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Patient Safety Learning

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  1. News Article
    A carer who murdered the elderly woman he was employed to look after had a history of violent crime including actual bodily harm, a report found. A safeguarding adults review over the death of a 77-year-old Devon woman in 2021 criticised working practices among organisations involved in her care. Devon and Cornwall Police did not disclose information about domestic abuse callouts involving the killer in a DBS check by the care provider. He was jailed for life in July 2022. The woman had seen her killer as "a grandson" figure, it said. The 35-year-old killer attacked hi
  2. News Article
    There is now an "imminent threat" of measles spreading in every region of the world, the World Health Organisation and the US public health agency has said. In a joint report, the health organisations said there had been a fall in vaccines against measles and less surveillance of the disease during the COVID pandemic. Measles is one of the most contagious human viruses but is almost entirely preventable through vaccination, though it requires 95% vaccine coverage to prevent outbreaks. A record high of nearly 40 million children missed a dose last year because of hurdles created
  3. News Article
    NHS England’s national cancer director has said that she is “cautiously optimistic” about reaching cancer waiting time targets by March 2023, but she refused to be drawn on what had happened to the government’s proposed 10 year cancer plan. Cally Palmer was speaking to MPs on the Health and Social Care Committee at a special one-off session on the urgent challenges facing cancer services, including workforce shortages, winter pressures, and poor performance. Latest figures from September, published on 10 November, show that 60.5% of patients began their first treatment within 62 days
  4. News Article
    Nicola Sturgeon has been accused of running a two-tier NHS after it emerged that tens of thousands of patients are going private for crucial operations and healthcare. Anas Sarwar, the Scottish Labour leader, cited figures that showed more than 39,000 patients underwent private procedures in the past year. These included thousands of hip and knee surgeries, costing an average of £12,500 per patient. “Often these are people who are forced to borrow money, turn to family and friends, or even remortgage their home to get healthcare that should be free at the point of need,” Sarwar told
  5. News Article
    Bosses at Nottingham's crisis-hit maternity units are set to miss a deadline for clearing a backlog of incomplete "serious incident" investigations. Nottingham University Hospitals Trust (NUH) has 53 outstanding maternity incidents yet to be investigated. The trust had said it aimed to complete investigations by December 23. But director of midwifery Sharon Wallis says they have not progressed as quickly as she had hoped. The Local Democracy Reporting Service said the trust has managed to clear a number of those incidents - but it declared another nine in September and Octo
  6. Content Article
    The workshops brought together a group of patients, whose recommendations for specialist advice and guidance are: Establish a three-way dialogue between the patient, GP, and the specialist to ensure patient partnership and shared decision making. Streamline the referral process for GPs to get the advice. Include pharmacists into the advice and guidance process. The group also suggested ways to better engage patients in the service: Consider the individual’s care and communication needs. Allow patients to add information to the e-referral system and incre
  7. Event
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    This Westminster conference will assess priorities and next steps for addressing the impact of Long Covid in Ireland. Areas for discussion include developing and implementing research into Long Covid, the state of specialised services in Ireland, and the implementation and development of the Model of Care, which recommended the development of eight post-acute and six Long Covid clinics. It will be a timely opportunity to discuss Ireland’s strategy for tackling long COVID following analysis from Denis Naughten TD - who is part-chairing this conference - which suggests that almost 340,
  8. Event
    Register
  9. News Article
    The NHS in England is facing a “perfect winter storm” with 10 times more people in hospital with flu than this time last year, and ambulances experiencing deadly delays when arriving at A&E with sick patients. There were an average of 344 patients a day in hospitals in England with flu last week, more than 10 times the number at the beginning of last December. And as many as 3 in 10 patients arriving at hospitals by ambulance are waiting at least 30 minutes to be handed over to A&E teams. Health chiefs say the crisis is leading to deaths. The figures on flu and ambulance
