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News

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

More than 175,000 appointments cancelled over three day junior doctors’ walk out

More than 175,000 patient appointments and surgeries were postponed this week during the three-day junior doctor walk-out, it has emerged.
NHS leaders have warned the strikes were the most disruptive yet with more appointments cancelled across three days than across any of the previous nurse strikes.
Data published by the NHS showed in total 181,049 patients had their care postponed, this included more than 5,000 mental health and hundreds of community health appointments. 
The news comes after nursing and ambulance unions accepted a pay offer from the government, for a 5.3 per cent increase in 2023-24, which their members will now vote on.
Read full story
Source: The Independent, 18 March 2023
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No one kept data on Tavistock children — it’s a monumental scandal

Twenty years ago, David Freedman helped to conduct an audit of the first 124 young people referred to the gender clinic, now he discovers it was never followed up.
David Freedman, 73, helped to conduct a clinical audit of the first 124 young people referred to the Gender Identity Development Service (Gids) from its inception in 1989. The London-based service, part of the Tavistock and Portman NHS Foundation Trust, is the only dedicated NHS clinic for transgender children.
When he discovered his clinical audit from two decades ago remained the only one conducted by the service, Freedman said he was “gobsmacked”, adding: “This was a service that was sailing into uncharted territory with vulnerable children and adolescents, where one has an extra duty of care, and the failure to collect any data in a coherent form to look at what they were doing . . . it’s pretty mind-boggling.”
Read full story (paywalled)
Source: The Times, 19 March 2023
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‘Insufficiently curious’ leaders ‘tolerated’ safety failures

Leaders at a mental health trust tolerated high levels of safety incidents and accepted verbal assurance with ‘insufficient professional curiosity’, a critical report has found.
An NHS England-commissioned review into governance at Tees, Esk and Wear Valleys Foundation Trust has been published, reviewing the organisation’s response to serious safety concerns flagged at the former West Lane Hospital in Middlesbrough.
It follows separate reports identifying “systemic failures” over the deaths of inpatients Christie Harnett, Nadia Sharif and Emily Moore.
The new report, conducted by Niche Consulting, criticises board and service leaders’ handling of concerns about the regular occurrence of restraint and self-harm.
More than a dozen incidents of inappropriate restraint, some seeing patients dragged along the floor, were identified in November 2018, resulting in multiple staff suspensions and some dismissals. 
Niche found there was a “lack of accountable leadership at all levels” and lack of evidence for decisions in response to the November 2018 incidents.
Read full story (paywalled)
Source: HSJ, 21 March 2023
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Trust told to pay more than £200k over dementia patient’s death

A hospital trust has been told to pay almost a quarter of a million pounds after pleading guilty to failing to provide safe care to a patient with advanced dementia who fatally injured himself. 
The Care Quality Commission (CQC) brought the prosecution against University Hospitals of Derby and Burton Foundation Trust after an incident in July 2019, when a patient died after absconding from the hospital.
Peter Mullis – who had advanced dementia – was admitted to Queen’s Hospital Burton emergency department and absconded twice. When he tried to a third time, he was followed by trust staff.
The CQC described how, despite being followed, Mr Mullis was able to climb over a barrier, fall down a grass bank and hit his head on concrete at the bottom. He was airlifted to the local trauma centre, but died of multiple traumatic injuries.
The CQC said UHDB did not take “reasonable steps” to ensure safe care was provided and that failure exposed Mr Mullis to “significant risk of avoidable harm”.
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Conference highlights racial disparity in UK maternal healthcare

