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Patient Safety Learning

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  1. News Article
    Governments should set aside 10% of health spending for preventive and public measures such as cycle lanes and anti-obesity strategies, a thinktank has said, warning that “political short-termism” over health is making the UK increasingly ill and unequal. The report by the Tony Blair Institute argues that a centralised NHS model “almost entirely focused on treating sickness” rather than on wider objectives is not only harming people’s health but hampering the economy, with more than 2.5 million people out of the labour market because of long-term ailments. The report emphasises the human cost as well, noting that the effect of diseases caused or exacerbated by lifestyle means UK life expectancy is stagnating, while men living in the London borough of Kensington and Chelsea can now expect to live 27 years longer than their peers in Blackpool, Lancashire. Along with a coherent central plan, the authors stressed the need for effective localism, with accountable regional bodies working to improve public health, rather than “the existing top-down and reactive approach of the NHS”. Read full story Source: The Guardian, 24 March 2023
  2. Content Article
    This new report from the Tony Blair Institute for Global Change sets out the need to both harness the power of new technologies and to create a streamlined, strategic state to revolutionise the delivery of public services. Nowhere is this approach more urgently needed than on the country’s health. Healthcare demands continue to increase while costs are spiralling as health takes up an ever-higher proportion of public spending. At the same time, outcomes are deteriorating, with UK life expectancy stagnating and health inequalities on the rise. So, we’re all paying more and more to achieve less and less. The report suggests a paradigm shift: we must begin to treat individual and collective health as a national asset. Government must focus its efforts and resources on creating the conditions in which population and individual health can flourish.
  3. Content Article
    If you are considering 'going private' for the first time, it can be confusing and overwhelming. Private Healthcare Information Network (PHIN) has created some short videos to guide you through your private healthcare journey and demonstrate how the PHIN website and search function can help you. These videos for patients clarify some essential healthcare terms and shows how you can use PHIN's website to make informed decisions when considering private medical treatment.  Have a watch, or if you prefer to read the information instead, PHIN has also included the text from each video below it. PHIN is an independent, government-mandated organisation publishing performance and fees information about private consultants and hospitals.
  4. Content Article
    In January 2023, Newmarket Strategy and BD, a global medical technology company, were part of a delegation of UK health leaders travelling to the global healthcare conference Arab Health in Dubai, United Arab Emirates. The purpose of the visit was to learn more about Connected Medication Management (CMM) and the role it can play in solving some of the most pressing challenges faced by health systems today. Connected Medication Management is a technology-driven approach to medication management that uses digital and automation technologies. It aims to optimise medication use by reducing medication errors to improve patient safety, whilst delivering productivity gains for the NHS. It also frees up nursing and other clinical staff to provide more patient care.
  5. News Article
    Police are investigating fresh allegations of sexual assault against a child patient by a care worker at a scandal-hit private mental health hospital group. It is the second time reports have been made about a former Huntercombe Group hospital after two care workers were quizzed over the alleged rape of a child at its Taplow Manor Hospital in Maidenhead last year. The latest allegations are from a patient at the group’s Ivetsy Bank Hospital, in Staffordshire, which was rated as inadequate last week. In a statement, Staffordshire Police confirmed it had received a report of sexual assault and said inquiries were ongoing. The news comes as the NHS’s safety watchdog has threatened to close Taplow Manor after hospital leaders failed to make improvements in care. The action comes after joint investigations by The Independent and Sky News found the private hospital had put the safety of young mental health patients at risk, with more than 50 patients and staff members alleging “systemic abuse” and poor care. Read full story Source: The Independent, 24 March 2023
  6. News Article