  10. News Article
    Hospital doctors failed to share with child protection services a list of "significant" injuries a five-year-old boy suffered 11 months before he was murdered, a case review has found. Logan Mwangi had a broken arm and multiple bruises across his body when he was taken to A&E in August 2020. But a paediatric consultant said these injuries were accidental and did not make a child protection referral. Logan, from Bridgend, was murdered by his mother, stepfather and a teenager. A Child Practice Review (CPR) has looked at how different agencies were involved with Logan's family
  11. News Article
    The rate of people from black backgrounds being restrained in mental healthcare has more than doubled in the past six years, widening the gap with other racial groups, according to official NHS data. Standardised rates of black and black British people subject to restrictive interventions – including physical, chemical and mechanical restraints – have leapt from 52.1 per 100,000 people in 2016-17 to 106.2 in 2021-22. That is compared to a much smaller increase of 30% in the same period for people from white backgrounds, from 15.8 per 100,000 to 20.5. NHS race and health observat
  12. News Article
    Nurses across the UK will go on strike for the first time over two days in the fortnight before Christmas after ministers rejected their pleas for formal talks over NHS pay. The Royal College of Nursing (RCN) said its members would stage national strikes – the first in its 106-year history – on 15 and 20 December. Senior sources said the industrial action was expected to last for 12 hours on both days – most likely between 8am and 8pm. The unprecedented national industrial action will seriously disrupt care and is likely to be the first in a series of strikes over the winter and into
  13. News Article
    Nine acute trusts accounted for a third of all ‘hours lost’ to ambulance handover delays last week, according to new data. The first NHS England winter sitrep data showed wide variation between providers on ambulance handover performance, with a small number of providers accounting for a huge proportion of delays. There were nine trusts where, for each ambulance arrival in the week to 20 November, an average (mean) of more than an hour was lost to handover delays. The providers accounted for around 7,000 hours lost, 33% the national total, despite only accounting for 7% of ambulance
  14. News Article
    Ministers have effectively ditched NHS England’s planned new bundle of A&E targets and want trusts to be firmly regulated on the existing four-hour standard and 12-hour breaches, HSJ understands. Multiple senior figures familiar with the process, from inside the NHS and government, said the performance focus for the next two years will be on the two existing accident and emergency waiting time measures, as well as ambulance handover delays. For the last three years, NHS England has been lobbying government to scrap the headline four-hour target, and replace it with a bundle of me
  15. News Article
    A report by the Scottish Public Services Ombudsman (SPSO) said the health board's own investigation into the patient's complaint was of "poor quality" and "failed to acknowledge the significant and unreasonable delays" suffered. The delays led 'Patient C' to develop a severe hernia which left them unable to work, reliant on welfare benefits, and requiring riskier and more complex surgery than originally planned. The watchdog criticised NHS bosses for blaming Covid for the delays when the patient had been ready for surgery since December 2018, and said there had been "no sense of urge
  16. News Article
    For the first time, more than 2.5 million people in the UK are out of work because of a long-term health problem. The number has jumped by half a million since the start of the pandemic - but, BBC News analysis reveals, the impact is spread unevenly across the country, with some regions and types of job far more affected. For Mary Starling, there are good days and bad days. The 61-year-old is on strong painkillers, for arthritis. She needs a knee replacement - but that could mean another 18 months on an NHS waiting list. Mary is keen to return to that work - but needs her operat
  17. Content Article
    What the SPSO found: The length of time the patient waited for a flexible sigmoidoscopy to be carried out was unreasonable. The use of a 'named person' list led to an unreasonable delay in carrying out a flexible sigmoidoscopy. The length of time the patient waited to been seen at an outpatient clinic in January 2020 to discuss surgery following a flexible sigmoidoscopy was unreasonable. The length of time patient waited for their planned surgery was unreasonable. The Board failed to address and acknowledge the significant and unreasonable delays in the patient'
