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

Watchdog calls for review of menopause link to poor mental health after woman’s suicide

The link between menopause and poor mental health should be reviewed, the health watchdog has said, after an inquiry into a woman’s suicide found staff lack training to spot the risks.
Frances Wellburn, 56, took her own life in 2020 after she was incorrectly assessed as being a “medium risk” of suicide by Tees, Esk and Wear NHS Trust (TEWV).
A national study by the Health and Safety Investigation Branch (HSIB), prompted by her death, warned that this was a national problem, with funding and capacity problems driving staff to use ineffective “checklist” tools when assessing suicidal patients.
HSIB also found staff were not trained to spot mental health risks associated with menopause, and menopause is not routinely considered a contributing factor among women with low mood who need help.
It said that women are often prescribed antidepressants when hormone replacement therapy (HRT) would be more appropriate.
In Ms Wellburn’s case, HSIB found TEWV staff had failed to take into account that she was going through menopause when they assessed her as being at medium risk of self-harm. This went against national guidance, which states scales should not be used to predict future suicide or self-harm.
Read full story
Source: The Independent, 23 March 2023
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Four-day junior doctor strike set for April

Junior doctors are to stage a four-day walkout in April in their fight to get a 35% pay rise in England.
Members of the British Medical Association (BMA) will take strike action from 11 April to 15 April.
Last week's walkout led to the cancellation of 175,000 treatments and appointments, with consultants brought in to provide cover in emergency care.
Hospitals bosses said the fallout from the strike would last weeks given the huge number of bookings that have to be rescheduled.
The new walkout of both planned and emergency care comes directly after the Easter weekend, which tends to be a busy period for the NHS.
Saffron Cordery, of NHS Providers, the membership organisation for NHS trusts in England, said demand would have built up over the bank holiday weekend.
"This threatens the biggest disruption from NHS walkouts so far," she said, adding: "There should be no doubt about the scale of the impact on patients, staff and the NHS."
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Source: BBC News, 23 April 2023
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Three-year wait for Essex girl, 8, to have tooth removed

An eight-year-old girl waiting three years to have three teeth removed has been left in "agony".
Ella Mann, from Dovercourt in Essex, first went to the dentist with an issue with a baby tooth in December 2019.
She was given a temporary filling and told it needed to be removed but has still not had the NHS procedure.
The youngster has now been placed on an NHS waiting list for the tooth extraction.
Ella's dad Charlie Mann, 54, said his daughter was sometimes in "agony".
Healthwatch England last year warned of people struggling to get dental treatment as increasing practices closed to new patients.
A BBC investigation identified cases of people driving hundreds of miles in search of treatment and pulling out their own teeth without anaesthesia.
Read full story
Source: BBC News, 23 March 2023
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NHS to miss April deadline to end 78-week waits by around 11k patients

National NHS forecasts are predicting there will be around 11,000 patients on the elective waiting list who have been waiting longer than 78 weeks at the start of April, the target for clearing this cohort, HSJ understands.
Senior NHS figures familiar with the forecasts told HSJ they had stood at around 9,000 last week, but mass cancellations during the three-day junior doctors’ strike had pushed up the potential outstanding cases by approximately 2,000.
One senior NHS figure close to national efforts said they “hoped” trusts could cut the figure to under 10,000 by the deadline, and that intense work was going on across systems to ensure the figure was as small as possible. 
It is understood system leaders expect the 78-week breach figure to be cut to around 2,000 by the summer. However, as has been the case for the 104-week breaches, they are also predicting a long tail due to a combination of complex cases and patients choosing to wait longer.
Read full story (paywalled)
Source: HSJ, 23 March 2023
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Police investigating ‘sexual assault’ at scandal-hit children’s hospital as watchdog threatens closure

Police are investigating fresh allegations of sexual assault against a child patient by a care worker at a scandal-hit private mental health hospital group.
It is the second time reports have been made about a former Huntercombe Group hospital after two care workers were quizzed over the alleged rape of a child at its Taplow Manor Hospital in Maidenhead last year.
The latest allegations are from a patient at the group’s Ivetsy Bank Hospital, in Staffordshire, which was rated as inadequate last week. In a statement, Staffordshire Police confirmed it had received a report of sexual assault and said inquiries were ongoing.
The news comes as the NHS’s safety watchdog has threatened to close Taplow Manor after hospital leaders failed to make improvements in care.
The action comes after joint investigations by The Independent and Sky News found the private hospital had put the safety of young mental health patients at risk, with more than 50 patients and staff members alleging “systemic abuse” and poor care.
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Source: The Independent, 24 March 2023
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USA: Healthcare leaders, staff differ on safety culture views

