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Patient Safety Learning

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  1. Patient Safety Learning
    A trust which last year was ordered to pay a whistleblowing nurse nearly £500,000 must now give a surgeon £430,000 to compensate him for the racial discrimination and harassment he faced after raising patient safety concerns.
    Tribunal judges previously upheld complaints made by Manuf Kassem against North Tees and Hartlepool Foundation Trust and have published a remedy judgment this week setting out the levels of damages the NHS organisation must pay.
    The judgment comes just over a year after a former senior nurse at the trust was awarded £472,600 for unfair dismissal after she warned high workloads had led to a patient’s death.
    Mr Kassem raised 25 concerns regarding patients’ care during a grievance meeting in August 2017. He alleged patients had “suffered complications, negligence, delayed treatment and avoidable deaths”.
    A trust review concluded appropriate processes were followed in the 25 cases. However, the tribunal ruled Mr Kassem was subjected to detriment after making the protected disclosure.
    According to the judgment, Mr Kassem was subsequently removed from the on-call emergency rota and his identity as a whistleblower was revealed by clinical director Anil Agarwal.
    In September 2018, he was the subject of a disciplinary investigation following several allegations against him made by colleagues and others, which concerned “unsafe working practices,” “excessive working hours,” and “potential fraudulent activity.”
    The investigation lasted 17 months and none of the allegations against Mr Kassem were upheld or progressed to a disciplinary hearing. 
    Read full story (paywalled)
    Source: HSJ, 15 March 2024
  2. Patient Safety Learning
    More children died after failing to get timely medical treatment during lockdown than lost their lives because of coronavirus, new research by the Royal College of Paediatrics and Child Health (RCPCH) suggests.
    Six children under the age of 16 have died from COVID-19 in Britain since the pandemic began, according to the Office for National Statistics (ONS). 
    However, seeking medical help too late was a contributory factor in the deaths of nine children in paediatric care new analysis has found, with the figure likely to be higher.
    A survey of 2,433 paediatricians, carried out by the RCPCH, found that one in three handling emergency admissions had dealt with children who turned up later than usual for diagnosis or treatment.
    Read full story (paywalled)
    Source: The Telegraph, 25 June 2020
  3. Patient Safety Learning
    A black NHS worker has launched legal action against the health service’s blood and transplant authority after witnessing years of alleged racism within the service.
    Melissa Thermidor, 40, from Bushey, Hertfordshire, has lodged an employment tribunal claim against NHS Blood and Transplant (NHSBT) and two executives who have since left the authority. Betsy Bassis and Millie Banerjee, who were the chief executive and chairwoman, have denied the allegations and intend to fight the tribunal claims.
    One colleague allegedly said: “White donors are more likely to shop at Waitrose and black donors at Tesco.” At subsequent meetings, the phrase “Tesco donors” was used. Staff also allegedly referred to “you people” when speaking to black members of the team.
    Thermidor claims she was constructively dismissed after whistleblowing about racism within NHSBT. The health authority, which supported 3,386 organ donations in the year to March last year as well as collecting blood from 761,000 donors, has been embroiled in allegations of bullying, racism and poor culture under Bassis and Banerjee’s leadership.
    Read full story (paywalled)
    Source: The Times, 21 August 2022
    Read NHS Blood and Transplant's response to the article.
  4. Patient Safety Learning
    An NHS hospital has been accused of posing a continuing risk to patients by “covering up” leadership failures, including not properly investigating the deaths of two babies.
    Dr Max Mclean, chairman of Bradford Teaching Hospitals trust, has quit in protest at the conduct of the trust’s chief executive, Professor Mel Pickup, after no action was taken over serious concerns about her performance.
    In a blistering resignation letter, Mclean said he “cannot, in good conscience, work with a CEO who has fallen so short of the standards expected of her role that there is a genuine safety risk to patients and colleagues”. He is calling for senior national NHS figures to establish new leadership at the trust, and has written to the head of NHS England to share his concerns about Pickup, who has been in post since 2019.
    Mclean told The Times there were parallels with the Lucy Letby scandal, when management ignored the concerns of whistleblowers. “Patients are at risk, babies are at risk, and there could be avoidable deaths unless there is a change of leadership,” he said.