    National NHS forecasts are predicting there will be around 11,000 patients on the elective waiting list who have been waiting longer than 78 weeks at the start of April, the target for clearing this cohort, HSJ understands. Senior NHS figures familiar with the forecasts told HSJ they had stood at around 9,000 last week, but mass cancellations during the three-day junior doctors’ strike had pushed up the potential outstanding cases by approximately 2,000. One senior NHS figure close to national efforts said they “hoped” trusts could cut the figure to under 10,000 by the deadline, and that intense work was going on across systems to ensure the figure was as small as possible. It is understood system leaders expect the 78-week breach figure to be cut to around 2,000 by the summer. However, as has been the case for the 104-week breaches, they are also predicting a long tail due to a combination of complex cases and patients choosing to wait longer. Read full story (paywalled) Source: HSJ, 23 March 2023
  7. News Article
    An eight-year-old girl waiting three years to have three teeth removed has been left in "agony". Ella Mann, from Dovercourt in Essex, first went to the dentist with an issue with a baby tooth in December 2019. She was given a temporary filling and told it needed to be removed but has still not had the NHS procedure. The youngster has now been placed on an NHS waiting list for the tooth extraction. Ella's dad Charlie Mann, 54, said his daughter was sometimes in "agony". Healthwatch England last year warned of people struggling to get dental treatment as increasing practices closed to new patients. A BBC investigation identified cases of people driving hundreds of miles in search of treatment and pulling out their own teeth without anaesthesia. Read full story Source: BBC News, 23 March 2023
  8. News Article
    Junior doctors are to stage a four-day walkout in April in their fight to get a 35% pay rise in England. Members of the British Medical Association (BMA) will take strike action from 11 April to 15 April. Last week's walkout led to the cancellation of 175,000 treatments and appointments, with consultants brought in to provide cover in emergency care. Hospitals bosses said the fallout from the strike would last weeks given the huge number of bookings that have to be rescheduled. The new walkout of both planned and emergency care comes directly after the Easter weekend, which tends to be a busy period for the NHS. Saffron Cordery, of NHS Providers, the membership organisation for NHS trusts in England, said demand would have built up over the bank holiday weekend. "This threatens the biggest disruption from NHS walkouts so far," she said, adding: "There should be no doubt about the scale of the impact on patients, staff and the NHS." Read full story Source: BBC News, 23 April 2023
  9. News Article
    It is ‘not right to normalise’ the current workload in general practice as numbers of GPs and practices goes down, the RCGP chair told delegates at Pulse Live this week. Professor Kamila Hawthorne highlighted the pressure GPs are under with general practice appointments increasing most last year, compared to A&E and outpatients. She also said her priority from a new GP contract would be better resourcing for GPs working in deprived areas. Her speech looked at the challenges facing general practice and imagined what the future could look like, including what the college can do to bring about change. Professor Hawthorne said: ‘The workload that we’re facing – it’s not right to normalise it. The sort of work days that we have in general practice, it is not right to normalise this. ‘The number of GPs is going down because they’re leaving the profession faster than they’re entering it. The number of practices in England is going down, and compared with affluent areas, GPs in deprived areas earn less but see more patients with more chronic illness.’ Read full story Source: Pulse, 21 March 2023
  10. Content Article
    How one Devon ICS has worked with local trusts to cut deliver extra capacity at a former Nightingale hospital, now converted into an elective centre.
  11. Content Article
    In this BMJ article, Ryan Essex and colleagues consider whether patients have more to gain than to lose from healthcare worker strikes in poorly functioning health systems Available research on the relationship between strikes and patient harm is limited and offers mixed results, most of which are not widely generalisable across different care settings, researchers said.  Overall, the researchers in the study observed a substantial decrease in the number of admissions or care visits during strikes, with broader care delivery changes varying based on who is striking. For example, when early-career physicians strike, research suggests wait times and length of stay are unaffected or become shorter.  "While patient safety obviously matters, the overly narrow framing of strikes as harmful to patients is not supported by current evidence; this also shifts focus away from the structural failings that drive strike action in the first place," "When health workers lack other avenues to enact change, failing to strike against suboptimal working conditions may actually be more harmful to patient health in the long run."
  12. Content Article
    Cincinnati Children’s Hospital Medical Center believes all patients and their families have a right to receive medical information in their preferred language. Andy Schwieter from Cincinnati Children’s shares how his organisation supports the diverse languages of the community they serve through improved communication.
