Jump to content
 View Profile  See their activity

  • Posts

    11,589

  • Joined

  • Last visited

Patient Safety Learning

Administrators

 Content Type 

News posted by Patient Safety Learning

  1. Patient Safety Learning
    A "virtual ward" enabling patients who want to die at home get the palliative care they need has launched.
    Hospice Outreach provides a "specialised pathway" for patients identified by existing services who would benefit from support.
    It is part of a project that supports people at the very end of their life.
    Dr Victoria Bradley, of Oxford University Hospitals NHS Foundation Trust (OUH), said it was about giving people "control and agency".
    OUH claims Hospice Outreach's virtual ward will mean more people will receive personalised care, including in their own homes if that is their choice.
    It said specialist palliative care would be "provided virtually or in person, depending on what is best for the patient".
    Amelia Foster, chief executive at Sobell House, said: "Being able to offer a virtual ward to those in a palliative crisis or at the end of their lives helping them to remain at home means more people can access our care in the way that they wish."
    Dr Bradley, who is the clinical lead for palliative medicine at OUH, said: "We can support with discharge from hospital to people's homes if that is their wish, and by reducing people's time in hospital and caring for them at home, we can offer the right support in their chosen surroundings."
    Read full story
    Source: BBC News, 14 March 2024
  2. Patient Safety Learning
    Doctors made do-not-resuscitate orders for elderly and disabled patients during the pandemic without the knowledge of their families, breaching their human rights, a parliamentary watchdog has said.
    In a new report on breaches of the orders during the pandemic, the Parliamentary Health Service Ombudsman (PHSO) found failings from at least 13 patient complaints.
    The research, carried out with the charity Dignity in Dying, found “unacceptable” failures in how end-of-life care conversations are held, and in particular with elderly and disabled patients.
    Following a review of complaints in 2019 and 2020 the PHSO found evidence in some cases that doctors did not even inform the patient or their family that a notice had been made and so breached their human rights.
    The report calls for health services in Britain to improve the approach by medics in talking about death and end-of-life care.
    In examples of cases reviewed, the PHSO revealed the story of 58-year-old Sonia Deleon who had schizophrenia and learning disabilities and a notice which was wrongly applied during the pandemic.
    In 2020, she was admitted to Southend University Hospital after contracting Covid-19 at age 58. On three occasions a notice was made but her family were never informed.
    Following Sonia’s death her family found out the reasons given by doctors for the DNAR which “included frailty, having a learning disability, poor physiological reserve, schizophrenia and being dependent for daily activities.”
    Sonia’s sister Sally-Rose Cyrille said: “I was devastated, shocked and angry. The fact that multiple notices had been placed in Sone’s file without consultation with us, without our knowledge, it was like being hit with a sledgehammer.
    Read full story
    Source: The Independent, 14 March 2024
  3. Patient Safety Learning
    Staff whistleblowers have raised concerns over patient safety at one of Northern Ireland's biggest health trusts.
    Information received by UTV under Freedom of Information shows that most of the worries from health workers at the Belfast Health Trust relate to the Royal Victoria Hospital.
    Belfast Health Trust said any concerns raised by staff are investigated.
    The Royal College of Nursing NI was due to hold a webinar with members on Tuesday evening to discuss concerns members have about safety of patients being treated on corridors.
    The RCN's Rita Devlin said that the number of concerns raised with health trusts through the whistleblowing policy is only the tip of the iceberg.
    The concerns included unsafe staffing levels, bed shortages, boarding of patients, ED overcrowding, alleged drug dealing on a hospital site, staff sleeping on night duty, lack of mental health beds and the quality of staff training.
    The Belfast Trust said all staff are encouraged to make management aware of issues giving them concern through the whistleblowing process.
    The Trust added: "Any concern we receive is subject to a fair and proportionate process of investigation.
    "Whistleblowing investigations are of a fact finding nature and all relevant learning is shared as appropriate and taken forward by the Trust."
    Read full story
    Source: ITVX. 12 March 2024
  4. Patient Safety Learning
    A board director has publicly criticised his trust for its treatment of Muslim staff and patients.
