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

Testing artificial hip and knee joints 'will save the NHS £200 million a year'... and reduce unnecessary pain for patients in future

Artificial hip and knee joints that have to be removed after failing early are to be examined routinely to save the NHS £200million a year – and reduce unnecessary pain for patients in future.
Less than 1 in 100 removed implants are examined to see why they failed, so surgeons don’t learn what went wrong or pick up on potential scandals.
Consultant orthopaedic surgeon Raghavendra Sidaginamale, of North Tees and Hartlepool NHS Trust, said: "Most removed implants are put in the bin. A wealth of information goes down the drain."
Now the NHS is setting up an Implants Analysis Service, enabling hospitals to send them off to be analysed for signs of unusual wear or chemical degradation.
Each year, 15,000 hip and knee replacements are replaced. If this happens within ten years, they are deemed to have failed early. Jason Wilson, of the IAS, said they are ‘like a black box flight recorder in a plane’, adding: "They hold a wealth of information we can learn from."
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Source: Daily Mail, 29 January 2023
Patient Safety Learning

Trusts ‘coping better with strikes’ and on track to eliminate 78-week waits, says NHSE director

Trusts are getting better at coping with industrial action and are still on track to hit the national target of eliminating the backlog of 78-week waiters, an NHS England director has told staff.
Paul Doyle, NHS England’s programme director for elective recovery, said: “We continue to make really good progress [on elective recovery]… we are very much in the end game now of meeting the 78-week ambition for the end of March.”
There have been concerns about the impact of recent strike action on eliminating the 78-week backlog, but Mr Doyle praised managers’ handling of the strikes and said administrative staff were doing an “incredible job”.
He added: “Most organisations affected have got better and better as time has gone on about making sure that there are as few cancellations as possible and that cancellations are rebooked quickly or that clinical time is put to good use such as doing virtual outpatient appointments or doing validation of waiting list.”
Read full story (paywalled)
Source: HSJ, 30 January 2023
Patient Safety Learning

Switch to cheaper drugs leaves Parkinson’s patients suffering ‘devastating effects’

Parkinson’s patients are suffering from “devastating effects” as GPs have started to switch to cheaper drugs which have different release rates into the body.
Parkinson’s UK put out a warning when a 65-year-old man who had been successfully managing the condition for 17 years suddenly needed help eating and getting dressed.
This happened after his branded medication Sinemet was changed to a cheaper form of the drug.
Barrie Smith - who comes from Birmingham - was left in pain, developed slow speech and experienced an uncontrolled tremor when his normal Sinemet medication was switched to a more generic form of medication last year without consultation. He called the effects “devastating”.
Dr Rowan Wathes, Associate Director of the Parkinson’s Excellence Network at Parkinson’s UK, said: “Changes to brands or manufacturers can trigger a significant deterioration of symptoms. It is vitally important for prescribers to specify the Parkinson’s medication brand or generic manufacturer on prescriptions for people with Parkinson’s. ”
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Source: The Independent, 30 January 2023
You may also be interested in the following blogs written by Parkinson's UK for the hub:
Medication delays: A huge risk for inpatients with Parkinson’s Keeping patients with Parkinson’s safe in hospital: 4 key actions for staff Preparing to go into hospital – tips for people with Parkinson's and their carers
Patient Safety Learning

Wards at Royal London Hospital mothballed amid concerns over fire safety

Six wards in a busy London Hospital, added at a cost of £24 billion during the pandemic, are lying empty because the builders did not install sprinklers. 
With the NHS in crisis, the Royal London Hospital in east London, has had to mothball the space, which is large enough to take 155 intensive care beds, while officials work out what to do with it. They have no patients in it since last May.
Source: The Sunday Times, 29 January 2023
Shared by Shaun Lintern on Twitter
Patient Safety Learning

UK dementia care agency’s half-hour home visits ‘lasted as little as three minutes’

