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Patient Safety Learning

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  1. Patient Safety Learning
    Families have been told they will have to prove liability for the harm caused to mothers and children at East Kent Hospitals University Foundation Trust before getting compensation.
    This is despite the inquiry having examined each case in detail and concluding 45 babies could have survived, while 12 who sustained brain damage could have had a different outcome. It also determined 23 women who either died or suffered injuries might have had better outcomes had care been given to “nationally recognised” standards. 
    However, NHS Resolution – which handles claims for clinical negligence – now says families must prove causation and a breach of duty of care before any compensation can be made. This stipulation has been made even in cases where the inquiry found different treatment would have been reasonably expected to make a difference to the outcome.
    The investigation into the trust’s maternity care led by Bill Kirkup reported 18 months ago. Speaking to HSJ, its author said: “I am disappointed that East Kent families are facing these problems after everything that has happened to them. Of course, it is true that the independent investigation panel was not in a position to rule on negligence, but we did provide a robust clinical assessment of each case.
    “I would have hoped that this could be taken into account in deciding to offer early settlement instead of a protracted dispute. It seems sad that a more compassionate approach has not been adopted.”
    Read full story (paywalled)
    Source: HSJ, 2 April 2024
  2. Patient Safety Learning
    Kara Dilliway was just three years old when she came down with a common ear infection in October 2022.
    She recovered quickly, as was expected, but just days after the infection cleared her parents found she was struggling to hear and talk.
    “We’d noticed she’d just started to say yes and no to things, that’s when we thought something is going on,” says her mother Sam Dilliway, a 41-year-old community care worker from Basildon, Essex. Doctors said she could have glue ear, a common condition in children – fluid build-up had started to cause problems with her hearing, and would need draining.
    But what should have been a minor ailment has turned into a never-ending ordeal for the family. What was a simple case of glue ear could now leave her with hearing loss for up to two years as she awaits routine treatment.
    It comes after data released in January found that over 10 million people have been left on NHS waiting lists for basic ear care services.
    Dr Aymat says that the long-term effects of such conditions being left untreated in children can be severe. While glue ear is unlikely to leave permanent damage, there is always a small risk of permanent hearing loss. However, the developmental effects are far more likely and potentially long-lasting.
    Read full story
    Source: The Independent, 1 April 2024
  3. Patient Safety Learning
    Hospitals are preparing to cut spending on doctors and nurses by hundreds of millions of pounds after being ordered to plug a £4.5 billion hole in the NHS budget.
    Chief executives at hospitals, mental health trusts and community services in England have been ordered to review staffing levels and draw up plans to close some services and merge others. They are also looking at banning or restricting the use of some agency workers.
    NHS bosses have been alerted in recent days to the scale of the cuts needed after negotiating financial plans for next year. The health service in England has a budget of £165 billion for the 2024-25 financial year, which starts next week. The budget rose by 3.2% in real terms between 2018-19 and 2023-24.
    Spending has been put under additional pressure by the cost of covering strikes by junior doctors which NHS England has said has cost more than £1.5 billion and affected more than 430,000 patients’ appointments.
    Saffron Cordery, deputy chief executive of NHS Providers, said services had been stretched by the need to pick up the pieces from a shortage of social care and other community services. She said an ageing population and poor public health meant patients in hospital were sicker and staying longer, needing more care.
    She said: “Trust leaders are being pushed to the very limits of what is possible, and there will be a situation where they have to make difficult choices about keeping basic services going versus investing in quality and improvement for the future. We are in a situation where we will be patching something that’s already a bit patched-together.”
    Read full story (paywalled)
    Source: Times, 31 March 2024
  4. Patient Safety Learning
    Experts and patient groups have warned that the high cost of private Covid vaccinations could exacerbate health inequalities and leave those more at risk from the virus without a vital line of defence.
    Both high street chain Boots and pharmacies that partner with the company Pharmadoctor are now offering Covid jabs to those not eligible for a free vaccination through the NHS, with the former charging almost £100 for the Pfizer/BioNTech jab.
    While Pharmadoctor says each pharmacy sets its own prices, it suggests the Pfizer/BioNTech jab will set customers back £75-£85, while the latest Novavax jab will cost about £45-£55.
    However experts have raised concerns that the high cost of the private jabs will widen inequalities, with the vaccinations unaffordable for many.
