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

Inquiry exaggerated trust death toll, claims CEO

A trust chief executive has suggested an inquiry team looking at 2,000 deaths is lacking in “expertise” and has created a “disproportionate impression” of the problems at his trust.
Essex Partnership University Trust is at the centre of a high-profile inquiry into the deaths of patients over a 20-year period, which was sparked after serious concerns were raised over specific cases.
The inquiry, led by Geraldine Strathdee, a former national clinical director for mental health, is reviewing the cases of 2,000 people who died while they were patients on a mental health ward in Essex or within three months of being discharged.
In a letter to the inquiry, obtained by HSJ through a freedom of information request, trust chief executive officer Paul Scott wrote: “The headline number of c.1,500 or c.2,000 deaths used in publicity by the inquiry is, in my opinion, not a fair reflection of the deaths that would be of interest to the inquiry.”
Read full story (paywalled)
Source: HSJ, 1 March 2023
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‘Toxic working environment’ exposed at troubled unit

Staff endured a “toxic and difficult working environment” at a maternity unit an employment tribunal has found.
The tribunal panel said that the case of a black midwife, Kemi Akinmaji, who partially won her case against East Kent Hospitals University Foundation Trust for racial discrimination showed “there were wider issues beyond the specific allegations before us and which were possibly related to race”.
The tribunal judgment said: “The evidence we heard reflected a toxic and difficult working environment generally where the claimant and colleagues were shouted and sworn at over differences of professional opinion. There was some evidence before us that there were wider issues beyond the specific allegations before us and which were possibly related to race…
“There is evidence of wider bullying of the claimant in the way the group of colleagues treated the claimant… We’ve also heard that the previous grievance had highlighted risks in respect of unconscious bias and identified recommendations which were not actioned.
“The race champion was not appointed and the unconscious bias training not sufficiently followed through. We also heard evidence of staff being wary of further such complaints. These matters were all concerning but we had to limit ourselves to the specific allegations brought by the claimant and which the respondent had been given an opportunity to address.”
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Source: HSJ, 1 March 2023
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BMA ‘rate card’ wipes out elective recovery gains, claims trust

A struggling acute trust says its failure to hit its elective care targets is directly linked to doctors’ demanding overtime rates in line with the British Medical Association’s rate cards, as national tensions around the issue intensify.
University Hospitals of Morecambe Bay Foundation Trust’s January performance report said its elective activity was down by around 1,000 cases over a two-month period, due to the issue.
Last summer, the BMA published a “rate card” outlining the “minimum” hourly pay consultants should receive for additional work, such as waiting list initiatives and weekend shifts. Some accused the union of “acting like football agents” by trying to inflate their members’ pay.
NHS chiefs have long been warning of the risk the rate card poses to elective recovery. But there are few examples of a trust making such an explicit link between their struggle to staff overtime shifts because of the rate card and subsequent failure to hit their elective targets, and placing a number on how many patients they were forced to add to the list because of the issue.
Read full story (paywalled)
Source: HSJ, 1 March 2023
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AI could help NHS surgeons perform 300 more transplants every year, say UK surgeons

Artificial intelligence could help NHS surgeons perform 300 more transplant operations every year, according to British researchers who have designed a new tool to boost the quality of donor organs.
Currently, medical staff must rely on their own assessments of whether an organ may be suitable for transplanting into a patient. It means some organs are picked that ultimately do not prove successful, while others that might be useful can be disregarded.
Now experts have developed a pioneering method that uses AI to effectively score potential organs by comparing them to images of tens of thousands of other organs used in transplant operations.
The project is being backed by NHS Blood and Transplant (NHSBT), which has almost 7,000 people in the UK on its waiting list for a transplant.
“We at NHSBT are extremely committed to making this exciting venture a success,” said Prof Derek Manas, the organ donation and transplantation medical director of NHSBT.
“This is an exciting development in technological infrastructure that, once validated, will enable surgeons and transplant clinicians to make more informed decisions about organ usage and help to close the gap between those patients waiting for and those receiving lifesaving organs.”
Read full story
Source: The Guardian, 1 March 2023
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£14bn plan to reduce NHS cancer backlogs in England is failing, MPs say

