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

Trust warned by CQC over staff sleeping on duty

A mental health trust has received a warning from the Care Quality Commission over staff sleeping on duty and other serious concerns.
Essex Partnership University Foundation Trust was sent a “letter of intent”, which warns the CQC is considering taking urgent enforcement action, following an unannounced visit in November, according to a board report last week.
The trust is already subject to a high-profile inquiry into hundreds of patient deaths.
Natalie Hammond, executive nurse, said this would be “a fine tuning of our health roster which will be an early warning system that will determine and flag all staff members that may be at risk of working too much or their hours of working might perform a pattern that means they are at risk more of falling asleep on duty.”
She added: “We’ve done learning lessons and videos that link the importance of being fit and alert for work and how when you’re not, what mitigation and what steps you should undertake and what risk there is to patient safety.”
Read full story (paywalled)
Source: HSJ, 1 February 2023
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Sickle cell: NHS staff ‘failing to follow healthcare guidelines’

NHS staff are failing to follow guidelines for providing care to sickle cell patients - and some of the advice has been branded as “unfit for purpose”.
The NHS Race and Health Observatory commissioned research, undertaken by Public Digital, to explore the lived experience of people undergoing emergency hospital admissions for sickle cell and managing crisis episodes at home.
The Sickle cell digital discovery report: Designing better acute painful sickle cell care, found that the existence of service-wide information tailored by the National Institute for Health and Care Excellence has “arguably not been designed for an ambulance, A&E and emergency setting”, and states it has been proven that this guideline is “not being used and adhered to consistently”.
Moreover, healthcare professionals have warned that the National Haemoglobinopathy Register (NHR) -  a database of patients with red cell disorders - is not being readily accessed, while patients reported being treated in a way that breached prescribed instructions.
“We believe that sickle cell crisis guidelines could be improved in terms of their usability in a high-pressure emergency setting, and in terms of promoting access to them,” the report authors concluded, adding that current guidance should be adapted.
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Source: The Independent, 31 January 2023
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North East ambulance staff lacked critical medicines, CQC finds

Ambulance crews in the North East frequently responded to emergencies without access to life-saving drugs, a damning inspection report has found.
The study of North East Ambulance Service NHS Trust (NEAS) concluded patients were potentially put at risk by the poor management of medicines.
The Care Quality Commission (CQC) found a deterioration of services and rated NEAS's urgent care as "inadequate".
In response, NEAS said it had faced a year of "unprecedented pressures".
The damaging assessment follows the launch of a full independent NHS review into numerous "tragic failings" involving patients.
Announcing the review, the then health secretary Sajid Javid said he was "deeply concerned" about claims NEAS had covered up mistakes.
Whistleblowers have told Newsnight multiple deaths were not investigated properly because information was not always provided to coroners and families.
Read full story
Source: BBC News, 1 February 2023
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NHS set to miss cancer backlog target three years running, NHSE plans reveal

NHS England has effectively admitted the backlog of cancer long-waiters will still be higher in March 2024 than before covid hit, in a document seen by HSJ.
The consultation document, detailing trajectories for reducing numbers waiting 62 days or more from referral, shows the expected national total in March 2024 is 18,755.
NHS England previously committed to reducing this to pre-pandemic levels (14,226) by March 2022, then delayed the target until March this year. 
There are now significant backlogs in diagnostics, with particular challenges in endoscopy and breast screening.
NHS Providers director of policy and strategy Miriam Deakin said: “Cancer is a key priority for trusts. They understand the risk to patients who have to wait.
“The pandemic left people waiting longer than NHS trusts wanted for diagnosis or to start treatment, with some people not coming forward, but now urgent referrals for suspected cancer are far higher than pre-pandemic.
Read full story (paywalled)
Source: HSJ, 1 February 2023
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Inquiry head to meet failing maternity bosses