    The former detective chief superintendent who has chaired the trust since 2019, raised nine serious issues about Pickup’s performance, which he said were confirmed by an independent investigation that concluded last month.
    However, the trust’s board met on October 2 and decided there would be no further action against Pickup, leaving Mclean with “no option” but to resign and speak publicly.
    Read full story (paywalled)
    Source: The Times, 10 October 2023
  5. Patient Safety Learning
    The government and NHS England appear unable to identify units set up to treat ‘long covid’, contrary to a claim by Matt Hancock in Parliament that the NHS had ‘set up clinics and announced them in July’. 
    There are growing calls for wider services to support people who have had COVID-19 and continue to suffer serious follow-up illness for weeks or months. Hospitals run follow-up clinics for those who were previously admitted with the virus, but these are not generally open to those who were never admitted.
    Earlier this month the health secretary told the Commons health committee: “The NHS set up long covid clinics and announced them in July and I am concerned by reports from Royal College of General Practitioners that not all GPs know how to get into those services.”
    Asked by HSJ for details, DHSC and NHS England declined to comment on how many clinics had been set up to date, where they were located, how they were funded or how many more clinics were expected to be “rolled out”.
    However, two charities and support groups — Patient Safety Learning and the Long Covid Support Group — told HSJ they were not aware of dedicated long covid clinics for community patients. An enquiry from Patient Safety Learning to NHS England has not been answered.
    The number of people affected by long covid is unclear due to a lack of research but there are suggestions it could be half a million or more. Symptoms can include fatigue, sleeplessness, night-time hypoxia, “brain fog” and cardiac problems. It appears to affect more people who were not hospitalised with coronavirus than those who were were. There is some evidence that small clinics have been set up locally on a piecemeal basis, without national funding.
    HSJ has only been able to identify only one genuine “long covid clinics” open to those who have never been in hospital with covid. 
    Trisha Greenhalgh, an Oxford University professor of primary care health sciences who has interviewed around 100 long covid sufferers, told HSJ: “Nobody I have interviewed had been seen in a long covid clinic but there is an awful lot of people who would like to be referred and who sound like the need to be but they haven’t.”
    Read full story (paywalled)
    Source: HSJ, 23 September 2020
    Read the letter Patient Safety Learning sent to NHS England
    hub Community thread - Long Covid: Where are these clinics?
     
  6. Patient Safety Learning
    A major trust’s Freedom To Speak Up Guardian has warned that a failure to address staff concerns about alleged bullying and long-standing ‘dysfunctional behaviours’ is damaging confidence and resulting in the loss of high-quality staff.
    Professor Julian Bion, presenting a half-yearly report to University Hospitals Birmingham Foundation Trust’s board, revealed that the majority of the 41 reports to the FTSU service between April and October this year had expressed a “fear of detriment” when raising concerns.
    Just under half (44%) of 34 concerns raised by the contacts related to “problematic attitudes and behaviours”, ranging from reports of micro-aggressions to overt bullying.
    Professor Bion, UHB’s FTSU guardian since 2019, told HSJ such concerns are always “complex and sensitive issues” and recognised that the trust is handling them during “difficult circumstances” for the NHS. UHB has seen very large numbers of covid patients throughout much of the pandemic.
    But he warned the board that several “common themes” were emerging in UHB’s complaints process – including a fear of detriment, “problematic” delays to cases being resolved, and a lack of response from divisional departments.
    Suggesting there is a “disinclination” within the trust to address concerns, he said: “Very often, these dysfunctional behaviours are known about for a long time but they haven’t been addressed.”
    Read full story (paywalled)
    Source: HSJ, 2 November 2021
  7. Patient Safety Learning
    A 13-year-old girl who died after contracting sepsis in an NHS hospital probably would have survived if doctors had identified the warning signs and transferred her to intensive care earlier, a coroner has ruled.
    Martha Mills was the first ever child to die at King’s College hospital (KCH) with a pancreatic injury of the type she sustained in a fall from her bike on an off-road family trail in Wales while on holiday last year. She was transferred to the south London hospital because it is one of three national centres for the care of children with pancreatic trauma.
    An inquest at St Pancras coroner’s court, north London, heard that several opportunities were missed to refer Martha to intensive care, which probably would have saved her life.