US clinical and nonclinical healthcare workers have an upward-trending perception of safety culture, but physicians and leaders do not agree, according to a Press Ganey report.
Press Ganey, a US company that focuses on patient satisfaction surveys, found in its annual safety culture trends report that senior management perceptions of all safety culture metrics are lower. Overall safety scores are down 0.04 points, prevention and reporting decreased 0.02 points, pride and reputation declined 0.05 points, and resources and teamwork are down 0.04 points. 
The report analysed 2022 data from 813,900 healthcare workers across 194 systems and 3,279 facilities.
"Senior management safety culture scores are typically higher than those of operational management, suggesting a more positive perspective among those at the highest levels of provider organizations," the report said. "Yet the continued downward trajectory of senior management scores stands out as significant." 
Among physicians, pride and reputation fell 0.12 points. Their perceptions of overall safety declined 0.06 points, prevention and reporting is down 0.03 points, and resources and teamwork is down 0.05 points. 
Other healthcare employees had higher perceptions of these metrics except for pride and reputation. Also, "fewer employees today say they would recommend their organization for care than in previous years," Press Ganey found. 
Read full story
Source: Becker's Hospital Review, 21 March 2023
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CQC’s ICS ratings put on hold

Plans for integrated care systems (ICSs) to be given Care Quality Commission (CQC) ratings are on hold, and no ratings will be issued until summer 2024 at the earliest, HSJ  understands. 
The government had previously said ICSs would be given ratings – after pressure from Jeremy Hunt, then Commons health committee chair and now chancellor – and there was an expectation the process would begin next month. 
However, while legislation says the CQC will review and assess ICSs, it does not require it to give ratings. 
HSJ understands the Department of Health and Social Care supports the CQC beginning early work on assessing ICSs shortly, but does not plan to sign off on ratings being issued, nor set any date for that to happen. 
It means that, at the very earliest, more detailed reviews leading to ratings could happen from spring/summer 2024. One source with knowledge of the decision said there was not strong support for ratings work to start, and the CQC still needed to do a lot of work to adapt its approach to ICSs. 
Read full story (paywalled)
Source: HSJ, 27 March 2023
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Two-thirds of UK workers with Long Covid have faced unfair treatment, says report

UK ministers should act to ensure Long Covid sufferers receive the support they need from employers, with as many as two-thirds claiming they have been unfairly treated at work, a report argues.
The report, from the TUC and the charity Long Covid Support, warns that failing to accommodate the 2m people who, according to ONS data, may be suffering from long Covid in the UK will create, “new, long-lasting inequalities”.
The analysis is based on responses from more than 3,000 long Covid sufferers who agreed to share their experiences.
Two-thirds said they had experienced some form of unfair treatment at work, ranging from harassment to being disbelieved about their symptoms or threatened with disciplinary action. One in seven said they had lost their job.
The report makes a series of recommendations, including urging the government to designate Long Covid as a disability for the purposes of the 2010 Equality Act, to make clear sufferers are entitled to “reasonable adjustments” at work; and to classify Covid-19 as an occupational disease to allow people who contracted it through their job to seek compensation.
Read full story
Source: The Guardian, 27 March 2023
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Australia: brain surgeon defends slapping patient after surgery

The high-profile Australian neurosurgeon Charlie Teo admits making an error by going “too far” and damaging a patient, but maintains she was told of the risks.
The doctor on Monday appeared at a medical disciplinary hearing to explain how two women patients ended up with catastrophic brain injuries.
Teo also defended allegations that he acted inappropriately by slapping a patient in an attempt to rouse her after surgery, contrasting it with Will Smith’s notorious slap of Chris Rock at the Academy Awards last year.
“It wakes them up and it wakes them up pretty quickly. And I will continue to do it.”
Charlie Teo tells inquiry he ‘did the wrong thing’ in surgery that left patient in vegetative state
One of the issues the panel of legal and medical experts is considering is whether the women and their families were adequately informed of the risks of surgery.
Both women had terminal brain tumours and had been given from weeks to months to live. They were left in essentially vegetative states after the surgeries and died soon after.
“We were told he could give us more time,” one of the husbands said, according to court documents. “There was never any information about not coming out of it".
Read full story
Source: The Guardian, 27 March 2023
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‘Waiting to die’: Woman’s agonising transplant surgery delay as waiting list hits 10-year high