    “The most disadvantaged in society are most likely to be exposed to respiratory viruses due to things like poverty, intergenerational households and crowded workplaces. While they might be most in need of a seasonal vaccine, they will also be the least likely to afford £100 in the midst of a cost of living crisis,” said Dr Marija Pantelic, of the University of Sussex.
    Read full story
    Source: The Guardian, 28 March 2024
  5. Patient Safety Learning
    Patients are dying needlessly every year due to vulnerable Britons with heart problems not being given antibiotics when they visit the dentist, doctors have said.
    Almost 400,000 people in the UK are at high risk of developing life-threatening infective endocarditis any time they have dental treatment, the medics say. The condition kills 30% of sufferers within a year.
    A refusal to approve antibiotic prophylaxis (AP) in such cases means that up to 261 people a year are getting the disease and up to 78 dying from it, they add. That policy may have caused up to 2,010 deaths over the last 16 years, it is claimed.
    That danger has arisen because the National Institute for Health and Care Excellence (NICE) does not follow international good medical practice and tell dentists to give at-risk patients antibiotics before they have a tooth extracted, root canal treatment or even have scale removed, the experts claim.
    The doctors – who include a professor of dentistry, two leading cardiologists and a professor of infectious diseases – have outlined their concerns in The Lancet medical journal. In it, they urge NICE to rethink its approach in order to save lives, citing pivotal evidence that has emerged since the regulator last examined the issue in 2015, which shows that antibiotics are “safe, cost-effective and efficacious”.
    Read full story
    Source: The Guardian, 2 April 2024
  6. Patient Safety Learning
    All trusts should pick a “designated lead” for improving how they work with primary care, according to new NHS planning guidance. 
    The guidance for 2024-25 published by NHS England today states: “Every trust should have a designated lead for the primary–secondary care interface.”
    It also asks integrated care boards to “regularly review progress” on how secondary care services are working with primary care.
    NHSE recovery plans include trying to cut the number of patients effectively referred back to GP practices by other services, in order to reduce GP workload.
    The guidance states: “Streamlining the patient pathway by improving the interface between primary and secondary care is an important part of recovery and efficiency across healthcare systems”.
    The planning guidance — published on Wednesday night after months of delays — also said systems should continue to develop integrated neighbourhood teams, including by trying to “improve the alignment of relevant community services” to primary care network footprints. 
    Read full story (paywalled)
    Source: HSJ, 27 March 2024
  7. Patient Safety Learning
    Tens of thousands of people with type 1 diabetes in England are to be offered a new technology, dubbed an artificial pancreas, to help manage the condition.
    The system uses a glucose sensor under the skin to automatically calculate how much insulin is delivered via a pump.
    Later this month, the NHS will start contacting adults and children who could benefit from the system.
    But NHS bosses warned it could take five years before everyone eligible had the opportunity to have one.
    This is because of challenges sourcing enough of the devices, plus the need to train more staff in how to use them.
    In trials, the technology - known as a hybrid closed loop system - improved quality of life and reduced the risk of long-term health complications.
    And at the end of last year, the National Institute of Health and Care Excellence (Nice) said the NHS should start using it.
    Prof Partha Kar, NHS national speciality advisor for diabetes, said the move was "great news for everyone with type 1 diabetes".
    "This futuristic technology not only improves medical care but also enhances the quality of life for those affected," he added.
    Read full story
    Source: BBC News, 2 April 2024
    Related reading on the hub:
    How safe are closed loop artificial pancreas systems?
  8. Patient Safety Learning
    More than 250 patients a week could be dying unnecessarily, due to long waits in A&E in England, according to analysis of NHS data.
    The Royal College of Emergency Medicine analysed the 1.5 million who waited 12 hours or more to be admitted in 2023.
    A previous data study had calculated the level of risk of people dying after long waits to start treatment and found it got worse after five hours.
    The government says the number seen within a four-hour target is improving. This is despite February seeing the highest number of attendances to A&E on record, it adds.
    The Royal College of Emergency Medicine (RCEM) carried out a similar analysis in 2022, which at that time resulted in an estimate of 300-500 excess deaths - more deaths than would be expected - each week.
    The analysis uses a statistical model based on a large study of more than five million NHS patients that was published in 2021.