    Mohammed Hussain posted on social media that some board members at Bradford Teaching Hospitals “are not heard and listened to”, and that there is a “dissonance” between its espoused values and the “lived experiences” of minority ethnic staff.
    Mr Hussain, a non-executive director since 2019, was responding to a post by CEO Mel Pickup, who had said the trust had a “variety of support offers for colleagues observing Ramadan”.
    He said there are “many examples” of Muslim families experiencing poor responses to complaints to the trust, while claiming that “outstanding” Muslim staff are having to “move out of the area to progress because they are not promoted internally”.
    The trust said its launching an investigation into the concerns raised by Mr Hussain. 
    Read full story (paywalled)
    Source: HSJ, 12 March 2024
  5. Patient Safety Learning
    NHS England has confirmed new financial incentives for trusts to deliver strong performance against the four-hour emergency target this month.
    National leaders are desperate for the NHS to hit the four-hour target in 76% of cases in March, telling trusts earlier this month that it was necessary to restore confidence in the health service.
    They took the unusual step at the start of the month of asking local leaders to sign a commitment to deliver the necessary performance. The recent pressure has come under criticism for encouraging hospitals to prioritise four-hour performance over caring for the sickest patients.
    It was also indicated there would be new financial incentives for those delivering the best performance.
    In a letter, NHSE confirmed a significant expansion to the criteria for trusts to claim a share of a £150m incentive fund, by improving their headline accident and emergency performance.
    Read full story (paywalled)
    Source: HSJ, 12 March 2024
  6. Patient Safety Learning
    Women working for the NHS will be entitled to two weeks’ leave if they have a miscarriage, in a move hailed as a major step to wider recognition of the trauma of baby loss.
    NHS England has announced that all staff who lose a baby before 24 weeks should receive up to 10 days’ paid leave to help them recover from the distress involved.
    “Baby loss is an extremely traumatic experience that hundreds of NHS staff experience each year and it is right that they are treated with the utmost care and compassion when going through such an upsetting experience,” said Dr Navina Evans, its chief officer for workforce, training and education.
    Women will also be able to take further paid time off after a miscarriage for medical examinations, scans or other tests, or to receive mental health support, as well as the two-week grieving period.
    Rachel Hutchings, a fellow at the Nuffield Trust health thinktank, said its recent research into how parenting and caring responsibilities affect surgeons found that some staff who had a miscarriage did not feel well supported by the NHS.
    “Although some organisations had already introduced additional support for people who experienced baby loss, it is incredibly welcome that this policy recognises the experiences of these individuals and will ensure a more consistent approach”, said Hutchings.
    Read full story
    Source: The Guardian, 13 March 2024
  7. Patient Safety Learning
    Women who freeze their eggs are being misled by some UK clinics about their chances of having a baby, a fertility charity says.
    The Fertility Network was reacting to BBC analysis that found 41% of clinics offering the service privately could be breaching advertising guidance.
    The watchdog which sets guidance says clinics "must not give false or misleading information".
    It comes as a record number of people are freezing their eggs.
    The UK fertility regulator, the Human Fertilisation and Embryology Authority (HFEA), also said it was concerned about the information given to those considering egg freezing.
    A successful pregnancy is not guaranteed by the procedure.
    Egg freezing for non-medical reasons, also known as social egg freezing, is an increasingly popular method for women to preserve their fertility in order to have children at a later date.
    Read full story
    Source: BBC News, 13 March 2024
  8. Patient Safety Learning
    Children will no longer routinely be prescribed puberty blockers at gender identity clinics, NHS England has confirmed.
    The decision comes after a review found there was "not enough evidence" they are safe or effective.
    Puberty blockers, which pause the physical changes of puberty, will now only be available as part of research.
    It comes weeks before an independent review into gender identity services in England is due to be published.
    An interim report from the review, published in 2022 by Dr Hilary Cass, had earlier found there were "gaps in evidence" around the drugs and called for a transformation in the model of care for children with gender-related distress.
    Health Minister Maria Caulfield said: "We have always been clear that children's safety and wellbeing is paramount, so we welcome this landmark decision by the NHS.