A £14bn plan to reduce NHS backlogs caused by Covid is failing to meet targets, with cancer waiting times at their worst-ever levels, parliament’s spending watchdog has said.
A report by the Commons’ public accounts committee said NHS England’s three-year recovery programme for elective and cancer care, agreed in 2022, was already “falling short” in its first year and expressed serious doubts that the wider plan would be achieved on time.
MPs found that although the first target was to eliminate two-year waits for elective care by July 2022, there were 2,600 patients who had been waiting more than two years in August 2022, and a record 7 million people on waiting lists in total.
The recovery programme was overoptimistic, the report said. “NHS England made unrealistic assumptions about the first year of recovery, including that there would be low levels of Covid-19 and minimal adverse effects from winter pressures.”
Read full story
Source: The Guardian, 1 March 2023
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The mesh in my body is a 'ticking time bomb'

Sam Hindle has 23cm of polypropylene mesh in her body and lives in constant fear that it will become unstable and cause irreversible damage.
"You are in your own Battle Royale, strapped to a time bomb, and thinking when is it going to go off," she told the BBC.
Sam, 46, is one of hundreds of women in Scotland who have suffered life-changing symptoms since they had a transvaginal mesh implant.
After years of campaigning by the women, the Scottish government has promised it will cover the costs of mesh removal at private clinics in the UK and US.
But Sam has been waiting more than two years just for a referral to the Complex Mesh Surgical Service in Glasgow to start the process.
The Scottish government announced last year that it had signed a contract to allow NHS patients to visit a US expert for mesh removal surgery
The contract with Gynaecologic and Reconstructive Surgery of Missouri, where Dr Dionysios Veronikis operates, follows a similar contract agreed with Spire Healthcare in Bristol.
The cost of each removal procedure is estimated to be £16,000 to £23,000. But in order to access such treatment, women have to be assessed by the national service in Glasgow.
Women like Sam say there are waiting years to just get referred for assessment. With further delays for appointments and then waits for surgery.
Read full story
Source: BBC News, 2 March 2023
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Mental health of young adults severely impacted by pandemic

A new study has found that the pandemic has severely affected people’s mental health and relationships all over the world, particularly for young adults.
The third annual mental state of the world report (MSW) commissioned by Sapien Labs, a non-profit research organisation, conducted a global survey to better understand the state of mental health.
The research compiled responses from over 400,000 participants across 64 countries, asking respondents about their family relationships, friendships and overall mental wellbeing.
The survey found that there has been little recovery in declining mental health during the pandemic, which the group measures by a score called “mental health quotient”. It had found that average score had declined by 33 points – on a 300-point scale – over the past two years and still showed no signs of recovery, remaining at the same level as 2021.
Read full story
Source: The Guardian, 1 March 2023
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Age discrimination leading to avoidable eating disorder deaths, government warned

The government must end “age discrimination” against eating disorder patients that is causing avoidable deaths, experts have warned.
A cross-party parliamentary group and the Royal College of Psychiatrists are calling for access targets to make sure adults with eating disorders get treated within a set time. The demands come after the healthcare watchdog said patients were dying while waiting to be seen.
Wera Hobhouse, chair of the All Party Parliamentary Group, and Agnes Ayton, chair of the Royal College of Psychiatrists’ eating disorder committee, said the targets must be equal to those for children, which were set in 2016.
According to the Health Service Journal, 19 patients under the care of inpatient and community eating disorder services have died since 2017.
A senior coroner in Norfolk also highlighted failings in 2019 and sent a warning to both NHS England and the Department for Health and Social Care, over the deaths of five young women.
Read full story
Source: The Independent, 1 March 2023
To support Eating Disorders Awareness Week, we have pulled together eight useful resources to help healthcare professionals, friends and family support people with eating disorders:
Top picks: Eight resources on eating disorders  
Patient Safety Learning