    RCEM president Dr Adrian Boyle said long waits were continuing to put patients at risk of serious harm.
    "In 2023, more than 1.5 million patients waited 12 hours or more in major emergency departments, with 65% of those awaiting admission," he said.
    "Lack of hospital capacity means that patients are staying in longer than necessary and continue to be cared for by emergency department staff, often in clinically inappropriate areas such as corridors or ambulances.
    "The direct correlation between delays and mortality rates is clear. Patients are being subjected to avoidable harm."
    Read full story
    Source: BBC News, 1 April 2024
  9. Patient Safety Learning
    The NHS is set to roll out artificial intelligence (AI) to reduce the number of missed appointments and free up staff time to help bring down the waiting list for elective care.
    The expansion to ten more NHS Trusts follows a successful pilot in Mid and South Essex NHS Foundation Trust, which has seen the number of did not attends (DNAs) slashed by almost a third in six months.
    Created by Deep Medical and co-designed by a frontline worker and NHS clinical fellow, the software predicts likely missed appointments through algorithms and anonymised data, breaking down the reasons why someone may not attend an appointment using a range of external insights including the weather, traffic, and jobs, and offers back-up bookings.
    The appointments are then arranged for the most convenient time for patients – for example, it will give evening and weekend slots to those less able to take time off during the day.
    The system also implements intelligent back-up bookings to ensure no clinical time is lost while maximising efficiency.
    It has been piloted for six months at Mid and South Essex NHS Foundation Trust, leading to a 30% fall in non-attendances. A total of 377 DNAs were prevented during the pilot period and an additional 1,910 patients were seen. It is estimated the trust, which supports a population of 1.2 million people, could save £27.5 million a year by continuing with the programme.
    The AI software is now being rolled out to ten more trusts across England in the coming months.
    Read full story
    Source: NHS England, 14 March 2024
  10. Patient Safety Learning
    While the importance of translating evidence into policies and practices is widely acknowledged by evidence producers, intermediaries, users, and funders, there is much less agreement on suitable mechanisms for promoting effective evidence use. As a response, the World Health Organization (WHO) has initiated an extensive and inclusive research priority-setting exercise in Knowledge Translation (KT) and Evidence-informed Policy-making (EIP) through a series of technical consultations.
    This priority-setting initiative, coordinated by the Evidence to Policy and Impact Unit in WHO’s Science Division, involves national and international researchers, practitioners, and organizations across all WHO regions. Collectively, they will assess the evidence base for effective research utilization in decision-making. The overarching goal of this project is to maximize the impact of KT and EIP research to promote the translation of evidence into effective policies that enhance population health and well-being. Key objectives include:
    Efficiency and Synergy: Streamlining research efforts in KT and EIP. Strategic Funding: Directing research funding toward identified priority areas. Effective Approaches: Enhancing understanding of evidence use for policy-making. Collaboration: Promoting cross-sectoral collaboration in KT and EIP research. Awareness: Championing for evidence-informed policy-making at all levels. In the first half of the 2024, global experts – selected during an open call – are now actively participating in a series of consultations to identify gaps and opportunities in KT and EIP research. The consultations provide a pivotal opportunity for participants to discuss current research gaps, harmonize terminology and chart a course toward shared priorities.
    Read full story
    Source: WHO, 22 March 2024
  11. Patient Safety Learning
    NHS teams are giving up on patients with severe eating disorders, sending them for care reserved for the dying rather than trying to treat them, a watchdog has warned the government.
    In a letter to minister Maria Caulfield, the parliamentary health service ombudsman Rob Behrens has hit out at the government and the NHS for failures in care for adults with eating disorders despite warnings first made by his office in 2017.
    The letter, seen by The Independent, urged the minister to act after Mr Behrens heard evidence that eating disorder patients deemed “too difficult to treat” are being offered palliative care instead of treatment to help them recover.
    The ombudsman first warned the government that “avoidable harm” was occurring and patients were being repeatedly failed by NHS systems in 2017, following an investigation into the death of Averil Hart.
    The 19-year-old died while under the care of adult eating disorder services in Norfolk and Cambridge. In 2021, following an inquest into her death and the deaths of four other women, a senior coroner for Cambridge, Sean Horstead, also sent warnings to the government about adult community eating disorder services.