    "Ending the routine prescription of puberty blockers will help ensure that care is based on evidence, expert clinical opinion and is in the best interests of the child."
    Read full story
    Source: BBC News, 13 March 2024
  9. Patient Safety Learning
    A mental health trust linked to thousands of unexpected patient deaths repeatedly failed to act on coroners' safety warnings, campaigners say.
    BBC News has been given exclusive access to new evidence from coroners' reports gathered by a campaign group.
    It wants a criminal investigation into why so many patients died at Norfolk and Suffolk NHS Foundation Trust - and has sent police the evidence.
    Campaigners, including patients and bereaved families, claim it is failing to make vital safety improvements despite promising to do so.
    Last summer, a report found more than 8,000 mental-health patients had died unexpectedly in Norfolk and Suffolk between 2019 and 2022. This is defined as the death of a patient who has not been identified as critically ill or whose death is not expected by the clinical team.
    The new evidence, based on 38 coroners' prevention of future death (PFD) reports since 2013, suggests there were repeated warnings more patients could die unless safety issues were addressed, including:
    dangerously poor record-keeping and communication family concerns being ignored unsafe levels of staffing at the trust. And campaigners say the trust's failure to improve safety has led to more deaths.
    Read full story
    Source: BBC News, 12 March 2024
  10. Patient Safety Learning
    At least 50,000 people will die from pancreatic cancer over the next five years unless the government gives more funding to improve how quickly the condition is diagnosed and treated, a major charity has warned.
    Pancreatic Cancer UK hit out at 50 years of “unacceptably slow progress” compared to other types of cancer as it warned that thousands of lives will be lost unless £35m of “urgent” investment is put towards improving survival rates of the disease.
    The charity predicted that pancreatic cancer – described by experts as the “quickest-killing cancer” – is expected to kill more people each year than breast cancer by 2027, which would make it the fourth-biggest cause of cancer deaths in the UK.
    The charity has also called for a commitment to treat everyone diagnosed with the cancer within 21 days, which it says would double the number of people getting treatment in time.
    Figures show that, compared to the 52.5% survival rate across the 20 most common cancers in the UK, those with pancreatic cancer have just a 7% survival rate.
    Around 10,500 people are diagnosed with the disease each year, with 9,558 deaths a year, according to Cancer Research UK, with more than half of people dying within three months of diagnosis.
    Read full story
    Source: The Independent, 12 March 2024
  11. Patient Safety Learning
    A large number of people in hospital beds waiting for onward care has forced an NHS trust to declare a critical incident to "protect patient safety".
    Isle of Wight NHS Trust said on Monday demand for its emergency departments was outstripping the number of free beds, leading to delays.
    People are being asked to collect their relatives as soon as they are ready to be discharged.
    In a statement, interim chief operating officer Victoria Lauchlan said: "We currently have a high number of people in hospital beds who are waiting for onward care arrangements in the community.
    "We are working as an island healthcare system to do everything we can to ensure we can help better support these people to be discharged home with a package of care or to care and nursing homes.
    "At this time we are asking people to help by collecting their relatives or friends as soon as they are ready to leave and helping with any additional care and support at home."
    Read full story
    Source: BBC News, 12 March 2024
  12. Patient Safety Learning
    Private hospitals are caring for a record number of patients paying through their own savings or private medical insurance, according to figures from the Private Healthcare Information Network. 
    Helen, a semi-retired frontline worker in south-east England, spent nearly £50,000 of her retirement savings on major spinal surgery to get her life back after two years of debilitating pain.
    Helen, 56, began experiencing extreme lower back pain and leg pain in September 2021, triggered by a dog colliding with her leg in the park. Though it was not caused by the trigger, she was diagnosed by the NHS with spondylosis in November 2021, and then a pars defect (a condition affecting the lower spine), and offered scans and physiotherapy. She said six months of physiotherapy, beginning in early 2022, resulted in no improvement, and she was offered pain management and a steroid epidural, which she said also did not help.
