discussing his medication.
During surgery, Dr Valero is alleged to have misinterpreted the patient’s anatomy or sought assistance from an experienced surgeon following mistakes.
In the case of the third patient, allegations which have not been admitted or proven, Dr Valero is reported to have inappropriately discharged a patient with learning disabilities and did not adequately assess their mental capacity.
Read full story
Source: The Independent, 25 January 2023
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NHS safety watchdog sends warning over charging for GP appointments

Charging for GP appointments will worsen patient safety and drive more people to A&E, the head of a national safety watchdog has warned.
Dr Rosie Benneyworth, the chief investigator for the Healthcare Safety Investigation Branch (HSIB), was responding to a suggestion by former health secretary Sajid Javid who said the present model of the NHS was “unsustainable”.
He said “extending the contributory principle” should be part of radical reforms to tackle growing waiting times.
But Dr Benneyworth said it would only drive more people to seek help from already overstretched services.
She said: “I don’t want to be drawn into the politics around this but I believe in free at the point of delivery NHS and my concern would be [if] we charge people that people would not come forward early for their care and that would leave people needing more urgent and emergency care, because of delayed presentations.”
Dr Benneyworth said there needed to be a bigger focus on patient safety in services outside of A&E, such as NHS 111 and out-of-hours services.
Read full story
Source: The Independent, 26 January 2023
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NHS ‘haemorrhaging’ senior emergency department nurses

Experienced emergency department nurses are “leaving in droves” because they feel unable to do their jobs properly under the current conditions, a doctor has warned.
Giving evidence to the Health and Social Care Select Committee yesterday, Dr Adrian Boyle, president of the Royal College of Emergency Medicine, raised concern about nurse retention and morale in emergency departments.
“We are haemorrhaging experienced emergency nurses because they are finding it very frustrating"
He said: “What I'm also seeing is that a lot of nurses, particularly the experienced nurses, they're almost like the [non-commissioned officers] of the health service, the sergeants who know how to get things done, are leaving in droves.”
Dr Boyle added: “We are haemorrhaging experienced emergency nurses because they are finding it very frustrating.
“The problem is not because there's too much work but they're unable to do the work that they're trained to do."
Read full story
Source: Nursing Times, 25 January 2023
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Immensa Covid test lab concerns ignored by Test and Trace

Concerns raised about dangerous discrepancies at a Covid testing lab which has since been blamed for causing an estimated 23 deaths were ignored by health officials for months.
Documents show Public Health Wales flagged "significant concerns" about results from Immensa, in Wolverhampton, in letters to colleagues in England.
They were told nothing was wrong and testing continued for six months.
Letters were released after a Freedom of Information request by the Times.
The UK Health Security Agency (UKHSA) has said as many as 39,000 positive results were wrongly reported as negative in September and October 2021, mostly originating from south-west England.
Read full story
Source: BBC News, 26 January 2023
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Medicine supply problems double in a year

Medicine supply issues have soared in the past year, with the number of unavailable medicines nearly doubling from 52 in January 2022 to 97 this month, figures seen by HSJ reveal.
Analysis of NHS supply alerts shared with HSJ shows a persistent monthly rise over the past year in the number of unavailable drugs. It also reveals that 12 “serious shortage protocols” – a more serious level of alert which allow pharmacists to dispense alternatives more easily – have been issued this month, compared to three in January last year.
This is based on an analysis by the British Generics Manufacturers Association of NHS Specialist Pharmacy Service (SPS) medicines supply tool data. SPS data, seen by HSJ, shows several “high impact” shortages, which means they have the potential to change clinical practice or have safety implications.
Read full story (paywalled)
Source: HSJ, 26 January 2023
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Trust underplayed ‘catastrophic’ IT outage

A major London trust has been criticised for ‘underplaying’ the problems caused by a ‘catastrophic’ IT outage, a new report has revealed.
The Guy’s and St Thomas’ Foundation Trust report also noted one patient suffered “moderate harm” and several others “low” level harm after last July’s incident, which was caused by a combination of a heatwave and ageing infrastructure. 
However, the trust said there was no evidence the “underplaying” of issues was deliberate.
The report identified one incident of “moderate” patient harm, in which a patient was unable to receive a pancreas transplant due to staff being unable to safely monitor critical observations. The patient has since had a successful operation, the trust’s report stated.
Another 20 “low” harm incidents were reported, which included delays in patients receiving their test results and/or medicines, while the report added the trust could not rule out that “further harm events may be identified” amidst an ongoing harm review.
Read full story (paywalled)
Source: HSJ, 27 January 2023
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