Donna Ockenden, who is leading an independent review examining how dozens of babies died or were injured at the Nottingham University Hospitals (NUH) trust, is due to meet with chief executive of NUH, Anthony May, and other members of the NUH executive team.
Speaking ahead of the meeting, she said: "The commitment I want to give to the women and families of Nottingham is that real learning, real improvement in maternity safety will happen throughout the life of this review.
"It won't be a case of waiting until the end and then presenting the trust with a huge amount of learning that they then have to start putting in place.
"Today's meeting with the trust is at executive level. Along with colleagues from NHS England, I'll be meeting with the chief executive and some of his colleagues to talk about how we will ensure that learning reaches the trust on a regular basis and in a timely way so families can be assured that the maternity improvement plan is including learning from our review."
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Source: BBC News, 2 February 2023
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Prescribing antidepressants for chronic pain lacks evidence, experts say

Researchers have warned there is a lack of evidence around prescribing antidepressants for chronic pain.
Guidance from the National Institute for Health and Care Excellence (Nice) in 2021 recommends that an antidepressant (amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline) can be considered for people aged 18 and over with pain lasting longer than three months which cannot be accounted for by another diagnosis.
The guidance said the drugs may help with quality of life, pain, sleep and psychological distress, even if the patient is not suffering depression.
A separate guideline on neuropathic (nerve) pain recommends offering a choice of treatments, including amitriptyline and duloxetine, alongside a discussion on possible benefits and side-effects.
However, researchers writing in the BMJ have warned that recommending antidepressants for pain is not always backed by evidence.
Professor Martin Underwood from the University of Warwick, said: “There is a role for antidepressants in helping people living with chronic pain, however, this is more limited than previously thought.
“Antidepressants may have unpleasant side effects that patients may wish to avoid.
“We need to work harder to help people manage their pain and live better, without relying on the prescription pad.”
Read full story
Source: The Independent, 1 February 2023
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Paramedics not sent to quarter of urgent calls, admits trust

Some ambulance trusts are not sending paramedics to up to around a quarter of their most serious calls, according to figures obtained by HSJ.
HSJ submitted data requests to all 10 English ambulance trusts after the Care Quality Commission raised concerns about the proportion of category one calls not being attended by a paramedic at South Central Ambulance Service Foundation Trust.
The regulator said in a report published in August last year that between November 2021 and April 2022 around 9% of the trust’s category one calls were not attended by a paramedic. Inspectors said this meant some patients “did not receive care or treatment that met their needs because there were not appropriately qualified staff making the decisions and providing treatment.”
But data obtained via freedom of information requests reveals other ambulance trusts had far lower proportions of category one calls attended by paramedics than the South Central service last year.
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Source: HSJ, 2 February 2023
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UK hospital declares major incident as A&E under ‘immense pressure’

A major hospital in the UK has declared a critical incident, warning it is facing “immense pressures” on its services.
Wigan’s Royal Albert Edward Infirmary urged people to avoid its A&E unless suffering a “life or limb-threatening emergency”.
Wrightington, Wigan and Leigh (WWL) Teaching Hospitals NHS Foundation Trust warned that “unprecedented attendances” meant the emergency department was “full”. It said it is working with partners to discharge patients who are ready to leave hospital.
The trust, which previously declared a critical incident in December, said the safety of its patients is the “top priority”.
By declaring a critical incident, hospitals are able to take action so that safe services are maintained despite increasing pressures.
Read full story
Source: The Independent, 1 February 2023
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‘We have to survive’: the women filling the gap in Texas borderlands’ medical deserts