    “I rarely ventured out in these two years … due to the extreme pain I was in when sitting, standing or walking. Life effectively stopped in 2021,” she said. Desperate, she booked a consultation in May 2023 with a neurosurgeon and was told she needed an operation.
    Helen asked whether it would be possible for the neurosurgeon, who also works within the NHS, to do it on the NHS rather than privately. A referral could be made, she was told – but the surgery was likely to involve a waiting time of 18 months to two years. “My husband and I discussed it, and he said: you’ve already had no life for the last two years, do you really want to wait another two?”
    She had the spinal surgery in August 2023 and is now managing her pain with over-the-counter medication, rather than the stronger painkillers she was on before. It cost her a staggering £48,345.
    The financial hit has been huge. “I was absolutely gutted to have to go private. This has knocked us both; we didn’t see us in our lives having to pay for something like this. We’ve managed our finances carefully and always saved where we can. But that lump sum [that we] can access when we retire … That lump sum has just gone now.”
    Read full story
    Source: The Guardian, 8 March 2024
     
  13. Patient Safety Learning
    Britain’s hard-pressed carers need all the help they can get. But that should not include using unregulated AI bots, according to researchers who say the AI revolution in social care needs a hard ethical edge.
    A pilot study by academics at the University of Oxford found some care providers had been using generative AI chatbots such as ChatGPT and Bard to create care plans for people receiving care.
    That presents a potential risk to patient confidentiality, according to Dr Caroline Green, an early career research fellow at the Institute for Ethics in AI at Oxford, who surveyed care organisations for the study.
    “If you put any type of personal data into [a generative AI chatbot], that data is used to train the language model,” Green said. “That personal data could be generated and revealed to somebody else.”
    She said carers might act on faulty or biased information and inadvertently cause harm, and an AI-generated care plan might be substandard.
    But there were also potential benefits to AI, Green added. “It could help with this administrative heavy work and allow people to revisit care plans more often. At the moment, I wouldn’t encourage anyone to do that, but there are organisations working on creating apps and websites to do exactly that.”
    Read full story
    Source: The Guardian, 10 March 2024
  14. Patient Safety Learning
    Millions of people are being urged to get checks for a condition which has been described as the “silent killer”.
    If left untreated, high blood pressure can lead to heart attacks, strokes, kidney disease and vascular dementia.
    Up to 4.2 million people in England are thought to be living with high blood pressure without knowing it – around a third of all those with the condition.
    Now, a new NHS Get Your Blood Pressure Checked campaign has been launched, backed by health charities, to warn people the condition often has no symptoms.
    England’s chief medical officer, Professor Sir Chris Whitty, said: “High blood pressure usually has no symptoms but can lead to serious health consequences.
    “The only way to know if you have high blood pressure is to get a simple, non-invasive blood pressure test.
    “Even if you are diagnosed, the good news is that it’s usually easily treatable.
    “Getting your blood pressure checked at a local pharmacy is free, quick and you don’t even need an appointment, so please go for a check today – it could save your life.”
    Read full story
    Source: The Independent, 11 March 2024
  15. Patient Safety Learning
    Almost £35 million will be invested to improve maternity safety across England with the recruitment of additional midwives and the expansion of specialist training to thousands of extra healthcare workers.
    The investment, which was announced as part of the Spring Budget 2024, will be provided over the next 3 years to ensure maternity services listen to and act on women’s experiences to improve care.  
    The funding includes:
    £9 million for the rollout of the reducing brain injury programme across maternity units in England, to provide healthcare workers with the tools and training to reduce avoidable brain injuries in childbirth investment in training to ensure the NHS workforce has the skills needed to provide ever safer maternity care. An additional 6,000 clinical staff will be trained in neonatal resuscitation and we will almost double the number of clinical staff receiving specialist training in obstetric medicine in England increasing the number of midwives by funding 160 new posts over 3 years to support the growth of the maternity and neonatal workforce  funding to support the rollout of maternity and neonatal voice partnerships to improve how women’s experiences and views are listened to and acted on to improve care. Health and Social Care Secretary Victoria Atkins said:
    "I want every mother to feel safe when giving birth to their baby.