    In an emotional witness statement, Martha’s mother, Merope, said that after their daughter contracted an infection on 21 August last year, she and her husband, Paul Laity, raised concerns about Martha’s deteriorating health a number of times but doctors sought to reassure them rather than escalate her care.
    Mills said in her statement that she explicitly raised her fears about Martha going into septic shock over the bank holiday weekend.
    On 29 August, Martha had high fever, low blood pressure, a racing heart and a rash, which was misdiagnosed by a junior doctor despite Mills voicing her concern that it was caused by sepsis. It was only the next day that Martha was admitted to paediatric intensive care.
    “I felt that my anxieties about all of Martha’s symptoms, and especially what they might mean when put together and considered in the round, weren’t given proper acknowledgement,” Mills told the court.
    Prof William Bernal, who produced a serious incident report on Martha’s death for KCH, said there were at least five occasions when she should have had a critical care review.
    He wrote that Martha’s chances of survival “would have been greatly increased” if she had been admitted to critical care earlier.
    The inquest heard that KCH was making changes in the wake of Martha’s death, including improving diagnostics and taking account of parents’ views.
    Read full story
    Source: The Guardian, 3 March 2022
  8. Patient Safety Learning
    The Health and Social Care Committee has launched a new inquiry to examine leadership, performance and patient safety in the NHS.
    Inquiry: NHS leadership, performance and patient safety
    MPs will consider the work of the Messenger review (2022) which examined the state of leadership and management in the NHS and social care, and the Kark review (2019) which assessed how effectively the fit and proper persons test prevents unsuitable staff from being redeployed or re-employed in health and social care settings.
    The Committee’s inquiry will also consider how effectively leadership supports whistleblowers and what is learnt from patient safety issues.
    An ongoing evaluation by the Committee’s Expert Panel on progress by government in meeting recommendations on patient safety will provide further information to the inquiry.
    Health and Social Care Committee Chair Steve Brine MP said:
    “The role of leadership within the NHS is crucial whether that be a driver of productivity that delivers efficient services for patients and in particular when it comes to patient safety.
    Five years ago, Tom Kark QC led a review to ensure that directors in the NHS responsible for quality and safety of care are ‘fit and proper’ to be in their roles. We’ll be questioning what impact that has made.
    We’ll also look at recommendations from the Messenger review to strengthen leadership and management and we will ask whether NHS leadership structures provide enough support to whistleblowers.
    Our Expert Panel has already begun its work to evaluate government progress on accepted recommendations to improve patient safety so this will build on that. We owe it to those who rely on the NHS – and the tax-payers who pay for it – to know whether the service is well led and those who have been failed on patient safety need to find out whether real change has resulted from promises made.”
    Terms of Reference
    The Committee invites written submissions addressing any, or all, of the following points, but please note that the Committee does not investigate individual cases and will not be pursuing matters on behalf of individuals.   Evidence should be submitted by Friday 8 March. Written evidence can be submitted here of no more than 3,000 words.   How effectively does NHS leadership encourage a culture in which staff feel confident raising patient safety concerns, and what more could be done to support this? What has been the impact of the 2019 Kark Review on leadership in the NHS as it relates to patient safety? What progress has been made to date on recommendations from the 2022 Messenger Review? How effectively have leadership recommendations from previous reviews of patient safety crises been implemented? How could better regulation of health service managers and application of agreed professional standards support improvements in patient safety? How effectively do NHS leadership structures provide a supportive and fair approach to whistleblowers, and how could this be improved? How could investigations into whistleblowing complaints be improved? How effectively does the NHS complaints system prevent patient safety incidents from escalating and what would be the impact of proposed measures to improve patient safety, such as Martha’s Rule? What can the NHS learn from the leadership culture in other safety-critical sectors e.g. aviation, nuclear? Read full story
    Source: UK Parliament, 25 January 2024
  9. Patient Safety Learning
    UK residents can apply for a Global Health Insurance Card (GHIC) to access emergency medical care in the EU when their current EHIC card runs out.
    Under a new agreement with the EU, both cards will offer equivalent healthcare protection when people are on holiday, studying or travelling for business. This includes emergency treatment as well as treatment needed for a pre-existing condition.
    The new GHIC card is free and can be obtained via the official GHIC website.
    Current European Health Insurance Cards (EHIC) are valid as long as they are in date, and can continue to be used when travelling to the EU. 