Pharmacy leaders hit out at NHS England ads redirecting patients from GPs

Pharmacies do not have the capacity to absorb pressure from GPs unless it comes with additional funding, pharmacy leaders have warned.
A new NHS England ad campaign, announced earlier this week, aims to redirect patients from GP practices to local pharmacies for minor conditions such as coughs, aches, cystitis and colds.
But community pharmacy negotiating body PSNC has spoken out against the campaign calling it ‘deeply concerning’, ‘irresponsible, ‘extremely unhelpful’ and ‘irritating’.
Malcom Harrison, chief executive of the Company Chemists’ Association (CCA) said: ‘Community pharmacies are often the best place for patient to go for help with minor health concerns. 
‘However the current situation that many pharmacies find themselves, with a 30% cut in real term funding, the NHS recruiting their pharmacists and technicians to work in general practice and with the continuing increase in the number of medicines prescribed, will mean that there is now a very real risk that when patients visit a pharmacy, they will be faced by exhausted teams and longer than expected waiting times.
‘The NHS policy of moving asking patients to visit their local pharmacy does not address the problem of delays to access in primary care, it simply moves it from one pressurized location to another.  The NHS must address the chronic underfunding of primary care, and of pharmacy in particular, if patients are to be able to access the care they need and should rightly expect.’
Read full story
Source: Pulse, 28 February 2023
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Older and overweight patients ‘hampering efforts to clear NHS backlogs’

Older and overweight patients are making it harder to clear NHS surgery backlogs, anaesthetists have warned.
New data reveal an “extremely worrying picture” of increasing age, rates of obesity and complexity of surgical patients across the UK, the Royal College of Anaesthetists said.
The average age of patients requiring anaesthesia increased by 2.3 years, from 50.5 to 52.8, over the last decade, while their BMI also jumped from 24.9 (borderline normal/overweight) to 26.7 (overweight).
The proportion of patients who are complex or have other comorbidities has also significantly increased, the study found.
When patients are older, overweight and have other problems, this makes anaesthetic and surgical care more complicated and higher risk, the authors said. Managing these patients safely takes longer during surgery and can lead to slower recovery times, requiring more time in hospital.
Read full story (paywalled)
Source: The Telegraph, 2 March 2023
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More than half of humans on track to be overweight or obese by 2035

More than half of the world’s population will be overweight or obese by 2035 unless governments take decisive action to curb the growing epidemic of excess weight, a report has warned.
About 2.6 billion people globally – 38% of the world population – are already overweight or obese. But on current trends that is expected to rise to more than 4 billion people (51%) in 12 years’ time, according to research by the World Obesity Federation.
Without widespread use of tactics such as taxes and limits on the promotion of unhealthy food, the number of people who are clinically obese will increase from one in seven today to one in four by 2035. If that happens, almost 2 billion people worldwide would be living with obesity. Evidence shows that obesity increases someone’s risk of cancer, heart disease and other diseases.
Prof Louise Baur, the federation’s president, said the stark findings were “a clear warning that by failing to address obesity today, we risk serious repercussions in the future.
“It is particularly worrying to see obesity rates rising fastest among children and adolescents.”
Countries need to take “ambitious and coordinated action” as part of a “robust international response” to tackle the growing health and economic crisis that obesity involves, the federation believes.
“Governments and policymakers around the world need to do all they can to avoid passing health, social and economic costs on to the younger generation,” Baur added.
Read full story
Source: The Guardian, 2 March 2023
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‘Significant escalation’ in strike action, warns ambulance chief

Ambulance chiefs have warned of a ‘significant escalation’ in the strike action being planned by unions next week – saying the flexibilities that helped deal with previous walk-outs will no longer be available.
In a letter to local NHS leaders, seen by HSJ, North West Ambulance Service said unions are “becoming more stringent in their approach”, and the trust’s ability to respond to incidents will be severely weakened.
For the last day of strike action in February, the GMB union told NWAS it was abandoning exemptions (derogations) for category 2 calls, which include heart attacks and strokes.
The NWAS letter, sent yesterday, said the Unite union also now intends to take this approach on 6 March.
Last month the head of the London Ambulance Service said the reduced level of service in the capital “causes harm to our patients”
Read full story (paywalled)
Source: HSJ, 2 March 2023
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Misplaced tube contributed to first UK child Covid death, coroner rules