A young woman receiving end-of-life care says she is “just waiting to die” as an agonising three-year wait for a kidney transplant has left her “living like a prisoner”.
Diana Isajeva is one of approximately 7,000 patients who are on the waiting list, according to the NHS Blood and Transplant service (NHSBT) – the highest figure in a decade.
The 29-year-old was due to have a transplant last year but was denied it at the last minute, after the living donor she was matched with pulled out just 24 hours before her planned surgery.
Data from NHSBT shows that the rate of families giving consent for their loved ones’ organs to be donated has dropped – despite a change in the law in 2020 aimed at boosting the number of organs available, which means that consent for donation is now presumed after death.
Professor Peter Friend, transplant lead for the Royal College of Surgeons (RCS), said decreasing donor rates are a “big challenge” and that it is concerning that the number of donations has not yet recovered to its pre-pandemic level.
Read full story
Source: The Independent, 27 March 2023
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Apologies for 2013 mental health failings over mum

A son has accepted a settlement and an apology from the north Wales health board nearly 10 years after his mother was a patient in a mental health unit.
Jean Graves spent nine weeks at the Hergest unit in Ysbyty Gwynedd in Bangor in 2013 after struggling with anxiety and depression.
Her son David said she was left "severely malnourished" and fell.
He previously said his mother - who was 78 when she was treated at the unit - collapsed six times and, over the course of six weeks, lost 25% of her body mass.
The health board also apologised for the "distress" the family experienced while seeking answers "over many years" and said it hopes to "learn and improve" from Mr Graves's experience.
In a letter to him, executives said: "It is very clear to us that we have failed your mother and that she should have had a better care whilst in our services."
It said her records were incomplete or were "amended without proper evidence" and she was placed on a ward with a mix of patients with both psychiatric illness and older organic mental illness, which was not "best practice".
Read full story
Source: BBC News, 26 March 2023
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NHS staff shortages in England could exceed 570,000 by 2036, leaked document warns

The NHS in England needs a massive injection of homegrown doctors, nurses, GPs and dentists to avert a recruitment crisis that could leave it short of 571,000 staff, according to an internal document seen by the Guardian.
A long-awaited workforce plan produced by NHS England says the health service is already operating with 154,000 fewer full-time staff than it needs, and that number could balloon to 571,000 staff by 2036 on current trends.
The 107-page blueprint, which is being examined by ministers, sets out detailed proposals to end the understaffing that has plagued the health service for years. It says that without radical action, the NHS in England will have 28,000 fewer GPs, 44,000 fewer community nurses and an even greater lack of paramedics within 15 years.
However, the Guardian understands that the chancellor, Jeremy Hunt, is playing a key role in behind-the-scenes moves by the Treasury to water down NHS England’s proposals to double the number of doctors that the UK trains and increase the number of new nurses trained every year by 77% – because it would cost several billion pounds to do that.
A senior NHS leader said: “Jeremy Hunt has been very resistant to the numbers in the workforce plan. The Treasury and Hunt don’t want numbers in it. They want it to be not very precise. They want the numbers to be projected in a different way that would be less expensive and to not commit to training specific numbers of doctors, nurses and others.
“While intellectually Hunt gets it, and emotionally he gets the patient safety argument, it seems that his priority, if the government has any financial headroom, is to use that for tax cuts or giving the army more money rather than training more doctors, nurses and speech and language therapists.
Read full story
Source: The Guardian, 26 March 2023
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Hull A&E is a 'death trap', whistleblowers warn

Whistleblowers have described the accident and emergency (A&E) department at Hull Royal Infirmary as "incredibly dangerous" and a "death trap".
The Care Quality Commission (CSC) found Hull University Teaching Hospitals required improvement overall and its A&E department was rated inadequate.
Two clinical staff members, who wished to remain anonymous, described it as a "toxic" place to work.
Speaking to the BBC, the two staff members who have worked in Hull's A&E department said they had raised concerns with senior managers and the CQC.
They said there were frequently fewer staff than needed and warned inexperienced staff, one whom had never seen a cardiac arrest, were working in areas like resuscitation, which was "incredibly dangerous".
"Nurses who aren't even signed off to give oral medication are being put in resuscitation," one said.
"It's a death trap, it is terrifying."
Despite these concerns, CQC inspectors in December and November did find the service "had enough nursing and support staff to keep patients safe".
Read full story
Source: BBC News, 28 March 2023
 