A dementia home care agency spent as little as three and a half minutes on taxpayer-funded care visits and filed records claiming far more care was given, according to evidence seen by the Guardian.
The hasty care was exposed by Susan Beswick’s family, who called it “totally inadequate”. They say they had been told visits to 78-year-old Beswick, who has Alzheimer’s disease, were supposed to last 30 or 45 minutes.
Across nine visits this month, care workers formally logged close to six hours of care. But security cameras suggest they were in the house for under one hour 20 minutes – less than nine minutes a visit on average.
On one evening visit, footage showed two carers entering, asking if Beswick had eaten and checking her incontinence pad, before leaving three minutes and 15 seconds later. But they appeared to log on a care tracking app that they had been with her for one hour and 16 minutes.
Beswick, who for years was a care worker herself, “deserves so much better”, said her daughter-in-law Karen Beswick.
“It’s upsetting us the way mum is being cared for here,” she said. “They come in and check her [incontinence] pad and go. They are supposed to be encouraging her to drink. They don’t really talk to mum a lot. It’s not good at all. I will start crying. We are all trying to get the best for mum.”
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Source: The Guardian, 30 January 2023
Patient Safety Learning

System’s trusts failing to tackle ‘completely unjust’ health inequalities

All three acute trusts in an integrated care system are failing to meet national requirements to tackle health inequalities after being overwhelmed by emergency and elective care pressures.
A report by Devon Integrated Care Board found progress on addressing variation in poor health outcomes had “slipped due to capacity issues.” Both Royal Devon University Healthcare Foundation Trust and Torbay and South Devon FT were rated “red” for a lack of headway.
All trusts were told by NHSE in 2021 to undertake a range of actions as part of work to reduce health inequalities during 2022-23.
These included publishing analyses of waiting times disaggregated by ethnicity and deprivation, using the waiting list data to identify disparities between different patient groups, and measuring access, experience and outcomes for patients from a deprived community or an ethnic minority background.
Sarah Sweeney, interim chief executive of National Voices, which represents health and care charities and patients, said she was “really concerned to see that some ICSs are not making as much progress on reducing health inequalities as expected and hoped”.
“These inequalities are completely unjust and preventable,” she said. 
Read full story (paywalled)
Source: HSJ, 30 January 2023
Patient Safety Learning

Cancer: Urgent action needed amid NHS pressures, warns charity

The Covid-19 pandemic cannot continue being blamed for poor cancer care, a charity boss has said.
Judi Rhys, of Tenovus Cancer Care, said urgent action was needed to save lives when more people than ever are living with cancer in Wales.
It comes as the Wales Cancer Network publishes a three-year plan to improve cancer outcomes and patient experience.
But the group's clinical director warned the immediate priority would be maintaining current services.
Prof Tom Crosby, clinical director for Wales Cancer Network, which was tasked by Wales' health minister to draw up the improvement plan, said the biggest pinch point at the moment was access to diagnostics.
"We're absolutely trying to shorten overall times for patients coming into the system being diagnosed and then being treated," he said.
On average in November, people suspected of having cancer had to wait 17 days for a first appointment and 23 days for a first test.
It was an average 31 days from point of suspicion to being told if they had cancer or not and an average 24 days from point of diagnosis to treatment starting.
"We hope that this year we will develop the first regional diagnostic centre and that is likely to be in south-east Wales," Prof Crosby said.
Read full story
Source: BBC News, 31 January 2023
Patient Safety Learning

NHS set to publish hidden figures which expose true scale of A&E waiting times

The NHS will start publishing “hidden” figures on A&E waiting times following several leaks reported by The Independent.
After unveiling its emergency care plan on Monday, NHS England confirmed it would release internal data each month - currently only made public once a year - showing how many people are waiting for longer than 12 hours after arriving at an emergency department.
The Independent has published several leaks of this data, which shows that these waiting times can be up to five times higher than publicly available NHS figures. Official monthly figures only count the number of hours patients wait after a decision to admit them has been made, and so mask the true scale of the problem.
The move comes after health secretary Steve Barclay said the NHS would, from April, publish this “real” number in a bid for “greater transparency.”
Writing in The Telegraph, he said: “Too much of the debate about A&E and ambulance services is based on anecdotal evidence. I want NHS managers and the wider public to have access to the same facts from the front line, starting with publishing the number of 12-hour waits from the time of arrival in A&E from April.”
Read full story
Source: The Independent, 31 January 2023
Patient Safety Learning