    Improving maternity care is a key cornerstone of our Women’s Health Strategy and with this investment we are delivering on that priority - more midwives, specialist training in obstetric medicine and pushing to improve how women are listened to in our healthcare system.
    £35 million is going directly to improving the safety and care in our maternity wards and will move us closer to our goal of making healthcare faster, simpler and fairer for all."
    Read full story
    Source: Gov.UK, 10 March 2024
  16. Patient Safety Learning
    The Priory healthcare group has been fined more than £650,000 over the death of a 23-year-old patient who was hit by a train after absconding from a mental health hospital.
    Matthew Caseby, a personal trainer, was able to leave Birmingham’s Priory hospital Woodbourne by scaling a wall after being “inappropriately unattended” for several minutes in September 2020, an inquest jury ruled in 2022.
    The healthcare company pleaded guilty to a criminal safety failing linked to the death of a patient, breaching the 2008 Health and Social Care Act, at Birmingham magistrates court on Friday.
    The London-based provider was charged after an investigation into the death of Caseby conducted by the Care Quality Commission.
    Caseby’s father, Richard Caseby, who had been campaigning for a prosecution of the healthcare organisation, told the court the company attempted to “evade accountability for its gross failures”.
    In a victim impact statement which he presented as part of the prosecution on Friday, he said: “I found it unbelievable that a private company commissioned by the NHS to care for its most vulnerable psychiatric patients in the greatest crisis of their lives could be so cruel and resort to such desperate tactics to hide the truth.”
    Read full story
    Source: The Guardian, 8 March 2024
  17. Patient Safety Learning
    Minority ethnic people, women and people from deprived communities are at risk of poorer healthcare because of biases within medical tools and devices, a report has revealed.
    Among other findings, the Equity in Medical Devices: Independent Review has raised concerns over devices that use artificial intelligence (AI), as well as those that measure oxygen levels. The team behind the review said urgent action was needed.
    Prof Frank Kee, the director of the centre for public health at Queen’s University Belfast and a co-author of the review, said: “We’d like an equity lens on the entire lifecycle of medical devices, from the initial testing, to recruitment of patients either in hospital or in the community, into the early phase studies and the implementation in the field after they are licensed,.”
    The government-commissioned review was set up by Sajid Javid in 2022 when he was health secretary after concerns were raised over the accuracy of pulse oximeter readings in Black and minority ethnic people.
    The widely used devices were thrown into the spotlight due to their importance in healthcare during the Covid pandemic, where low oxygen levels were an important sign of serious illness.
    The report has confirmed concerns pulse oximeters overestimate the amount of oxygen in the blood of people with dark skin, noting that while there was no evidence of this affecting care in the NHS, harm has been found in the US with such biases leading to delayed diagnosis and treatment, as well as worse organ function and death, in Black patients.
    The team members stress they are not calling for the devices to be avoided. Instead the review puts forward a number of measures to improve the use of pulse oximeters in people of different skin tones, including the need to look at changes in readings rather than single readings, while it also provides advice on how to develop and test new devices to ensure they work well for patients of all ethnicities.
    Read full story
    Source: The Guardian, 11 March 2024
  18. Patient Safety Learning
    Patient Safety Awareness Week, an annual recognition event in the USA that occurs in March, is intended to encourage everyone to learn more about health care safety.
    During this week, the Institute for Healthcare Improvement (IHI) seeks to advance important discussions locally and globally, and inspire action to improve the safety of the health care system — for patients and the workforce.
    Patient Safety Awareness Week serves as a dedicated time and platform for growing awareness about patient safety and recognising the work already being done.
    IHI works with partners around the world to improve the safety of health care for patients, caregivers, and the health care workforce.
    Learn more about IHI's work to advance patient and workforce safety.
  19. Patient Safety Learning
    Distressed elderly patients are being “treated like animals” and left begging for care as NHS staff struggle to cope with overwhelmed wards and an ever-increasing ageing population, an investigation by The Independent has revealed.
    Scores of families have come forward to share harrowing allegations of neglect as one top doctor warns that elderly people are receiving care “well below the standards they should expect” – including long waits in waiting rooms and “degrading” corridor care.