Unconscious bias in the UK healthcare system is contributing to the stark racial disparity in maternal healthcare outcomes, a conference has heard.
The Black Maternal Health Conference UK, also heard that black women not being listened to by healthcare professionals was also a contributing factor.
The conference, organised by The Motherhood Group, was arranged to highlight the racial inequality in maternal healthcare and the disparity in maternal mortality between white, ethnic minority and black women in the UK.
Black women in the UK are four times more likely to die in pregnancy and childbirth than white women, according to a report published by MBRRACE-UK. Asian women are twice as likely to die in pregnancy or childbirth.
Sandra Igwe, who founded the NGO The Motherhood Group in 2016 after the traumatic birth of her daughter, told the PA Media that the event was an opportunity to “bridge the community, stakeholders, professionals, [and] government”, de-stigmatise mental health and bring about change to improve black maternal health.
“There are so many stats – so why wouldn’t we have a whole day’s conference dedicated to addressing these, just scratching the surface of some of the stats?”
Charities and activists have been raising alarm bells about the dangerous consequences of unconscious bias in maternal healthcare for many years. Igwe co-chaired the Birthrights inquiry, a year-long investigation into racial injustice in the UK maternity services, which heard testimony from women, birthing people, healthcare professionals and lawyers and concluded that “systemic racism exists in the UK and in public services”.
Read full story
Source: The Guardian, 20 March 2023
Sandra Igwe is our hub topic lead for Black Maternal Health. Read our recent interview with Sandra.
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Hundreds left with lost or damaged eyesight after NHS delays

Hundreds of patients have lost their eyesight or had it irreparably damaged because of NHS backlogs, new research suggests.
NHS England clinicians have filed 551 reports of patients who lost their sight as a result of delayed appointments since 2019, with 219 resulting in “moderate or severe harm”, according to an FoI request by the Association of Optometrists, which believes that hundreds more cases are unreported.
Its chief executive, Adam Sampson, said sight loss was a “health emergency”, and urged ministers to introduce a national eye health strategy to enable high street and community optometrists to ease some of the burden on hospitals.
He said: “There are good treatments available for common age-related eye conditions like macular degeneration but many hospital trusts simply do not have the capacity to deliver services.
“Optometry is ideally placed to take away some of that burden – optometrists are already qualified to provide many of the extended services needed and are available on every high street, so patients can be treated closer to home. It’s incomprehensible and absolutely tragic that patients are waiting, losing their vision, in many parts of the country because of the way eye healthcare is commissioned.”
Read full story
Source: The Guardian, 21 March 2023
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Warnings against 'reckless' weight loss surgery abroad

Seven British patients who travelled to Turkey for weight loss surgery died after operations there, a BBC investigation into the trend has found.
Others have returned home with serious health issues after having had gastric sleeve operations, during which more than 70% of the stomach is removed.
The operations, used to treat morbid obesity, are carried out in the UK, but, because it can take years to get one through the NHS, some people are looking abroad for treatment.
British doctors say that they're treating an increasing number of patients who have travelled to Turkey and returned with serious complications.
Dr Ahmed Ahmed, a leading surgeon and member of council at the British Obesity and Metabolic Surgery Society, says he's treated patients returning from Turkey who have had an entirely different operation to the one they understood they had paid for.
The BBC has also been told that some people are being accepted for surgery who do not have a medical need for it. The BBC contacted 27 Turkish clinics to see if they would accept someone for treatment who was considered to have a normal BMI. Six of the clinics we approached were happy to accept someone with a BMI of 24.5 for extreme weight loss surgery.
Separately, the BBC also found that some clinics who refused the treatment actually then encouraged patients to put on weight, to enable them to be accepted for surgery.
One said: "You need to gain 6.7kg to have sleeve surgery. I think you can easily eat some food and then lose weight easily." Another asked: "How soon can you gain weight?"
Dr Ahmed says the practices are "reckless" and "unethical".
Read full story
Source: BBC News, 21 March 2023
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Specialist NHS centres aim to halve maternity deaths in England

Women at risk of dying in pregnancy or childbirth will be treated at a network of specialist NHS centres under a national drive to halve maternal deaths.
For the first time, women in England with conditions such as heart disease, epilepsy or cancer will have access to specialist care from doctors trained to treat medical problems in pregnancy.
Two thirds of maternal deaths in the UK are due to medical conditions that pre-date or develop during pregnancy, rather than direct complications of birth. Previously there was no dedicated national service for these women.
The 17 NHS centres, covering every region of the country, aim to prevent these deaths by bringing together specialist doctors, obstetricians, midwives and nurses under one roof.
GPs and A&E staff will also be trained to identify “red flag” symptoms of illnesses in pregnant women and refer patients directly to the centres, where they can be assessed and receive medication or procedures.
Read full story (paywalled)
Source: The Times, 20 March 2023
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Thousands of English NHS 999 calls answered in Wales