Minister calls for staff evidence in deaths inquiry

A health minister has called for more staff to take part in an inquiry into deaths at a mental health trust.
An independent review into 1,500 deaths at the Essex Partnership University Trust (EPUT) over a 21-year period was launched in 2020.
It emerged earlier this month that 11 out of 14,000 staff members had come forward to give evidence to an independent inquiry.
The trust said it was encouraging staff to take part in the inquiry.
During a parliamentary debate, Health Minister Neil O'Brien said the trust was being given a "last chance" before the government intervened and instigated a statutory inquiry.
A statutory inquiry would allow staff to be compelled to give evidence.
In December, a further 500 deaths were made known to the review chair, Dr Geraldine Strathdee.
She said the inquiry could not continue without full legal powers.
Chelmsford MP Vicky Ford said she had been told by the chief executive of EPUT that staff were "very scared" to give evidence.
Read full story
Source: BBC News, 31 January 2023
Patient Safety Learning

Ambulance workers to strike on 10 February

Thousands of ambulance staff across five services in England - London, Yorkshire, the South West, North East and North West - will walk out on Friday 10 February, Unison says.
It means strikes over pay will now be happening across the NHS every day next week, apart from Wednesday.
Life-threatening 999 calls will be attended to but others may not be.
Downing Street says the continuing industrial action will concern the public.
The NHS's biggest day of industrial action is set to happen on 6 February, when many nurses and ambulance crews across England and Wales will be on strike.
Unison says the government must stop "pretending the strikes will simply go away" and act decisively to end the dispute by improving pay.
The union warned that unless the government had a "major rethink" over NHS pay, and got involved in "actual talks" with unions, it would announce strike dates running into March.
The government says the above-inflation pay rises requested are unaffordable.
Read full story
Source: BBC News, 31 January 2023
Patient Safety Learning

‘The wait was agony’: Women with life-threatening breast cancer face weeks of delays

“I was worried it would grow and spread,” Charlotte Park, a breast cancer patient tells The Independent. “What happens if I hadn’t been that really pushy person? Sometimes I still go into a dark place and I think: I am so lucky to be here.”
The 50-year-old, from Richmond in Yorkshire, found a lump in her breast in June 2020 and went straight to see her GP who informed her she would have to wait two weeks to see a specialist. After a fortnight of waiting, she started to panic and rang the clinic who said they were still working through referrals from four to six weeks prior to her referral.
“I was getting frustrated and impatient by this point,” Ms Park recalls. “There was no leeway and they didn’t see if they could squeeze me in. I just felt frustrated. There was nothing I could do. It was all out of my hands. I was feeling teary.”
Ms Park is one of thousands of women with breast cancer in England facing delays of weeks or months to see a specialist or receive treatment. Data, shared exclusively with The Independent, shows delays were substantially worse for those with breast cancer than other forms of cancer.
In the end, Ms Park was forced to wait 25 days to see a specialist. The wait was “agony”, she said. It was difficult to definitively determine if the delays caused her cancer to grow, she noted.
Her comments come in the context of thousands of women with breast cancer being forced to wait longer than the NHS-recommended time of two months to get treatment, in a situation branded “perilous” by healthcare professionals. Exclusive data shows only seven in ten women in England received treatment for breast cancer two months after getting an urgent doctor’s referral between January and November 2022.
This amounts to just more than 16,500 women and is way below the NHS target for 85% of breast cancer patients diagnosed via an urgent GP referral to start their cancer treatment within two months of their GP visit.
Read full story
Source: The Independent. 31 January 2023
Patient Safety Learning

Ian Paterson: Further 1,500 patients to be recalled

A further 1,500 patients of convicted breast surgeon Ian Paterson are to be recalled and their treatment investigated.
Spire Healthcare, which runs private hospitals, said patients were being contacted after a trawl of IT systems.
Paterson was jailed for 20 years in 2017 for 17 counts of wounding people with intent.
The healthcare provider said it remained committed to tracking down all "outstanding patients".
The former surgeon subjected hundreds of patients to needless and damaging surgery over 14 years.
A 2020 independent inquiry ruled "a culture of avoidance and denial" left him free to perform botched operations in NHS and private hospitals in Birmingham and Solihull.
The inquiry recommended all 11,000 patients Paterson treated should be recalled for review.
Read full story
Source: BBC News, 1 February 2023
Patient Safety Learning