    In one shocking case, a 96-year-old patient admitted to the hospital with a urinary tract infection (UTI) was allegedly left semi-naked and delirious in his hospital bed – before choking on vomit after being sedated without his family’s permission, his daughter told The Independent. Another patient, 99, was traumatised after being left in a bed next to the body of a dead woman.
    The investigation was sparked by the horrific story of 73 year old Martin Wild who was left so desperate for pain medication he was forced to call 999 from his hospital bed.
    It comes as analysis by the Independent shows the government was warned three times last year by coroners over the increasing risk to elderly patients’ lives amid fears they are not being “effectively safeguarded”.
    Read full story
    Source: The Independent, 11 March 2024
  20. Patient Safety Learning
    More than 7,300 people waited longer than 24 hours for emergency treatment in Scottish hospitals last year, with the longest wait more than 122 hours.
    Public Health Scotland statistics obtained by Scottish Labour through freedom of information (FoI) revealed that 7,367 patients were in an emergency department for more than 24 hours before being discharged, admitted or transferred in 2023.
    The longest wait in A&E last year occurred at NHS Ayrshire and Arran’s University Hospital Crosshouse, where a patient waited more than 122 hours, or the equivalent of five days. Waits of more than 88 hours were recorded in NHS Borders, and 72 hours in NHS Lanarkshire.
    Dame Jackie Baillie, Scottish Labour’s health spokeswoman, has demanded action from Neil Gray, the health secretary.
    “Scotland’s A&E departments are in the grip of a deadly crisis, with lives being put on the line day in and day out,” she said. “That some people have waited days — even a working week — to be seen is dangerous and disgraceful.
    “Hard-pressed A&E staff are working tirelessly to look after patients, but SNP mismanagement has created a perfect storm in our hospitals. Neil Gray has inherited an NHS in deadly disarray from his colleagues.
    “It’s time for action to be taken now to bolster A&E departments by tackling delayed discharges and investing in primary care to avoid putting further pressure on hospital services.”
    Read full story (paywalled)
    Source: The Times, 11 March 2024
  21. Patient Safety Learning
    England’s NHS Ombudsman has warned that cancer patients could be put at risk because of over-stretched and exhausted health staff working in a system at breaking point and delays in diagnosis and treatment.
    The Parliamentary and Health Service Ombudsman (PHSO) revealed that between April 2020 and December 2023, his Office carried out 1,019 investigations related to cancer. Of those 185 were upheld or partly upheld.
    Issues with diagnosis and treatment were the most common cancer-related issues investigated by PHSO. These issues included treatment delays, misdiagnosis, failure to identify cancer, the mismanagement of conditions, and pain management.
    Complaints about cancer care also included concerns about poor communication, complaint handling, referrals, and end-of-life care.
    Most investigations were about lung cancer, followed by breast cancer and colorectal cancer.
    The Ombudsman recently closed an investigation around the death of Sandra Eastwood whose cancer was not diagnosed for almost a year after scans were not read correctly. The delay meant she missed out on the chance of treatment which has a 95% survival rate.
    In 2021, PHSO published a report about recurrent failings in the way X-rays and scans are reported on and followed up across the NHS service.
    Mr Behrens said, “What happened to Mrs Eastwood was unacceptable and her family’s grief will no doubt have been compounded by knowing that mistakes were made in her care.
    “Her case also shows, in the most tragic of ways, that while some progress has been made on my recommendations to improve imaging services, it is not enough and more must be done.
    “Government must act now to prioritise this issue and protect more patients from harm.”
    Read full story
    Source: Parliamentary Health and Health Service Ombudsman, 9 March 2024
  22. Patient Safety Learning
    The lives of thousands of blind and partially sighted people are being put at risk by delays in vital care that they have a legal right to after being assessed as visually impaired, according to a report.
    More than a quarter of English councils are leaving people who have just been diagnosed as blind waiting more than a year for vision rehabilitation assessments and potentially life-saving support, the report by the RNIB revealed.