Thousands of 999 calls are being transferred to the Welsh Ambulance Service because they are taking more than five minutes to answer in England, HSJ can reveal.
More than 50,000 calls – 1.2% of all made – were sent to a different ambulance service than the one intended between October and the middle of February, under a new system of routing unanswered calls was introduced.
It automatically diverts calls which have not been answered after five minutes, rerouting them to services with current capacity, while a BT operator remains on the line until the call is answered.
The Welsh Ambulance Service explained it records details from the transferred caller, prioritises the response level and provides lifesaving instructions if required, including having access to a national database of defibrillators.
However, it is unable to despatch ambulances outside its area and does not provide clinical assessment. Instead the details are transferred electronically into the “home” trust’s computer-aided despatch system.
Read full story (paywalled)
Source: HSJ, 21 March 2023
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UK GPs have the highest stress levels, finds survey of 10 countries’ doctors

GPs in the UK have some of the highest stress levels and lowest job satisfaction among family doctors, a 10-country survey has found.
British GPs suffer from high levels of burnout, have a worse work/life balance and spend less time with patients during appointments than their peers in many other places.
Heavy workloads, seemingly endless paperwork and feelings of emotional distress are prompting many GPs to stop seeing patients regularly or even retire altogether, the research found.
Seven in 10 (71%) NHS family doctors find their job “extremely” or “very stressful”, the joint-highest number alongside GPs in Germany among the countries analysed.
The Health Foundation, which undertook the survey, said its “grim” findings showed that the “unsustainable” pressures on GPs and number of them quitting pose a threat to the NHS’s future.
Patient Safety Learning

Unregulated ‘eating disorder coaches’ putting people at risk, say experts

Vulnerable mental health patients are being put at risk by unregulated “eating disorder coaches” who do not have the necessary qualifications, experts have said.
As demand for eating disorder support soars – hospital admissions for eating disorders increased by 84% in the last five years – more people are filling gaps in NHS care.
So-called eating disorder coaches, who tend to be personal trainers or dietitians recovering from the illness themselves, are charging as much as £1,000 a month for sessions to offer support to others despite having little or no training and expertise.
The Guardian has found that many coaches cite short courses, which are intended as professional development for psychologists, as a qualification to practise.
The National Centre for Eating Disorders (NCED) offers a number of professional training courses, accredited by the British Psychological Society (BPS). The Guardian found a number of coaches were using these courses to claim they were qualified to offer professional services to people with eating disorders.
Agnes Ayton, chair of the Royal College of Psychiatrists’ eating disorders faculty, said she was “amazed” to see people “advertising themselves as experts after going on one course”.
“Eating disorders sit between physical and mental health so the risks associated with eating disorders can be physically debilitating and potentially fatal,” Ayton said. “I don’t know why there is not better regulation on that because there is lots of regulation for a medical professional – but therapy is the first line of treatment for eating disorders, and if it is not delivered properly, it can be harmful or misleading.”
Read full story
Source: The Guardian, 21 March 2023
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Bristol children must be in crisis before autism referral, say parents

Children must now be in crisis before they can be referred for an autism diagnosis, parents claim.
The strict new eligibility criteria in the Bristol region comes after a 350% rise in the number waiting more than two years for assessment.
Changes made by the NHS mean children will only be referred with "severe and enduring" mental health issues.
The Integrated Care Board (ICB) said it meant resources could now focus on those with "the highest clinical need".
Some parents have launched the campaign Assess for Autism in protest against the rule change.
An Assess for Autism spokesperson said children would now have to be at crisis point before being referred, describing the policy as "deeply concerning" and "regressive".
However, healthcare provider Sirona, which provides autism diagnosis services, and the Integrated Care Board (ICB), which formally approved the new policy, insist it is necessary because families are waiting too long.
They said resources can now be focused on those with the "highest clinical need or are the most vulnerable".
Read full story
Source: BBC News, 22 March 2023
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Polio vaccine catch-up push to launch in London