  13. News Article
    A father-of-two died of sepsis three days after being sent home from A&E with antibiotics for a suspected urinary tract infection, an inquest heard. Alex Blewitt, 48, died in July 2022 after suffering a cardiac arrest caused by a perforated bowel and sepsis. Senior coroner for Milton Keynes, Dr Sean Cummings, said Mr Blewitt's death was avoidable. The coroner recorded a narrative conclusion and said he intended to issue a prevention of future deaths report. Mr Cummings said: "The doctor, who saw and assessed Mr Blewitt in the emergency department, did not read the Urgent Care Centre communication that was provided and did not record important factual information in the clinical note. "Mr Blewitt was discharged, but returned two days later when suffering with sepsis due to a previously undiagnosed bowel perforation." Mr Blewitt's widow, Amy Blewitt, said: "Alex was in such pain and kept asking the hospital for help, but they sent him home. "My plea to the hospital is please, please don't let this type of mistake ever happen to anyone else ever again." Read full story Source: BBC News, 22 March 2023
  14. News Article
    Trust executives and senior managers have been criticised by a former national director for their lack of support for an under-pressure A&E. An independent review described York Hospital as “reluctant” to trigger internal escalation processes, and suggested it should be quicker to admit extra patients to inpatient wards during busy periods. Professor Matthew Cooke, a former national clinical director for emergency care who conducted the review, said that during his two-day visit to the department he witnessed a 60-hour delay for a patient to be admitted: “I was surprised not to see any senior managers or executives in the ED, despite such long delays. ED staff reported they rarely saw the executive team.” Professor Cooke also warned of uncertainty over escalation processes, including for reducing pressure in the emergency department by “boarding” patients on wards beyond normal capacity. He said: “On the second morning, there were multiple patients on oxygen in ordinary seats in majors waiting room, cared for by a single nurse. I find it difficult to understand how this is safer than boarding one extra patient on several wards.” “Staff perceived that the organisation was reluctant to move to higher escalation levels and I sensed this meant staff no longer pushed for such actions.” Read full story (paywalled) Source: HSJ, 23 March 2023
  15. News Article
    Self-harm hospital admissions for children aged eight to 17 in the UK jumped 22% in one year. The age group is now the largest for self-harm admissions, with all others seeing a drop, according to NHS data. Charities say early access to support is vital, but high thresholds and long waiting lists mean more young people are ending up in hospital. Emily Nuttal, 29, first struggled with self-harm when she was 12. At 13, she was first admitted to A&E. At that time, she was struggling with changes at school, bullying and troubles at home. Over the years, she said she had had varied experiences in accident and emergency departments. "It's been times where it's been really empathetic and passionate people, understanding, supportive. And there's been times where there's been that stigma and judgement." She said being labelled as "attention-seeking" was really difficult and made it harder to reach out for help again. "I would then only go if I was forced upon by the crisis service, or if somebody else noticed, and they got people involved," she said. Read full story Source: BBC News, 23 March 2023
  16. News Article
    The link between menopause and poor mental health should be reviewed, the health watchdog has said, after an inquiry into a woman’s suicide found staff lack training to spot the risks. Frances Wellburn, 56, took her own life in 2020 after she was incorrectly assessed as being a “medium risk” of suicide by Tees, Esk and Wear NHS Trust (TEWV). A national study by the Health and Safety Investigation Branch (HSIB), prompted by her death, warned that this was a national problem, with funding and capacity problems driving staff to use ineffective “checklist” tools when assessing suicidal patients. HSIB also found staff were not trained to spot mental health risks associated with menopause, and menopause is not routinely considered a contributing factor among women with low mood who need help. It said that women are often prescribed antidepressants when hormone replacement therapy (HRT) would be more appropriate. In Ms Wellburn’s case, HSIB found TEWV staff had failed to take into account that she was going through menopause when they assessed her as being at medium risk of self-harm. This went against national guidance, which states scales should not be used to predict future suicide or self-harm. Read full story Source: The Independent, 23 March 2023
  17. News Article