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My daughter took her own life after pain caused by mesh surgery

A woman whose daughter took her own life after being left in chronic pain caused by giving birth has spoken of her family's heartbreak.
Sara Baines, 34, from Flintshire, died in September last year leaving her family devastated.
This week an inquest heard Sara suffered from chronic pain due to complications resulting from surgical mesh that was implanted after she gave birth in 2011.
Her mother, Alison Sharrock, says Sara was failed by the health system on multiple occasions.
Sara bled heavily whilst giving birth and suffered a second-degree tear. She had to have two surgeries to repair the tear, neither of which was completely successful. Sara found herself completely incontinent, at the age of 24.
In 2015, Sara was advised to have mesh fitted.
Alison said: "We were told the mesh was a 'quick-fix'. It felt like the answer to all her problems and she was thrilled. She had surgery but afterwards, though the incontinence improved, she had terrible abdominal pain."
The pain became so severe that Sara was offered a hysterectomy, aged 28. Afterwards, the pain only intensified, and her general health deteriorated. She suffered water infections, skin rashes, gum disease and unexplained pain. Unable to eat or sleep, she became depressed and anxious.
"She felt nobody was really listening to her. She felt she was gaslighted and fobbed off," said Alison.
Kath Sansom, founder of Sling The Mesh which has almost 10,000 members suffering irreversible pan and complications from surgical mesh implants, said: "Our hearts go out to Sara's family. Nine out of 10 people in our support group were not told any risks of having a plastic mesh permanently implanted."
Read full story
Source: Mail Online, 24 March 2023
Further reading on the hub:
Doctors’ shocking comments reveal institutional misogyny towards women harmed by pelvic mesh “There’s no problem with the mesh”: A personal account of the struggle to get vaginal mesh removal surgery ‘Mesh removal surgery is a postcode lottery’ - patients harmed by surgical mesh need accessible, consistent treatment 
Patient Safety Learning

Trust fears medics will be ‘harassed’ if it publishes surgery report

Two external reviews have been carried out into a trust’s general surgery services amid concerns about whether it is a ‘safe interpersonal working environment’.
But University Hospitals Sussex Foundation Trust has refused to make the reviews – which were both completed last year – public, partly because of what it says are concerns that they could lead to “harassment” of doctors who spoke to the authors.
Both reviews were into aspects of the general surgery services at the Royal Sussex County Hospitals in Brighton. The trust has had a series of highly critical Care Quality Commission reports into some of its surgical services and a “well led” report is expected to be released in the next few weeks.
The trust has refused HSJ’s Freedom of Information Act request to release the reviews, arguing that those interviewed had been promised confidentiality, and the issues involved are “emotive and sensitive matters”.
“Disclosure could cause those involved in the reviews damage, distress and upset and could even lead to harassment,” it said.
Read full story
Source: HSJ, 27 March 2023
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Birmingham hospital apologises after delays leave baby disabled

Dilshad Sultana was 36 weeks pregnant with her second child in 2019 when she experienced stomach pain and noticed her baby was moving less.
Mrs Sultana, from Sutton Coldfield, said she had been due to have a Caesarean section on 8 July but on 20 June she started to feel pain in her abdomen and lower back.
She said she was confused but that it did not feel like a contraction and called hospital staff at about 17:00 to say it felt like her baby was moving less.
After following advice to rest and take pain relief, she attended hospital at about 22:30 and staff started monitoring Shanto's heart rate.
It was not until almost three hours later that Shanto was delivered by emergency C-Section. Shanto suffered severe brain damage and would spent the next 22 days in intensive care, suffering seizures and multiple brain haemorrhages.
Shanto now requires around-the-clock care and Mrs Sultana enlisted lawyers to pursue a care of medical negligence against the trust.
Birmingham Women's and Children's NHS Foundation Trust has admitted liability and made a voluntary interim payment allowing the family to move to a new home specifically adapted to meet Shanto's extensive care, therapy and equipment needs.
Fiona Reynolds, the chief medical officer, said: "We'd like to offer our heartfelt apologies again to the family.
"It's clear the standard of care we offered to them fell below those required and expected. For this, we are truly sorry."
Now, Mrs Sultana is campaigning for change - she wants to see mothers listened to in maternity care and more attention paid to monitoring babies' heart rates.
Read full story
Source: BBC News, 27 March 2023
 
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