London primary-school pupils not fully vaccinated against polio are to be offered catch-up jabs after Easter.
The disease, common in the UK in the 1950s, was eliminated by 2003. But poliovirus traces were found in north and east London sewage in early 2022.
An emergency vaccination-booster campaign in London last summer reached more than 370,000 children.
And in early November, the latest tests found less of the virus - but officials say there is no room for complacency.
Dr Vanessa Saliba, from the UK Heath Security Agency, told BBC News: "We have early signs that there's less spread of poliovirus in London - but we will need 12 months of no detections before the World Health Organization could declare that the UK is no longer an infected country."
Polio causes paralysis in a very small number of cases where the virus attacks the nerves in the spine and base of the brain - but most are asymptomatic.
Read full story
Source: BBC News, 23 March 2023
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‘I worry my young patients will die’: UK’s eating disorder services not fit, say GPs

Young people with eating disorders are coming to harm and ending up in A&E because they are being denied care and forced to endure long waits for treatment, GPs have revealed.
NHS eating disorders services are so overwhelmed by a post-Covid surge in problems such as anorexia that they are telling under-19s to rely on charities, their parents or self-help instead.
The “truly shocking” findings about the help available to young people with often very fragile mental health emerged in a survey of 1,004 family doctors across the UK by the youth mental health charity stem4.
The shortage of beds for children and young people with eating disorders is so serious that some are being sent hundreds of miles from home or ending up on adult psychiatric wards, GPs say.
“The provision is awful and I worry my young patients may die,” one GP in the south-east of England told stem4. Another described the specialist NHS services available in their area as “virtually non-existent and not fit for purpose”.
Read full story
Source: The Guardian, 22 March 2023
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‘Fifth of UK hospitals cancelled operations’ during three days of 2022 heatwave

A fifth of UK hospitals were forced to cancel operations during the three days in July last year when temperatures soared, research suggests.
The findings, published in a letter to the British Journal of Surgery, are based on surveys from surgeons, anaesthetists and critical care doctors working during the heatwave from July 16-19 2022, when temperatures reached as high as 40C in some parts of the country.
The researchers received 271 responses from 140 UK hospitals – with one in five (18.5%) reporting elective surgeries being cancelled due to the heatwave.
The respondents also said surgical services were poorly prepared for heatwaves, with 41% of operating theatres having no means to control ambient temperature, while more than a third (35.4%) reported making changes to maintain routine surgical activity during the period.
These include delayed discharge of high-risk patients, changes to surgical teams, selecting lower-risk patients to have surgery, and restricting surgical activity to day cases.
Other measures included longer staff breaks, extra fluids to patients, and surgeries earlier in the morning when temperatures were lower.
Read full story
Source: The Independent, 23 March 2023
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Mum was given her baby's remains in supermarket carrier bag

A terminally ill mother says she was "horrified" after she was handed her baby's remains in a supermarket carrier bag by NHS officials.
Lydia Reid's son Gary was a week old when he died in 1975. She later discovered his organs had been removed for tests without her permission and only received them last month after almost 50 years of campaigning.
The 74-year-old, told BBC Scotland she was visited last month by the head of NHS Lothian as well as another senior NHS official.
"I thought they were coming to help me sign some papers. When they arrived I noticed one of them was carrying a Sainsbury's carrier bag," Ms Reid said.
"Then they said they wanted to complete the list of body parts in case anything had been missed out. She handed me the Sainsbury's bag and said she wanted me to check them now."
Inside the carrier bag was a six-inch box containing body parts preserved in wax.
"I was so shocked and said 'How dare you. That is the only parts of my son and you want to hand them to me in a carrier bag.
"I was absolutely horrified. She said she didn't realise it would be a problem."
Tracey Gillies, medical director for NHS Lothian said: "I would like to repeat publicly the apology we made to Ms Reid in person for the upset and distress this has caused.
Ms Reid has been a leading figure in the Scottish campaign to expose how hospitals unlawfully retained dead children's body parts for research.
Read full story
Source: BBC News, 23 March 2023
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