    A terminally ill mother says she was "horrified" after she was handed her baby's remains in a supermarket carrier bag by NHS officials. Lydia Reid's son Gary was a week old when he died in 1975. She later discovered his organs had been removed for tests without her permission and only received them last month after almost 50 years of campaigning. The 74-year-old, told BBC Scotland she was visited last month by the head of NHS Lothian as well as another senior NHS official. "I thought they were coming to help me sign some papers. When they arrived I noticed one of them was carrying a Sainsbury's carrier bag," Ms Reid said. "Then they said they wanted to complete the list of body parts in case anything had been missed out. She handed me the Sainsbury's bag and said she wanted me to check them now." Inside the carrier bag was a six-inch box containing body parts preserved in wax. "I was so shocked and said 'How dare you. That is the only parts of my son and you want to hand them to me in a carrier bag. "I was absolutely horrified. She said she didn't realise it would be a problem." Tracey Gillies, medical director for NHS Lothian said: "I would like to repeat publicly the apology we made to Ms Reid in person for the upset and distress this has caused. Ms Reid has been a leading figure in the Scottish campaign to expose how hospitals unlawfully retained dead children's body parts for research. Read full story Source: BBC News, 23 March 2023
  18. News Article
    A fifth of UK hospitals were forced to cancel operations during the three days in July last year when temperatures soared, research suggests. The findings, published in a letter to the British Journal of Surgery, are based on surveys from surgeons, anaesthetists and critical care doctors working during the heatwave from July 16-19 2022, when temperatures reached as high as 40C in some parts of the country. The researchers received 271 responses from 140 UK hospitals – with one in five (18.5%) reporting elective surgeries being cancelled due to the heatwave. The respondents also said surgical services were poorly prepared for heatwaves, with 41% of operating theatres having no means to control ambient temperature, while more than a third (35.4%) reported making changes to maintain routine surgical activity during the period. These include delayed discharge of high-risk patients, changes to surgical teams, selecting lower-risk patients to have surgery, and restricting surgical activity to day cases. Other measures included longer staff breaks, extra fluids to patients, and surgeries earlier in the morning when temperatures were lower. Read full story Source: The Independent, 23 March 2023
  19. News Article
    Young people with eating disorders are coming to harm and ending up in A&E because they are being denied care and forced to endure long waits for treatment, GPs have revealed. NHS eating disorders services are so overwhelmed by a post-Covid surge in problems such as anorexia that they are telling under-19s to rely on charities, their parents or self-help instead. The “truly shocking” findings about the help available to young people with often very fragile mental health emerged in a survey of 1,004 family doctors across the UK by the youth mental health charity stem4. The shortage of beds for children and young people with eating disorders is so serious that some are being sent hundreds of miles from home or ending up on adult psychiatric wards, GPs say. “The provision is awful and I worry my young patients may die,” one GP in the south-east of England told stem4. Another described the specialist NHS services available in their area as “virtually non-existent and not fit for purpose”. Read full story Source: The Guardian, 22 March 2023
  20. News Article
    London primary-school pupils not fully vaccinated against polio are to be offered catch-up jabs after Easter. The disease, common in the UK in the 1950s, was eliminated by 2003. But poliovirus traces were found in north and east London sewage in early 2022. An emergency vaccination-booster campaign in London last summer reached more than 370,000 children. And in early November, the latest tests found less of the virus - but officials say there is no room for complacency. Dr Vanessa Saliba, from the UK Heath Security Agency, told BBC News: "We have early signs that there's less spread of poliovirus in London - but we will need 12 months of no detections before the World Health Organization could declare that the UK is no longer an infected country." Polio causes paralysis in a very small number of cases where the virus attacks the nerves in the spine and base of the brain - but most are asymptomatic. Read full story Source: BBC News, 23 March 2023
  21. Content Article
    In this blog, Patient Safety Learning looks in detail at the results of the NHS Staff Survey 2022, focusing on responses relating to reporting, speaking up and acting on safety concerns. It includes the following key points: It is difficult to imagine other safety critical industries would deem these results acceptable. Nearly half of all respondents did not feel confident their organisation would address their concerns about unsafe clinical practice. It is hugely concerning that over 40% of respondents could not say that they would be treated fairly if involved in a patient safety incident. This could significantly undermine the willingness of staff to raise concerns, with significant consequences for patient safety. There needs to be greater urgency to improve the safety culture in the health service. NHS England needs to recognise the scale of this challenge and provide clarity on how it will work with organisations to tackle this. NHS England, working in partnership with the National Guardian and the Care Quality Commission, should bring forward as a matter of urgency robust and specific commitments to drive forward the work of improving the safety culture in the NHS.