Community health workers are stepping in to provide critical services and information in rural areas in Texas, USA, with few hospitals or doctors.
When Claudia Salazar and her family migrated to San Elizario, Texas, a small city in El Paso county, they settled into a colonia – informal, low-income housing often found in rural parts along the US-Mexico border.
But the remoteness of their new home soon presented problems – Salazar suddenly found herself in a medical desert. The nearest hospital is a 35-minute drive away. Even that is challenging to get to – the community’s mostly farm worker population works 10- to 12-hour days, and often lacks adequate time to travel for medical attention between workdays.
The lack of consistent medical access is just one of the many public health issues that colonias face, and a group of women familiar with the dynamics in this region thought of a relatively simple solution: bringing medical care to the people who need it most in these borderland communities. “Familias Triunfadoras has been really helpful since they provide a mobile unit clinic,” Salazar said. “That’s when we get a chance to visit a doctor or get a doctor’s appointment.”
Familias Triunfadoras is a San Elizario-based non-profit that is composed of women who step in as community organizers to connect residents like Salazar to resources they may not know exist. Their efforts to make healthcare more accessible in medical deserts like San Elizario has proven invaluable to residents.
Read full story
Source: The Guardian, 2 February 2023
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‘Massively reduced’ length of stay emerging at much criticised new hospital, says CEO

The CEO of a troubled trust has said evidence is emerging of ‘massively reduced’ length of stay in a new hospital criticised for being too small.
Emergency staff have raised concerns about a lack of space and bed capacity at the new Royal Liverpool Hospital, which opened in October, as services have come under severe pressure this winter. The new building, on a next-door site to the old hospital, has fewer beds, although more have opened elsewhere in the city.
In an interview with HSJ, Liverpool University Hospitals Foundation Trust chief executive officer James Sumner acknowledged aspects of the new building have created difficulties, including in relation to accident and emergency configuration and capacity, but added the move’s benefits are beginning to be seen.
He said a new care model and single rooms throughout the whole hospital are helping to reduce length of stay, as well as eliminating bed closures due to infection outbreaks.
He said: “We’ve got really good evidence of massively reduced length of stay in this new building, [with] about 70 fewer people every day waiting over seven, 14 and 21 days in hospital.
Read full story (paywalled)
Source: HSJ, 1 February 2023
Patient Safety Learning

Breakthrough in preventing hepatitis B transmission from mothers to children

Hepatitis B transmission from mothers to babies has been eliminated in England, according to the World Health Organisation (WHO).
The WHO elimination target is that less than 2% of babies born to mothers with hepatitis B go on to develop the infection.
And data from the UK Health Security Agency (UKHSA) shows the figure for England currently stands at 0.1%
The UKHSA said progress had been made in tackling the viral infection, which can cause liver damage, cancer and death if left untreated.
A six-in-one vaccine is offered to all babies on the NHS when they are eight, 12 and 16 weeks of age.
Health and Social Care Secretary Steve Barclay said: “We are paving the way for the elimination of hepatitis B and C, with England set to be one of the first countries in the world to wipe out these viruses.”
Read full story
Source: The Independent, 2 February 2023
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Patient Safety Learning

Patient Safety Commissioner: 'We are heading straight back to Mid Staffs'

A seismic shift is needed in the way that patients’ and families’ voices are heard, with shared decision-making and patient partnership as the destination, says Patient Safety Commissioner, Dr Henrietta Hughes, on the day the Patient Safety Commissioner 100 Days Report is published.
In the report, Henrietta reflects on her first 100 days in this new role. She sets out what she has heard, what she has done and her priorities for the year ahead.
"Everyone... has a part to play in delivering safe care – know that you can make a difference by putting safety at the top of your agenda. Introduce patient voices into your governance – in your board meetings, commissioning and contracts meetings, design of strategies, policies and processes, team meeting agendas, annual objectives, appraisals, reviews of complaints and incidents, inspections, and reward and recognition.
"I want us to be able to look back in astonishment on the way that we operate now. This is the moment to set a new course with shared decision-making and patient partnership as our destination. Without listening and acting on patient voices, safety will continue to be compromised and patients and families will continue to suffer the consequences of harm."
Read full story (paywalled)
Source: HSJ, 2 February 2023
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Cancer warnings could be put on all breast implants a decade on from scandal that left women 'dying in silence'