    You don't need to apply for a GHIC until your current EHIC expires. People should apply at least two weeks before they plan to travel to ensure their card arrives on time.
    Read full story
    Source: BBC News, 11 January 2021
  10. Patient Safety Learning
    Britain is in the grip of a new silent health crisis. For 14 of the past 15 weeks, England and Wales have averaged around 1,000 extra deaths each week, none of which are due to Covid. 
    If the current trajectory continues, the number of non-Covid excess deaths will soon outstrip deaths from the virus this year.
    Experts believe decisions taken by the Government in the earliest stages of the pandemic – policies that kept people indoors, scared them away from hospitals and deprived them of treatment and primary care – are finally taking their toll.  
    Prof Robert Dingwall, of Nottingham Trent University, a former government adviser during the pandemic, said: “The picture seems very consistent with what some of us were suggesting from the beginning.
    “We are beginning to see the deaths that result from delay and deferment of treatment for other conditions, like cancer and heart disease, and from those associated with poverty and deprivation. 
    “These come through more slowly – if cancer is not treated promptly, patients don't die immediately but do die in greater numbers more quickly than would otherwise be the case.”
    Read full story (paywalled)
    Source: The Telegraph, 18 August 2022
  11. Patient Safety Learning
    Death rates among seriously ill COVID-19 patients dropped sharply as doctors rejected the use of mechanical ventilators, analysis has found.
    The chances of dying in an intensive care unit (ICU) went from 43% before the pandemic peaked to 34% in the period after.
    In a report, the Intensive Care National Audit & Research Centre said that no new drugs nor changes to clinical guidelines were introduced in that period that could account for the improvement. However, the use of mechanical ventilators fell dramatically.
    Before the peak in admissions on 1 April, 75.9% of COVID-19 patients were intubated within 24 hours of getting to an ICU, a proportion which fell to 44.1% after the peak.
    Meanwhile, the proportion of ICU patients put on a ventilator at any point dropped 22 percentage points to 61% either side of the peak.
    Researchers suggested this could have been a result of “informal learning” among networks of doctors that patients on ventilators were faring worse than expected.
    Read full story
    Source: The Telegraph, 3 September 2020
  12. Patient Safety Learning
    A “commended” NHS nurse has been awarded nearly £500,000 for being wrongly sacked after she claimed that high workloads led to a patient’s death.
    Linda Fairhall, 62, a 44-year veteran of the health service, said she made 13 separate pleas to bosses warning that her colleagues were overburdened, but she was ignored each time.
    Fairhal told officials at the University Hospital of North Tees and Hartlepool that she was worried about a recently imposed policy that obliged nurses to monitor patients who took prescribed medicines and maintained that it led to nurses having to conduct 1,000 extra patient visits a month without extra resources.
    She said nurses were overwhelmed by the additional responsibility, which resulted in rising “anxiety” among staff and higher rates of absence. However, Fairhall told the tribunal in Teesside that nothing was done in response to her concerns, and ultimately a patient died.
    The tribunal heard that the nurse raised her last warning with officials just before she went on annual leave. On her return she was suspended and investigated for “bullying and harassment”, then sacked for gross misconduct.
    A tribunal has now ruled that the decision to dismiss Fairhall was “materially influenced” by her complaints regarding patient safety, with the panel adding that it could not “genuinely believe” that she was guilty of misconduct.
    Read full story (paywalled)
    Source: The Times, 4 January 2023
    Read the full tribunal decision: Ms L Fairhall v University Hospital of North Tees and Hartlepool Foundation Trust
  13. Patient Safety Learning
    It has been revealed that three patients a day are dying from starvation or thirst or choking on NHS wards. 
    In 2017, 936 hospital deaths were attributed to one of those factors, with starvation the primary cause of death in 74 cases.The Office for National Statistics data reveals malnutrition deaths are 34% higher than in 2013.
    Over-stretched nurses are simply too busy to check if the sick and elderly are getting nourishment. 
    However, Myer Glickman from the ONS says the data is not conclusive proof of poor NHS care. He said:“There has been an increase over time in the number of patients admitted to hospital while already malnourished. This may suggest that malnutrition is increasingly prevalent in the community, possibly associated with the ageing of the population and an increase in long-term chronic diseases.”