Jess Hodgkinson: Lack of medication contributed to mother's death

A woman who died shortly after giving birth to her daughter did not receive the correct medication, a coroner has ruled.
Jess Hodgkinson, 26, from Chesterfield, died from a pulmonary embolism in 2021.
Assistant coroner Matthew Kewley said there was a "failure" to ensure Ms Hodgkinson received blood thinners right up until the birth.
Chesterfield Coroner's Court heard Ms Hodgkinson had a high risk pregnancy due to severe hypertension.
On 21 April 2021, a consultant in Chesterfield prescribed a prophylactic dose of tinzaparin due to an increased risk of clotting, the inquest heard.
During the inquest, the consultant said the intention was for Ms Hodgkinson to continue to receive a daily dose of anticoagulant medication up until birth.
Ms Hodgkinson was transferred to a hospital in Sheffield the next day, but there was a "failure to communicate" the medication plan, Mr Kewley said.
After being discharged, clinicians in Chesterfield "failed to identify" Ms Hodgkinson was no longer receiving the medication, the coroner said in his ruling.
On 13 May, Ms Hodgkinson attended Chesterfield Royal Hospital and a decision was made to carry out an emergency Caesarean section. The procedure was successful and Ms Hodgkinson's baby was born. But after delivery, Ms Hodgkinson went into cardiac arrest and later died.
In his concluding remarks, Mr Kewley said: "There was a failure to ensure that Jess received anticoagulant medication that a clinician had intended should be taken until birth. This failure made a more than minimal, negligible or trivial contribution to Jess' death".
Read full story
Source: BBC News, 31 January 2023
 
Patient Safety Learning

Boy dies of cancer after doctors dismissed mother’s warnings six times

A little boy whose headaches turned out to be a brain tumour died in his parent’s arms just four months after his diagnosis.
Rayhan Majid, aged four, died after doctors discovered an aggressive grade three medulloblastoma tumour touching his brainstem.
His mother Nadia, 45, took Rayhan to see four different GPs on six separate occasions after he started having bad headaches and being sick in October 2017.
No one thought anything was seriously wrong, but when his headaches didn’t clear up Nadia rushed him to A&E at the Queen Elizabeth University Hospital in Glasgow.
An MRI scan revealed a 3cm x 4cm mass in Rayhan’s brain.
Rayhan underwent surgery to remove as much of the tumour as possible and was told he would need six weeks of radiotherapy and four months of chemotherapy.
But before the treatment even started another MRI scan revealed the devastating news that the cancer has spread.
Read full story
Source: The Independent, 30 January 2023
Sam

Elderly people waited nearly twice as long in A&E in England as in 2021

The amount of time people over 80 spend in A&E in England has almost doubled in a year, leaving them at increased risk of coming to harm and dying, emergency care doctors are warning.
An analysis by the Royal College of Emergency Medicine (RCEM) found that people of that age are spending 16 hours in A&E waiting for care or a bed, a huge rise on the nine hours seen in 2021.
The college, which represents the UK’s A&E doctors, warned that long waits, allied to overcrowding in hospitals and older people’s often fragile health, is putting them in danger.
Doctors specialising in emergency and elderly care warned that older people forced to spend a long time in A&E are more likely to suffer a fall, develop sepsis, get bed ulcers or become confused.
Dr Adrian Boyle, the RCEM’s president, said that it is also likely that some older people are dying as a result of the delays they are facing, combined with their often poor underlying health.
The risks older people face while waiting in sometimes chaotic A&E units are so great that they are likely to be disproportionately represented among the 500 people a week who the RCEM estimates are dying as a direct result of delays in accessing urgent medical help.
Read full story
Source: The Guardian, 31 January 2023
Patient Safety Learning

Prolific surgeon found guilty of misconduct and dishonesty

A prolific surgeon accused of poor care — some with a ‘catastrophic outcome’ — and altering patient notes has been found guilty of misconduct following a tribunal hearing. 
Jeremy Parker, who performed hundreds of operations at Colchester Hospital and the private Oaks Hospital until his suspension in 2019, faced a misconduct hearing in December and January.
The medical practitioners tribunal investigated allegations that between August 2015 and November 2018, Mr Parker failed to provide good clinical care to six patients. It was also alleged he performed surgery in breach of restrictions on his clinical practice between October 2018 and January 2019 and that his actions were dishonest.
Richard Holland, opening the tribunal case for the General Medical Council, said Mr Parker’s care of six patients – referred to as patients A-F – was “deficient” in a number of ways, with that provided to patient A leading to a “catastrophic outcome” where their leg was amputated below the right knee following “catastrophic blood loss” caused by severing of an artery during surgery.
Read full story (paywalled)
Source: HSJ, 1 February 2022
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