Ministers are considering putting a cancer warning on all breast implants a decade after women had ‘a cocktail of chemicals intended for mattresses’ put into their bodies.
Experts and MPs are calling for tighter regulation and better support after the PIP faulty breast implant scandal left women – including breast cancer survivors – ‘suffering and dying in silence’.
Health minister Maria Caulfield pledged on Monday to consider a so-called ‘black-box’ warning on breast implant packaging like in the US.
It came during a debate on the faulty breast implant scandal which saw 47,000 British women given ‘ticking time bomb’ implants made by Poly Implant Prothese (PIP).
PIP implants were outlawed in 2010 when they were revealed to be made with substandard silicone and up to six times more likely to rupture.
Victims of the scandal have reported a wide range of serious side-effects as experts say they are linked to a raft of health problems including the new form of cancer.
Anyone with a PIP implant can officially apply to have it removed by the NHS, but Labour MP Fleur Anderson said: ‘Many applications have been turned down, leaving women with a ticking time bomb in their body.
‘They are unable to afford to get their implants removed privately, are worried that they will rupture further, and are experiencing clear side-effects.’
The MHRA acknowledged the risk of cancer for all breast implants but said PIP implants are not at greater risk than any other. 
Read full story
Source Mail Online, 31 January 2023
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Infected blood inquiry: Five things we have learned

A long-running public inquiry into what has been called the worst treatment disaster in the history of the NHS will hear its final evidence on Friday.
It is thought tens of thousands were infected with HIV and hepatitis between 1970 and 1991 after being given a contaminated drug or blood transfusion.
The inquiry, which started in 2018, has reviewed thousands of documents and heard testimony from 370 witnesses.
A total of 1,250 people with haemophilia and other bleeding disorders contracted HIV after being given a protein made from blood plasma known as Factor VIII.
About half of that group later died of an Aids-related illness.
Researchers found that 380 of those infected with HIV - about one in three - were children, including some very young toddlers.
One of the key questions the inquiry will now have to answer is whether more could and should have been done to prevent those infections and deaths.
Hundreds of victims of the scandal have received annual support payments but - before this inquiry - no formal compensation had ever been awarded for loss of earnings, care costs and other lifetime losses
Further recommendations on compensation are expected when the inquiry publishes its final report, which is likely to be around the middle of the year.
Read full story
Source: BBC News, 3 February 2023
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‘Very high’ Do Not Attend rates caused by IT failures, trust discovers

An acute trust has discovered an IT issue which appears to have led to ‘very high’ numbers of patients not turning up for their appointments.
Bedfordshire Hospitals Foundation Trust discovered appointment letters were being lost, and not sent to patients, during intermittent server failures, its board was told yesterday.
The trust’s “did not attend“ rate has been between 10% and 12% over the last year, compared to the national average of 7%, according to its board papers.
The issue relates to patients with appointments booked at Luton and Dunstable Hospital. It is not yet clear how many patients were affected.
The trust is now planning to ensure every patient with an appointment booked this year receives a new appointment letter, and an apology if they did not previously receive one.
Read full story (paywalled)
Source: HSJ, 2 February 2023
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Murder-accused nurse sent card to grieving parents

Nurse Lucy Letby sent a sympathy card to the grieving parents of a baby girl just weeks after she allegedly murdered the infant, a court has heard.
She is accused of trying to kill the premature baby, referred to as Child I, three times before succeeding on a fourth attempt on 23 October 2015.
She denies murdering seven babies and attempting to murder 10 others.
Manchester Crown Court was shown an image of a condolence card Ms Letby sent to the family of Child I ahead of her funeral on 10 November.
The card was titled "your loved one will be remembered with many smiles".
Inside, Ms Letby wrote: "There are no words to make this time any easier.
"It was a real privilege to care for [Child I] and get to know you as a family - a family who always put [Child I] first and did everything possible for her.
"She will always be part of your lives and we will never forget her.
"Thinking of you today and always. Lots of love Lucy x."
It is alleged that before murdering Child I, Ms Letby attempted to kill the infant on 30 September and during night shifts on 12 and 13 October.
The prosecution said she harmed the premature infant by injecting air into her feeding tube and bloodstream before she eventually died in the early hours of 23 October 2015.
Read full story
Source: BBC News, 2 February 2023
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