    Yet campaigners say too many vulnerable people are being “forgotten to death” in NHS hospitals and urgent action is needed to identify and treat malnutrition.
    In a recent pilot scheme the number of deaths among elderly patients with a fractured hip was halved by simply having someone to feed them. Six NHS trusts employed a junior staff member for each ward tasked with getting 500 extra calories a day into them. More survived and the patients spent an average five days less in hospital, unblocking beds and saving more than £1,400 each.
    It wasn’t just the calories though – it helped keep their morale up.
    Because, as one consultant said: “Food is a very, very cheap drug that’s extremely powerful.”
    Read full story
    Source: Mirror, 4 February 2020
  14. Patient Safety Learning
    An external review into the Healthcare Safety Investigations Branch (HSIB), the national safety watchdog, has revealed ‘damaging’ cultural problems, including bullying, sexism and racism which go ‘right to the top of the organisation’.
    The King’s Fund was commissioned by NHS England to undertake a review of the HSIB’s leadership and culture, as it prepares to be an independent organisation.
    The review, seen by HSJ, concluded: “Bullying, sexism, racism and other forms of discrimination and unprofessional behaviours appear to be prevalent and tolerated – this goes right to the top of the organisation.”
    The result of this was found to be “very damaging to the health and wellbeing of staff, diminished the culture and undermines the potential of the organisation”
    The review also described a “perceived command-and-control approach to leadership, lack of openness to challenge, hierarchical approaches to management and behaviour that is out of step with the organisation’s values”.
    The reviewers also identified a “strong voice from staff”, which felt that senior maternity investigation team leaders were “not being held accountable for behaviours that had a very negative impact on staff”.
    Read full story (paywalled)
    Source: HSJ, 21 January 2022
  15. Patient Safety Learning
    A trust chief who blew the whistle on her predecessor’s ‘aggressive’ behaviour and lack of interest in patient safety says it was the hardest thing she has had to do in her career.
    Janelle Holmes, who is now chief executive of Wirral University Teaching Hospital Foundation Trust, was among four Wirral University Teaching Hospital Foundation Trust senior executives who wrote to regulators in 2017 about the behaviour of the trust’s then CEO David Allison.
    They said he would react with “dismay and aggression” to concerns being raised about service quality, and staff were afraid to speak up as a result. The intervention led to Mr Allison’s departure and a subsequent independent investigation found “deep systemic cultural issues”. Mr Allison always denied his behaviour was inappropriate.
    In an interview with HSJ, Ms Holmes talked of the difficulties in taking those actions, and the subsequent efforts to overhaul the trust’s culture.
    She said: “From a personal integrity perspective, it was the right thing to do…and I [also] felt I had a personal responsibility to make it right afterwards.
    “But yes, it was the most difficult thing I’ve ever had to do.”
    She said: “I remember watching Sir David Dalton (the ex-Salford CEO) probably more than 10 years ago… say ‘we are harming patients’.. it was like ’you can’t say that’.
    “But actually [there was a] complete sea change and [it became] an organisation where [speaking out] was the right thing to do. That’s the only way you can ensure you’re delivering good quality high standard services. If you’re acknowledging mistakes happen, you’re learning from them, you’re correcting things… I think that then starts to shape how our clinicians and staff feel.
    Read full story (paywalled)
    Source: HSJ, 12 May 2022
  16. Patient Safety Learning
    NHS England and Improvement have launched an independent review into the care and death of a man with learning disabilities, following concerns raised by HSJ. 
    The regulator has appointed Beverley Dawkins to carry out an independent review of the case of Clive Treacy, as part of the learning disability mortality review programme.
    Clive, who died in 2017, had previously been denied a review under LeDer and, according to emails seen by HSJ, his death was never officially recorded by the programme, which is meant to record all deaths of people with a learning disability.
    NHS England and Improvement overturned the decision earlier this year after HSJ presented evidence of a series of failures in his care between 2012 and 2017.
    Today, it was confirmed to us that Ms Dawkins has been commissioned to carry out the review, and that it would review his care throughout his life, as well as his death.  
    Read full story
    Source: HSJ, 23 July 2020
  17. Patient Safety Learning
    Trusts have been urged to reflect on their disciplinary procedures, and review them annually where required, following the death of a senior nurse who took his own life after being dismissed.