    Read full story
    Source: The Independent, 27 March 2024
  12. Patient Safety Learning
    An investigation published by The BMJ today reveals new details of requests to recall striking junior doctors from picket lines for patient safety reasons. 
    Documents show that while most trusts in England did not make such requests, those that did were rejected by the BMA in most cases. Some of these trusts warned of potential harm to patients from cancelling operations at the last minute and short staffing, reports assistant news editor Gareth Iacobucci.
    However, the BMA said it takes concerns about patient safety “incredibly seriously” and provided The BMJ with summaries of why requests were turned down.
    The union’s chair of council Phil Banfield said, “Throughout industrial action we have engaged thoroughly and in good faith with the derogation process, considering each request carefully to ensure that granting a derogation is necessary and the last and only option.”
    He said that poor planning by some trusts had led to some routine care being inappropriately booked in on strike days. In other instances, he said trusts had failed to make sufficient effort to draft in the necessary cover for strike days.
    Read full story
    Source: BMJ, 28 March 2024
  13. Patient Safety Learning
    Patients at the hospital that treated killer Valdo Calocane were discharged too soon and released in a worse state into the community, the NHS safety watchdog has found.
    Serious failings by Nottinghamshire Hospital Foundation Trust in keeping patients and the public safe have been identified in a review from the Care Quality Commission (CQC).
    More than 1,200 patients are waiting to be seen by community services, the report found. Meanwhile, several hundred who are receiving treatment did not have a clinician overseeing their care,the CQC found.
    The review was launched by the government following the conviction of killer Valdo Calocane, who was under the care of the NHS trust’s community services.
    The CQC review said patients reported that crisis services are either “useless” or detrimental to their health.
    The three broad areas of concern, highlighted in the CQC’s report, were:
    High demand for services was leading to long waiting times for care and a lack of oversight of those waiting. The trust does not have enough staff to keep patients safe in the community and within some hospital services. Senior leaders at the trust do not have clear oversight of the risks and issues within the service. Read full story
    Source: The Independent, 27 March 2024
  14. Patient Safety Learning
    A new mum was confused for another patient and mistakenly fitted with a contraceptive coil after a C-section.
    Another patient in north Wales almost had the wrong toe removed during surgery to amputate two others.
    A third incident happened when a patient, unable to swallow oral medication, had it crushed, mixed with water and administered with a syringe.
    These so-called "never events" happened at hospitals in the Betsi Cadwaladr health board area in February.
    In a report into the three incidents in February, Betsi Cadwaladr health board outlined how a patient had a coil - an intrauterine device which prevents pregnancy - inserted after undergoing a Caesarean section.
    Described in the report as "wrong procedure", it had been planned for a different patient but a mistake had been made after the "list order was changed due to the increase in category for this patient".
    Another incident, described in the report as "wrong site surgery", described a patient who was due to have their second and third toes amputated. However, an incision was made in their fourth toe by accident.
    Luckily, the error was spotted and the correct toes were amputated.
    In the third never event, described as "wrong route", the report details the case of a patient who was unable to swallow oral medication.
    To administer it, a member of staff crushed it, mixed it with water and "inadvertently" gave it intravenously, according to the report.
    Read full story
    Source: BBC News, 28 March 2024
  15. Patient Safety Learning
    A senior mental health nurse suffered “degrading and humiliating” treatment while she languished for 10 days on an unsuitable NHS ward during a mental health crisis, The Independent has been told.
    Rachel Luby, 36, was admitted to Basildon Hospital A&E in Essex on 5 January this year after attempting to take an overdose of over-the-counter medicine following a traumatic assault.
    This, she claimed, was the start of weeks of horrific care she endured while waiting for a mental health bed. It culminated in her being restrained and forced into a caged van “like an animal”.
    She revealed her story after The Independent reported on a warning from top emergency doctors that self-harming and suicidal patients who go to A&E are not being treated with compassion because staff are overwhelmed.
    Ms Luby, an award-winning nurse, said she waited more than a week and a half in a general hospital before she was moved to a bed on a mental health ward.
    Ms Luby was able to leave the ward and find medication to overdose again, despite staff allegedly assessing her as a risk. In a second incident, she went to the bathroom and attempted to take her own life.