  18. News Article
    The NHS staffing crisis will be solved only if doctors and nurses get more flexible about their job descriptions and break down barriers between roles, according to Rishi Sunak’s health adviser. Bill Morgan argues that training times for doctors and nurses may have to be reduced, and suggests developing “sub-consultants” and entirely new medical professions, He wants ministers to create an Office for Budget Responsibility-style body to predict future workforce needs. The Treasury has held down the numbers of doctors and nurses Britain trains to prevent “supply-induced demand”, which
  19. News Article
    Ministers are considering the use of body cameras within mental health units as part of the government’s response to NHS abuse scandals, The Independent has learned. Senior sources with knowledge of the conversation between the Department for Health and Social Care and the NHS have raised concerns about the plans. There are fears that using the technology in mental health units could have implications for human rights and patient confidentiality. One senior figure criticised the proposals and said: “The DHSC are all talking about body-worn cameras, closed circuit TV, etc... The whole
  20. News Article
    Ambulance crews could not respond to almost one in four 999 calls last month – the most ever – because so many were tied up outside A&Es waiting to hand patients over, dramatic new NHS figures show. An estimated 5,000 patients in England – also the highest number on record – potentially suffered “severe harm” through waiting so long either to be admitted to A&E or just to get an ambulance to turn up to help them. Ambulance officers warned that patients were dying every day directly because of the delays since the service could no longer perform its role as a “safety net” for
  21. News Article
    Greater Manchester’s mental health trust has been placed into the ‘equivalent of special measures’, the Manchester Evening News can reveal. The crisis measures enforced by the NHS come after allegations that patients were abused at a mental health unit run by the beleaguered trust. The Edenfield Centre is a mental health care facility in the grounds of the former Prestwich Hospital and was the subject of a BBC Panorama programme that claims patients were abused. Since the episode aired, 30 staff are facing disciplinary action and a dozen have already been sacked, the Manchester Evening Ne
  22. News Article
    A maternity unit criticised for the preventable stillbirth of a baby is under investigation after the unexpected death of a second baby. The newborn baby died in December last year after her birth at the standalone midwifery-led unit (MLU) at Lagan Valley Hospital in Lisburn. Despite this, the unit continued to operate as normal for another three months when the South Eastern Trust temporarily paused births at the MLU. The second tragedy came four years after Jaxon McVey was stillborn when his delivery at the unit went catastrophically wrong. A post-mortem found he died as
  23. News Article
    Attending physicians and advanced practice clinicians in US emergency departments are more concerned about medical errors resulting in patient harm than in malpractice litigation, according to a study published JAMA Network Open. The findings are based on an online survey of 1,222 ED clinicians across acute care hospitals in Massachusetts from January to September 2020. Respondents used a Likert scale of 1 (strongly disagree) to 6 (strongly agree) to indicate their degree of agreement with statements on how fearful they are of making a mistake that leads to a patient harm in their day-to-
  24. News Article
    A young mother lost both her feet and all 10 fingers to sepsis after a significant delay in treatment, an investigation has found. Sadie Kemp has been left permanently disabled from the “dangerous condition”, whilst an NHS hospital probe found a 3.5 hour delay in starting her care. Sadie is now calling for lessons to be learned after the internal report found numerous concerns in her treatment that ultimately led to her needing multiple amputations. The 35-year-old mother-of-two first attended A&E with agonising back pain caused by a kidney stone on Christmas night 2021.
  25. News Article
    Performance failings at NHS Supply Chain are impacting patient care, staff wellbeing and retention, and local procurement teams are struggling to mitigate their impact, local procurement chiefs have claimed. The group of senior NHS buyers have raised their concerns in a highly critical letter to NHS Supply Chain chief executive Andrew New and NHS England’s chief commercial officer Jacqui Rock. The letter, seen by HSJ, was signed by 22 heads of procurement at trusts and integrated care systems. It raises concerns about the NHSSC’s core functions, like delivering products on time and i
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