    NHS England’s chief people officer Prerana Issar has written to trust leaders to highlight Imperial College Healthcare Trust’s new disciplinary procedures, which were put in place following Amin Abdullah’s suicide.
    Mr Abdullah, a senior nurse at Charing Cross Hospital in west London, was suspended in September 2015 before being let go from his job that December. He died in February 2016 after setting himself on fire.
    An independent investigation criticised both the trust and its staff and concluded he had been “treated unfairly”. The summary report produced by the trust was labelled a “whitewash”, which “served to reassure the trust that it had handled the case with due care and attention”, and the delay of three months between the events and hearing were “troubling”.
    The report, which also criticised the delays as “excessive” and “weak” in their justification, said Mr Abdullah found the delay “stressful” and caused him to become “distressed”.
    In the letter sent on Tuesday, seen by HSJ, Ms Issar said: “The shared learning from Amin’s experience has demonstrated the need for us to work continuously and collaboratively, to ensure that our people practices are inclusive, compassionate and person-centred, with an overriding objective as to the safety and wellbeing of our people… our collective goal is to ensure we enable a fair and compassionate culture in our NHS. I urge you to honestly reflect on your organisation’s disciplinary procedure…"
    Read full story (paywalled)
    Source: HSJ, 3 December 2020
  18. Patient Safety Learning
    England’s test and trace service is being sub-contracted to a myriad of private companies employing inexperienced contact tracers under pressure to meet targets, a Guardian investigation has found.
    Under a complex system, firms are being paid to carry out work under the government’s £22bn test and trace programme. Serco, the outsourcing firm, is being paid up to £400m for its work on test and trace, but it has subcontracted a bulk of contact tracing to 21 other companies.
    Contact tracers working for these companies told the Guardian they had received little training, with one saying they were doing sensitive work while sitting beside colleagues making sales calls for gambling websites.
    One contact-tracer, earning £8.72 an hour, said he was having to interview extremely vulnerable people in a “target driven” office that encouraged staff to make 20 calls a day, despite NHS guidance saying each call should take 45 to 60 minutes.
    Another call centre worker, who had no experience in healthcare or emotional support, said she suffered a nervous breakdown during an online tutorial about phoning the loved ones of coronavirus victims in order to trace their final movements.
    Read full story
    Source: The Guardian, 14 December 2020
  19. Patient Safety Learning
    Catherine O’Connor, who was born with spina bifida and used a wheelchair all her life, was looking forward to the surgery to fix her twisted spine.
    Tragically, after a catastrophic loss of blood, she died on the operating table at Salford Royal Hospital in Manchester.
    She died in February 2007 but only now has an NHS-commissioned report concluded the “unacceptable and unjustifiable” actions of her surgeon, John Bradley Williamson, “directly contributed” to her death. Williamson pressed on with the surgery despite being explicitly told he needed a second consultant surgeon.
    Her case is one of more than a hundred of Williamson’s being reviewed by Salford Royal Hospital amid allegations by whistleblowers of a cover-up by managers and a “toxic culture” within his surgery team.
    An internal list produced by concerned clinicians as long ago as 2014 describes some of Williamson’s patients being left paralysed or in severe pain as a result of misplaced spinal screws and others being rushed back to theatre for life-saving surgery.
    Separately, leaked minutes of a meeting between staff and the hospital’s new chief executive in December 2021 described a “snapshot” of five of Williamson’s patients which “clearly identified significant areas of clinical care, avoidable harm and avoidable death”. They added: “Concerns around Mr Williamson continue to be raised and remain unaddressed.”
    Read full story (paywalled)
    Source: The Times, 17 July 2022
  20. Patient Safety Learning
    Thousands of NHS-funded talking therapy sessions are still being carried out by unaccredited practitioners every month, despite NHS England trying to stop the practice for at least five years.
    NHS Digital data for January this year showed 44,170 sessions involved practitioners who were neither in training nor had done an accredited course. The actual figure could be higher as, of the 517,027 sessions in total carried out, data about who was involved was missing for more than half (328,433).
    Since last June, practitioners delivering NHS-funded “low intensity” talking therapies – previously known as Improving Access to Psychological Therapies – are required to be part of either the British Psychological Society or the British Association for Cognitive and Behavioural Psychotherapies’ registers. The registers, which were set up in 2021, confirm practitioners have completed an accredited course, ensure continuous professional development and provide a framework for striking off. 