    She told The Independent: “I feel that this is something I will not recover from. I will not ever reach out for help in the future.
    “If this is the treatment that I’m getting as a nurse, then what the heck is happening to those that don’t have the voice or education that I have? It horrifies me to think what is happening to people that are far more vulnerable than me.”
    Read full story
    Source: The Independent, 27 March 2024
  16. Patient Safety Learning
    Trusts will be told to hit the four-hour A&E target in 78% of cases by next year after NHS England finally made an agreement with government, HSJ understands.
    The new target is just two percentage points higher than the target set for the current year of 76% – and must be hit in March 2025, according to NHS planning guidance.
    NHS England will also aim to maintain “core” general and acute beds at 99,000 on average across 2024-25 after funding was agreed with the government. This would maintain the beds at levels seen over recent months, but it would be a significant increase in the permanent “sustainable” beds available in the health service compared with previous years.
    Most trusts have fallen well short of the 76% target through much of 2023-24, and NHSE has pressed for them to make last-ditch attempts in recent weeks to try and get closer to the target ahead of the March 2024 deadline. This has included offering new capital funding rewards for improvement and telling trusts to focus on non-admitted patients.
    Elective recovery targets are expected to slip, and government has conceded making significant progress on these is almost impossible, with ongoing doctors strikes on top of other capacity problems. 
    Read full story (paywalled)
    Source: HSJ, 27 March 2024
  17. Patient Safety Learning
    A hacker group is in possession of at least a “small number” of patients’ data following a cyber-attack, NHS Dumfries and Galloway has said.
    Reports emerged on Wednesday of a post by the group Inc Ransom on its darknet blog, alleging it was in possession of three terabytes of data from NHS Scotland.
    The post included a “proof pack” of some of the data, which has been confirmed by the board to be genuine.
    The chief executive of the NHS board, Jeff Ace, said in a statement: “We absolutely deplore the release of confidential patient data as part of this criminal act.
    “This information has been released by hackers to evidence that this is in their possession. We are continuing to work with Police Scotland, the National Cyber Security Centre, the Scottish government and other agencies in response to this developing situation.”
    Patients whose data has been leaked will be contacted by the board, he said, while patient-facing services would continue as normal.
    Read full story
    Source: The Guardian, 27 March 2024
  18. Patient Safety Learning
    Measles cases in the US are rising, as major health organizations plead for increased vaccination rates and experts fear the virus will multiply among unvaccinated populations.
    Most notably, this year’s tally of measles cases has now outpaced last year’s total.
    On Thursday, there were 64 confirmed cases in 17 states, compared with 58 cases in the entirety of last year, according to the US Centers for Disease Control and Prevention (CDC). By Friday, the tally in Chicago grew by two to a total of 17.
    “Measles is one of the most contagious diseases known to man,” said Dr David Nguyen, an infectious disease specialist at Rush University Medical Center.
    Experts say that these incidents could approach the outbreak that spanned 31 states in 2019, when 1,274 patients got sick and 128 were hospitalized in the worst US measles outbreak in decades.
    “Every measles outbreak can be entirely preventable,” said Dr Aniruddha Hazra, associate professor of medicine at the University of Chicago.
    The American Medical Association has issued an appeal to increase vaccination rates, while the CDC released a health advisory urging providers to ensure all travelers, especially children over six months, receive the MMR vaccine. 
    Read full story
    Source: The Guardian, 26 March 2024
     
  19. Patient Safety Learning
    Poor mental health cost society £300 billion in 2022 – the equivalent of double the NHS budget, according to new research.
    The figure covers economic costs such as sickness absence, human costs including reduced quality of life and wellbeing, and health costs such as care, the Centre for Mental Health said.
    The NHS Confederation’s mental health network, which commissioned the centre to carry out the research for the year 2022, said it shows that a failure to invest in early mental health help is a “false economy” which is making the country poorer and “causing unspoken anguish” to those affected.
    The report’s authors said the majority of costs stemming from mental ill-health fall on sufferers and their families – amounting to some £175 billion.
    The researchers said their study incorporates for the first time some of the wider costs, including the impact of presenteeism – whereby someone experiencing mental health difficulties attends work but is less productive due to impaired cognitive function and emotional distress.