  22. News Article
    Potentially deadly fungal infections with Candida auris are spreading rapidly in US healthcare facilities, with cases nearly doubling between 2020 and 2021, the US Centers for Disease Control and Prevention has said. The number of cases rose by 44% to 476 in 2019, up from 330 in 2018, and subsequently by 59% to 756 in 2020 and by an additional 95% to 1,471 in 2021, the agency’s researchers reported on Monday in Annals of Internal Medicine. Also concerning was a tripling in 2021 of the number of cases that were resistant to echinocandins, the class of drugs most often recommended for treatment of the disease. The most common Candida auris symptoms include a high fever and chills that do not improve after antibiotic treatment for suspected bacterial infections, according to guidelines from the CDC. Additional symptoms can develop if the infection spreads. Dr Waleed Javaid – an epidemiologist, infectious disease expert and director of infection prevention and control at New York’s Mount Sinai Downtown – told NBC News that the new findings were “worrisome”. Read full story Source: The Guardian, 21 March 2023
  23. News Article
    Children must now be in crisis before they can be referred for an autism diagnosis, parents claim. The strict new eligibility criteria in the Bristol region comes after a 350% rise in the number waiting more than two years for assessment. Changes made by the NHS mean children will only be referred with "severe and enduring" mental health issues. The Integrated Care Board (ICB) said it meant resources could now focus on those with "the highest clinical need". Some parents have launched the campaign Assess for Autism in protest against the rule change. An Assess for Autism spokesperson said children would now have to be at crisis point before being referred, describing the policy as "deeply concerning" and "regressive". However, healthcare provider Sirona, which provides autism diagnosis services, and the Integrated Care Board (ICB), which formally approved the new policy, insist it is necessary because families are waiting too long. They said resources can now be focused on those with the "highest clinical need or are the most vulnerable". Read full story Source: BBC News, 22 March 2023
  24. News Article
    Vulnerable mental health patients are being put at risk by unregulated “eating disorder coaches” who do not have the necessary qualifications, experts have said. As demand for eating disorder support soars – hospital admissions for eating disorders increased by 84% in the last five years – more people are filling gaps in NHS care. So-called eating disorder coaches, who tend to be personal trainers or dietitians recovering from the illness themselves, are charging as much as £1,000 a month for sessions to offer support to others despite having little or no training and expertise. The Guardian has found that many coaches cite short courses, which are intended as professional development for psychologists, as a qualification to practise. The National Centre for Eating Disorders (NCED) offers a number of professional training courses, accredited by the British Psychological Society (BPS). The Guardian found a number of coaches were using these courses to claim they were qualified to offer professional services to people with eating disorders. Agnes Ayton, chair of the Royal College of Psychiatrists’ eating disorders faculty, said she was “amazed” to see people “advertising themselves as experts after going on one course”. “Eating disorders sit between physical and mental health so the risks associated with eating disorders can be physically debilitating and potentially fatal,” Ayton said. “I don’t know why there is not better regulation on that because there is lots of regulation for a medical professional – but therapy is the first line of treatment for eating disorders, and if it is not delivered properly, it can be harmful or misleading.” Read full story Source: The Guardian, 21 March 2023
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