A misplaced medical tube contributed to the death of the first child in the UK to die after contracting Covid, a coroner has found.
Ismail Mohamed Abdulwahab, 13, of Brixton, south London, died of acute respiratory distress syndrome, caused by Covid-19 pneumonia, on 30 March 2020, three days after testing positive for coronavirus. He had a cardiac arrest before he died.
Ismail’s death prompted widespread alarm about the potentially lethal impact of Covid on children.
Hours before Ismail died, an endotracheal tube (ET) used to help patients breathe was found to be in the wrong position. A consultant in paediatric intensive care decided to leave it and monitor him.
Giving his judgment on Thursday, senior coroner Andrew Harris said: “I am satisfied that he [Ismail] would not have died when he did were it not for the tube misplacement.”
On Wednesday, the inquest at London Inner South London coroner’s court heard evidence from Dr Tushar Vince, a consultant in paediatric intensive care at King’s College hospital who treated Ismail on 29 March after he had been intubated.
Asked by Harris if it would be reasonable to put the positioning of the ET on the death certificate as one of the causes, Dr Vince said: “I think it would be reasonable to consider it, yes.”
She said: “I was so focused on the lungs I just didn’t see how high this tube was and I’m so sorry that I didn’t see it.”
Read full story
Source: The Guardian, 2 March 2023
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Covid inquiry: what stage is it at and what will it look at?

The Covid-19 Inquiry is a public inquiry to examine the UK’s response to the pandemic, as well as its wide-sweeping impact.
In the UK, at least 216,726 people have had Covid-19 mentioned on their death certificate since the start of the pandemic.
Multiple lockdowns, school closures and furloughs later, a public inquiry aims to gauge what lessons can be learned for the future.
Two preliminary hearings have already taken place on 28 February and 1 March. The next one will be on 21 March and will cover Scotland, including strategic issues, political governance, lockdowns and restrictions. The inquiry is chaired by Baroness Heather Hallett, a former Court of Appeal judge.
The inquiry has been split into three modules: resilience and preparedness, core UK-decision making; political governance, and the impact of Covid-19 on healthcare systems across the UK.
In Spring 2022, the inquiry held a public consultation on its draft terms of reference which allowed people to give their opinions on the topics the inquiry would cover.
The public inquiry has come under heavy criticism after it was announced that structural racism will not be explicitly considered.
Read full story
Source: The Independent, 2 March 2023
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Inside the A&E crisis: ‘We were lined up so patients wouldn’t see the bodies’

An NHS whistleblower has sacrificed his career to capture on hidden camera the brutal reality of working in an ambulance service.
After watching yet another patient die needlessly in the back of his ambulance, Daniel Waterhouse became a whistleblower. That decision would end his career with the NHS at the age of only 30.
Waterhouse, from Finchley, north London, said his decision to go undercover for a Channel 4 Dispatches programme to be broadcast on Thursday was not easy.
“I thought about it for quite a while,” said Waterhouse, an emergency medical technician who wore hidden cameras and microphones while on shift for the East of England Ambulance Service. “It was a moral choice, and there’s a caveat to that as well, because going undercover in those situations could be considered immoral and will draw criticism I’m sure.
“But I think patient safety outweighs that, and those occasions were so strong in my head that I thought, ‘If only some change can happen, where some people don’t have to go through that and die or suffer permanent disability, then it would be worth it’.”
Read full story (paywalled)
Source: The Times, 3 March 2023
 
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The patients who gave up waiting on the NHS

There are 625,000 people on a hospital waiting list in Scotland. That figure is the highest on record and equivalent to one in nine of the population.
Backlogs have soared since the Covid pandemic and more people faced with long waits are seeking private treatment.
An opinion poll commissioned by BBC Scotland suggests one in five of those who replied said they - or one of their family - had paid for private medical care in the past 12 months.
Most (73%) said they would have preferred to use the NHS.
Linda Fyfe, from South Ayrshire, was among those not prepared to wait for NHS treatment when she needed a hip replacement.
Within months Linda went from living with the "bearable" pain in her right hip to being unable to comfortably move more than 100 yards.
The 75-year-old said the pain changed her whole lifestyle and she could not wait between 12 and 18 months for an operation on the NHS.
The retired social work administrator was quoted £14,000 to go private in the UK but this was more than she could afford. She opted to have the same procedure done in Lithuania for about half the price. 
The Kaunas clinic that treated Linda said it sees about 10 people a month from Scotland and more from across the UK."I made the right decision. I couldn't have gone another year or 18 months and it might even have taken longer.
Read full story
Source: BBC News, 6 March 2023
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