    The report stated: “While it is impossible to fully assess the extent of the problem, and a pound sign is admittedly an imperfect proxy for some of the impacts, there is nevertheless value in estimating the economic cost of mental ill-health.
    “It helps us to appreciate the significance of mental ill-health as an issue deserving of policy attention, investment and reform.”
    Read full story
    Source: The Independent, 27 March 2024
  20. Patient Safety Learning
    Senior bosses have shared concerns about the closure of the NHS gender identity clinic for young people, leaked emails seen by BBC News reveal.
    Hospital executives voiced worry about the cancellation of appointments, patients lacking information and poor communication with the new services.
    In one email, the service's director, Dr Polly Carmichael, said cancellations could potentially put patients at risk.
    The controversial Gender Identity Development Service (Gids), which is run by the Tavistock and Portman NHS Foundation Trust, is due to close later this week.
    Its closure was announced in July 2022, after an independent review said a "fundamentally different" model of care for young people with gender-related distress was needed.
    It will initially be replaced by two new regional hubs; a London-based southern hub and a north of England hub. Additional hubs are expected to open in the coming years.
    However, BBC News has spoken to staff at the existing service who say, just days before the 31 March closure, they have been unable to answer basic questions from patients about the future of their care.
    They say they still do not have enough details about how the new services will operate or when some provisions will be fully operational in the new clinics.
    Read full story
    Source: BBC News, 27 March 2024
  21. Patient Safety Learning
    Public satisfaction with the NHS has dropped again, setting a new low recorded by the long-running British Social Attitudes survey.
    Just 24% said they were satisfied with the NHS in 2023, with waiting times and staff shortages the biggest concerns.
    That is five percentage points down on last year and a drop from the 2010 high of 70% satisfaction.
    The findings on the NHS, published by the Nuffield Trust and King's Fund think tanks, show once again that performance has deteriorated after a new record low was seen last year.
    In total, since 2020, satisfaction has fallen by 29 percentage points.
    Of the core services, the public was least satisfied with A&E and dentistry.
    The survey also showed satisfaction with social care had fallen to 13% - again the lowest since the survey began.
    The major reasons for dissatisfaction were long waiting times, staffing shortages and lack of funding.
    Read full story
    Source: BBC News, 27 March 2024
  22. Patient Safety Learning
    An ambulance trust is having to protect its staff from the effects of fumes – including potential cancer risk – as they are spending so long in their vehicles outside hospitals.
    South Western Ambulance Service Foundation Trust (SWASFT) has carried out a risk assessment of the impact of diesel engine emissions after following concerns from staff, many of whom are spending hours waiting to handover on each shift. The region has faced the worst handover delays to emergency departments in recent years.
    Ambulance engines normally have to be kept on while waiting, to keep essential equipment running, and sometimes for warmth. But with queues of a dozen or more ambulances at times, staff and patients can be exposed to substantial emissions for long periods.
    The trust’s risk assessment – which has been seen by HSJ – warns exposure to diesel emissions is associated with eye and upper respiratory tract irritation, while prolonged exposure can lead to coughing, increased sputum production and breathlessness.
    There is also “epidemiological evidence which indicates that sustained occupational exposure to diesel engine exhaust emissions may result in an increase in the risk of lung cancer”.
    It gives a risk rating of 20 – one of the highest possible – which, under the trust’s policies, indicates “activities must not proceed” until mitigations are in place.
    Read full story (paywalled)
    Source: HSJ, 27 March 2024
  23. Patient Safety Learning
    Government’s standards watchdog has launched a review into accountability in public bodies, warning that problems are too often not dealt with quickly and effectively.
    Over the next few months, the Committee on Standards in Public Life will look at “where public bodies should focus their attention to maximise the likelihood of problems being uncovered and addressed before issues escalate and lives are damaged”.
    In a letter to the prime minister about the review, CSPL chair Doug Chalmers said the committee had been “struck by how, when failures occur within public institutions, it repeatedly seems to be the case that indicators of emerging issues were present, but missed, with the result that the window to respond appropriately, before problems escalate, has often also been missed”.
    In its announcement of the review, CSPL said it had seen “several examples of major failures within public institutions” in recent years where “opportunities were missed to address issues before they escalated”.
    “We are asking, when things go wrong in public bodies, why does it take so long for problems to be recognised and the leadership to respond appropriately and, most importantly, what needs to change?”