    Meanwhile, NHSE’s IAPT manual – first published in 2018 – states all clinicians should have completed an accredited training programme and a “robust and urgent” plan should be in place to train those who have not, including the possibility of those without accreditation being prevented from working alone. 
    Read full story (paywalled)
    Source: HSJ, 3 May 2023
  21. Patient Safety Learning
    The NHS in London is planning to “fundamentally shift the way we deliver health and care” in the wake of coronavirus, according to documents obtained by HSJ.
    The plans from NHS England and Improvement’s London office say leaders should:
    Plan for elective waiting times to be measured at integrated care system level, rather than trust level. Accept “a different kind of risk appetite than the one we are used to”. Expect decisions from the centre on the location of cancer, paediatric, renal, cardiac, and neurosurgical services. Plan for a permanent increase in critical care capacity. Transform to a “provider system able to be commissioned and funded on a population health basis”. Work towards “a radical shift away from hospital care”. Expect “governance and regulatory landscape implications” plus “streamlined decision-making”. The document, titled Journey to a New Health and Care System, says there are three “likely” phases, with the final new system in place “from November 2021”.
    The preceding two phases are “action programmes” over the next 12 to 15 months which will be about reconfiguring services to deal with “immediate covid, non-covid and elective need”, and “transition” when the move to new configurations is evaluated and “public consent” sought.
    Read full story
    Source: HSJ, 11 May 2020
  22. Patient Safety Learning
    PRESS RELEASE
     (London, UK, 6 July 2020) – Thousands of ‘Long COVID’ patients are feeling unheard and unsupported. The charity Patient Safety Learning is giving these patients a voice to ensure urgent action is taken by leaders in health and social care.
     Helen Hughes, Chief Executive of Patient Safety Learning, said: “There is growing evidence that there are many patients recovering in the community with long-lasting symptoms who are feeling abandoned, confused and without support. We must take action to better understand the needs of these patients and provide them with safe and effective care.”
     Although Patient Safety Learning welcomes the recent government announcement of an online patient recovery portal and treatment plans, questions remain around whether this will meet the specific health needs of Long COVID patients. “These patients have felt unheard for too long; we must make sure they do not slip through the net,” adds Hughes.
     Long COVID patients are those with confirmed or suspected COVID-19 who continue to struggle with prolonged, debilitating and sometimes severe symptoms months later*.
     It is crucial that Long COVID patients are heard and supported, and that research is undertaken to better understand Long COVID and its long-term effects on physical and mental health. 
     Long COVID patient Barbara Melville told Patient Safety Learning, “the worst part is that I’ve had to fight so hard to get the referrals I need” and another, Dr Jake Suett, said that, after joining the ‘Long Covid Support Group’ on Facebook, he “was suddenly faced with the realisation that there were thousands of us in the same position” and that it confronted him “with the tremendous volume of genuine human suffering that was going unrecorded and unnoticed”.
     Patient Safety Learning is calling for leaders in health and social care to act urgently by funding research into Long COVID and ensuring that patients are given a platform to raise concerns and receive appropriate support.
     The charity has identified the current key issues as being:
     There is a lack of guidance and support for Long COVID patients who have been managing their illness and recovery from home (to date, much of the guidance has been designed specifically for patients who have been acutely unwell and in hospital).
    There is a lack of understanding around the effects of Long COVID on patients’ mental health and wellbeing. There is a risk that symptoms of other serious conditions are being overlooked for individuals with Long COVID and, instead, are being attributed simply as after-effects of COVID-19.  Patient Safety Learning’s proposed actions to address the safety issues concerning Long COVID care can be found on our website.
    Notes to editors:
    *The symptoms for those with Long COVID vary greatly but many are experiencing rashes, shortness of breath, neurological and gastrointestinal problems, abnormal temperatures, cardiac symptoms and extreme fatigue.
    Patient Safety Learning is a charity, which helps transform safety in health and social care, creating a world where patients are free from harm. We identify the critical factors that affect patient safety and analyse the systemic reasons they fail. We use what we learn to envision safer care. We recommend how to get there. Then we act to help make it happen. For more information: www.patientsafetylearning.org  Patient Safety Learning’s blog published today on patient safety concerns for Long COVID patients outlining these issues in more detail can be found here.  A blog by Dr Jake Suett published today in which he outlines his experience of suspect Long COVID calls needed can be found here.  An open letter from Dr Jake Suett to MPs to make clear the needs of this group can be found here.