    It cited the example of one person who died while waiting for council help. The Guardian can reveal that the case involved a woman from Church Stretton in Shropshire who had been waiting 18 months for an assessment when she tripped on a pothole and died later from head injuries. She had been trying to teach herself how to use a white cane, without any support or training, despite getting a certificate of visual impairment.
    Councils are obliged to provide such help for those coping with a recent visual impairment under the 2014 Care Act. The support involves helping people cope practically and mentally with visual impairment at a critical time after a diagnosis.
    The social care ombudsman recommends that councils should provide these services within 28 days of someone receiving a certificate of visual impairment.
    But the RNIB report, which is based on freedom of information requests to councils in England, found that 86% were missing this 28-day deadline. The report, Out of sight – The hidden scandal of vision rehabilitation warned that the delays uncovered in the figures were dangerous.
    Read full story
    Source: The Guardian, 10 March 2024
  23. Patient Safety Learning
    A fertility clinic in London has had its licence to operate suspended because of “significant concerns” about the unit, the regulator has said.
    The Homerton Fertility Centre has been ordered by the Human Fertilisation and Embryology Authority (HFEA) to halt any new procedures while investigations continue.
    The clinic in east London said there had been three separate incidents highlighting errors in some freezing processes. This resulted in the “tragic loss of a small number of embryos” that either did not survive or became “undetectable”, which means an embryo stored in frozen liquid solution in a container cannot be found during subsequent thawing.
    The clinic has informed the patients affected and apologised for any distress caused.
    Homerton Healthcare NHS foundation trust said it began an investigation in late 2023 and immediately made regulators fully aware of it. The HFEA is now conducting its own investigation alongside the trust.
    In a statement, the clinic said that while the investigators had not been able to find any direct cause of the errors, it had made changes in the unit to prevent the recurrence of such incidents.
    All staff now work in pairs to ensure all clinical activities are checked by two healthcare professionals, competencies of staff within the unit have been rechecked, and security at the unit has been increased.
    Read full story
    Source: The Guardian, 8 March 2024
  24. Patient Safety Learning
    Patients are being exposed to radiation doses at the “upper limit of safe” because a hospital is relying on a radiology machine three years after its “end of life” with a substandard second-hand part.
    The risk was revealed in board papers from Medway Foundation Trust, in Kent, among several other serious problems linked to outdated equipment.
    Recent board papers said the machine was necessary for maintaining the trust’s interventional radiology service which includes being on-call 24/7.
    It said: “Owing to the age of the machine we are experiencing a growing number of faults and breakdowns and due to its age no new parts are available.
    “At present a second hand tube has been installed to replace the existing faulty equipment.”
    But the papers went on to say the second-hand part has a defect “causing serious issues with the imaging [which] has the potential to increase imaging acquisitions required which will increase patient radiation dose and lengthen the procedure time”. 
    A business case for a new machine described current radiation doses as “within the upper limit of safe”.
    The trust indicated “mitigations” are in place, including additional reviews of patients who use it.
    Read full story (paywalled)
    Source: HSJ, 11 March 2024
  25. Patient Safety Learning
    Patients in parts of England are facing an uphill struggle to see a GP, experts say, after an analysis showed wide regional variation in doctor numbers.
    The Nuffield Trust think tank found Kent and Medway had the fewest GPs per person, followed by Bedfordshire, Luton and Milton Keynes.
    It comes as ministers have struggled to hit the pledge to boost the GP workforce by 6,000 this Parliament.
    But the government said it had plans in place to tackle shortages.
    However, Dr Billy Palmer, of the Nuffield Trust, said: "Solely boosting the number of staff nationally in the NHS is not enough alone - the next government should set a clear aim of reducing the uneven distribution of key staffing groups and shortfalls to tackle unfairness in access for patients."
    The think-tank report found while the government had met its target to increase the number of nurses by 50,000 this Parliament, the rises had not been felt evenly, with some specialist nurse posts, such as health visitors and learning-disability nurses, seeing numbers shrink.
    Dr Palmer said minimum numbers of GPs may have to be set for local areas - and better incentives to attract them to those with the fewest.
    Read full story
    Source: BBC News, 8 March 2024
×
×
  • Create New...