    Rather than reinvestigating previous incidents, the committee will look at how to encourage more effective accountability within public bodies “so that problems are addressed before catastrophic failure”, Chalmers said.
    As part of the review, CSPL has opened a consultation today inviting members of the public to submit evidence on why public bodies might fail to act quickly when problems arise, along with suggestions on how to tackle problems better and examples of good practice. The consultation closes on 14 June.
    Read full story
    Source: Civil Service World, 25 March 2024
  24. Patient Safety Learning
    The US Supreme Court will hear oral arguments on whether to restrict access to mifepristone, a commonly used abortion pill.
    It is considered the most significant reproductive rights case since the court ended the nationwide right to abortion in June 2022.
    The Biden administration hopes the court will overturn a decision to limit access to the drug over safety concerns raised by anti-abortion groups.
    The pill has been legal since 2000.
    The current legal battle in the top US court began in November 2022 when the Alliance for Hippocratic Medicine, an umbrella group of anti-abortion doctors and activists, filed a lawsuit against the Food and Drug Administration, or FDA.
    The group claims that mifepristone is unsafe and further alleges that the federal agency unlawfully approved its use in September 2000 to medically terminate pregnancies through seven weeks gestation.
    Mifepristone is used in combination with another drug - misoprostol - for medical abortions, and it is now the most common way to have an abortion in the US.
    Medical abortions accounted for 63% of all abortions in 2023, up from 53% in 2020, according to the Guttmacher Institute.
    In total, more than five million US women have used mifepristone to terminate their pregnancies.
    Read full story
    Source: BBC News, 26 March 2024
  25. Patient Safety Learning
    Norah Bassett was hours old when she died in 2019, after multiple failings in her care. What can be learned from her heartbreaking loss?
    The maternity unit at the Royal Hampshire county hospital in Winchester was busy the evening when Charlotte Bassett gave birth. When the night shift came on duty, a midwife introduced.
    “She was very brusque,” Charlotte, 37, a data manager, remembers. “She said, ‘We’ve got too many people here. I’ve got this and this to do.’” Charlotte tried to breastfeed Norah, but she wasn’t latching. The midwife told Charlotte to cup feed her with formula. She didn’t stay to watch. Charlotte poured milk from a cup into Norah’s rosebud mouth. Blood came out. It was staining the muslin. The midwife didn’t seem concerned.
    “I was drowning my child, who was drowning in her own blood. And there was no one there to say: this isn’t normal,” Charlotte says.
    The Health Services Safety Investigations Body (now HSSIB but at the time known as HSIB), which investigates patient safety in English hospitals, produced a report into Norah’s care in 2020. One sentence leaped out to Charlotte and her husband James. “An upper airway event (such as occlusion of the baby’s airway during skin-to-skin) may have contributed to the baby’s collapse.” In other words, it was possible that Charlotte might have smothered her daughter.
    “So Charlotte spent four years in agony,” says James, “thinking it was her.”
    Dr Martyn Pitman remembers the night Norah died, because it was unusual. A crash call, for a baby born to a low-risk mother. It played on his mind, because eight days earlier, on 4 April 2019, Pitman, a consultant obstetrician and gynaecologist, had presented proposals for enhanced foetal monitoring to a meeting of the maternity unit’s doctors and senior midwives. Pitman, 57, who is an expert in foetal monitoring, felt the proposals would prevent more babies suffering brain injuries at birth. “We’re not that good at detecting the high-risk baby, in the low-risk mum,” he says.
    Another doctor would later characterise the meeting as “hideous … hands down the worst meeting I’ve ever been to. Martyn … was being set upon.” A midwife felt the animosity in the room was “personal towards Martyn”, and was “appalled” by the “unprofessionalism that I saw from my midwifery colleagues”.
    James and Charlotte join an unhappy club: a community of parents whose children died young, after receiving poor care, and were told their deaths were unavoidable, or felt blamed for them.
    “I’ve spoken to so many families,” says Donna Ockenden, who authored a 2022 report into Shrewsbury’s maternity services, “who have been blamed for the eventual poor outcome in their cases. This has included being blamed for their babies’ death.” She has also met the families of women blamed for their own deaths. “This never fails to shock me,” she says.
    Read full story
    Source: The Guardian, 26 March 2024
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