  23. Patient Safety Learning
    The NHS has publicly recognised that chronic urinary tract infections (UTIs) exist and has updated its advice for patients following pressure from campaign groups.
    For many patients who develop a UTI, their experience is extremely painful but short-lived. But for thousands of others, a one-off acute attack turns into a chronic infection that dominates their lives and lasts for months or even years.
    NHS Digital updated its website to last week to provide information around chronic bladder infections where previously there was none.
    Campaigners say this is a “huge step forward” but there is still a long way to go in improving testing and treatments for the condition. 
    Chronic UTI sufferer Leah Herridge has been pushing for the change alongside Chronic Urinary Tract Infection Campaign (CUTIC) and Bladder Health UK.
    The NHS website’s Cystitis page has been updated to include mentions of chronic UTI and to acknowledge that current tests may not pick up these infections. 
    Previously, the NHS made no mention of chronic UTIs, meaning GPs and even consultants would often default to misdiagnosing patients with interstitial cystitis.
    Specialists say the infections, which often begin as an acute bout of cystitis, can occur when bacteria become embedded within the bladder wall and become difficult to treat with short courses of antibiotics.
    “People tend to think chronic means really bad. What it means is everlasting,” said Carolyn Andrew, from CUTIC.
    In August 2021, Ms Herridge sent a letter to NHS Digital demanding the web page be updated. The campaign was backed by CUTIC and Bladder Health UK as well as 100 other chronic UTI sufferers who also wrote letters.
    “NHS Digital has actually been really, really fantastic at working with us and I do feel like they have really co-produced, certainly the interstitial cystitis page with the leading professionals in the area, the charities and myself,” said Ms Herridge.
    Read full story
    Source: iNews, 14 March 2022
  24. Patient Safety Learning
    Trainee medics in a troubled maternity department have flagged concerns with national regulators over the safety of patients, it has emerged.
    Last year the General Medical Council said it had concerns about the treatment of obstetric and gynaecology trainees at University Hospitals Birmingham and placed medics at Good Hope Hospital and Heartlands Hospital under intensive support known as “enhanced monitoring”.
    The GMC’s review flagged serious concerns about emergency gynaecology cover arrangements and said there was a real risk trainees would become hesitant and reluctant to call on consultant support. In September it placed additional restrictions on training, due to “ongoing significant concerns about the learning environment and patient safety”.
    Now it has emerged in board papers for Birmingham and Solihull integrated care board that Health Education England, now part of NHS England, and the GMC carried out a follow-up visit to UHB in late March to review progress. 
    Board documents state that “several patient safety concerns [were] reported by postgraduate doctors in training to the visiting team”, with a subsequent feedback letter from HEE urging immediate changes to dedicated consultant time and job plans.
    Read full story (paywalled)
    Source: HSJ, 17 May 2023
  25. Patient Safety Learning
    Several NHS trusts are offering a ‘treatment’ for birth trauma which uses a technique which lies outside national guidelines and which is criticised by specialists as potentially causing ‘more harm than good’.
    The ‘Rewind’ technique is promoted as a fast treatment for post-natal post-traumatic stress disorder (PTSD) – also known as birth trauma - which involves the “reprocessing” of painful memories.
    HSJ has learned of several trusts, including East and North Herts Trust, Chelsea and Westminster Hospital Foundation Trust and James Paget University Hospital FT, where the therapy is being offered. It is thought there are other trusts which are providing it or have explored it. Typically, it is provided by midwives who have undergone training in the technique.
    But Nick Grey, a clinical psychologist who was on the National Institute for Health and Care Excellence panel which looked at PTSD, said it was “absolutely clear cut” that it was bad practice to offer the technique as a branded therapy for PTSD, although he said it could be embedded as part of other treatments.
    He told HSJ: “It should not be offered to mothers with PTSD… they are being done a disservice if they are not given evidence-based treatment. There is no evidence that this [provides] treatment for sub-clinical PTSD or trauma,” he said.
    Read full story (paywalled)
    Source: HSJ, 11 November 2020
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