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Patient Safety Learning

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  1. Content Article
    Many people will experience mental health problems in their lives. Around one in six adults in England have a common mental health disorder, and around half of mental health problems start by the age of 14.  This report from the National Audit Office focuses on the implementation of NHS commitments as set out in the Five Year Forward View for Mental Health, Stepping forward to 2020/21: The mental health workforce plan for England and the the NHS Long Term Plan. It examines whether the government has achieved value for money in its efforts to date to expand and improve NHS-funded mental health services by evaluating whether DHSC, NHSE and other national bodies: have a clear understanding of how much their work to date has reduced the gap between mental and physical health services met ambitions to increase access, capacity, workforce and funding for mental health services are well placed to overcome the risks and challenges, including the impact from COVID-19, to achieving future ambitions.
  2. Content Article
    There is little longitudinal information about the type and frequency of harm resulting from medication errors among outpatient children with cancer. This study aimed to characterise rates and types of medication errors and harm to outpatient children with leukaemia and lymphoma over 7 months of treatment.
  3. News Article
    The independent data watchdog has called for greater clarity from NHS England on how it will ensure there are “as strong… if not stronger” safeguards on health and care data following its takeover of NHS Digital. NHS Digital – whose role included controlling access to large amounts of NHS data – became part of NHS England on 1 February, and its teams and functions are due to merge in coming months. In an interview with HSJ, national data guardian Nicola Byrne said the merger creates “an inherent tension in having one organisation be both data custodian and the organisation seeking to access the data”, although it “makes sense in terms of streamlining and efficiencies”. Concerns have been raised about the merger’s information governance implications by campaign group medConfidential, the British Medical Association and politicians. These include that there would be less transparency over the handling of data, and that NHSE would be “marking its own homework” as both controller of, and a major user of, data. Read full story (paywalled) Source: HSJ, 8 February 2023
  4. News Article
    A Norfolk surgeon who left two patients with life-changing injuries has received a formal warning by a disciplinary panel. Camilo Valero Valdivieso was found guilty of "serious misconduct" by an independent medical panel after two operations went wrong in six days. One of his patients, Paul Tooth, 65, said his life was "a constant struggle" since his operation in January 2020. However, the panel found the surgeon had "learned from these events". The findings from the Medical Practitioners Service (MPTS) panel said that his actions had "risked damaging public confidence in the profession". It heard that he twice "misinterpreted the anatomy" - on one occasion severing a patient's gallbladder. The panel also concluded Mr Valero's fitness to practise was not currently impaired, allowing him to continue working. Read full story Source: BBC News, 7 February 2023
  5. News Article
    A mother who has seen her suicidal 12-year-old daughter shuttled between placements and then held in a locked and windowless hospital room says she is frightened for her child’s life. Since going into care in Staffordshire nine months ago, Becky (not her real name) has attempted to take her own life on several occasions. Her case throws fresh light on the chronic nationwide shortage of secure accommodation for vulnerable children. “I am constantly told there is nowhere for her,” said her mother, who cannot be identified for legal reasons. “I fear I’ll soon be arranging her funeral due to the systemic failings in health and social care.” Becky has been alone in a locked hospital room since 27 January. The room has no window or access to the outdoors, no furniture except for a bed, and she is permitted no belongings. All human contact is conducted through a hatch. The child’s court-appointed guardian told the high court at a hearing to discuss Becky’s case that she considered “the risk to Becky’s life to be catastrophic”. Read full story Source: The Guardian, 7 February 2023
  6. News Article
    NHS waiting lists are unlikely to fall in 2023, and the backlog is unlikely to be significantly tackled until mid-2024 despite being one of Rishi Sunak’s priorities for this year, research suggests. The NHS has struggled to increase the number of people it is treating from its waiting lists each month due to ongoing pressures from Covid-19, although there have been signs of improvement in the past month, analysis from the Institute for Fiscal Studies (IFS) has found. Max Warner, an IFS economist and one of the report’s authors, said that although the NHS had made “real progress” to reduce the number of patients waiting a very long time for care, efforts to increase overall treatment volumes had “so far been considerably less successful”. The NHS Providers’ chief executive, Julian Hartley, urged the government to introduce a fully funded workforce plan and to talk to unions about pay for this financial year as strikes were causing huge disruption to services, and risked undoing hard-won progress made on care backlogs. “Mounting pressures on acute, ambulance, mental health and community services, such as chronic workforce shortages, could hamper efforts to cut the backlog further if left unchecked,” he said. Read full story Source: The Guardian, 8 February 2023
  7. Content Article
    In this analysis, the Health Foundation looks at the outlook for health funding following the 2022 Autumn Statement, draws out some implications for clearing the NHS estate maintenance backlog and looks at the potential impact of pay and other cost pressures on NHS spending power. 
  8. Event
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    Hear about the work undertaken on digital storytelling via the NHS England cancer alliances and how they have been used to improve services. There will also be a session by Macmillian Cancer Care on digital storytelling project which shares peoples experiences of cancer diagnosis and treatment. Register
  9. Event
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    Here at Solent, we have fundamentally changed the way we work with local people and communities. We want to ensure that the way we develop, design and improve our services is based on what really matters most to people who use them, not that we believe as health professionals is important. We now actively recognise and celebrate the strengths of our community, as people with exceptional knowledge, skills and expertise, that which sadly often goes untapped by providers of health and care services. By working with the Touch Network, we are enabling people to unlock stories about difficult times. This helps us understand what we do well, and what we need to change to ensure people who use our services have a positive experience of care. Do join us, Debs Carter, Founder of Touch Network and Sarah Balchin, Director of Community Engagement and Experience, to hear our story of sharing and learning. Register
  10. Content Article
    The Patient Experience Library's patient surveys tracker offers one-click access to the key patient experience datasets for every Trust in England. 
  11. News Article
    Thousands of patients are being recalled for urgent eye checks after regulators raised safety concerns related to a product used in cataract surgery. It is thought around 20 trusts have suspended use of the EyeCee One lenses, after the Medicines and Healthcare Products Regulatory Agency warned of links to higher pressure in the eye, which can cause lost vision. The MHRA has issued an alert ordering trusts to recall patients who have had surgery since October, and estimates between 2 and 4 per cent of patients could have complications. The watchdog stressed reduced vision would only occur if patients were not treated. It is thought the complications could be down to the way the implant was being used in surgery, rather than the product itself. Read full story (paywalled) Source: HSJ, 7 February 2023
  12. Content Article
    The MHRA is aware of cases of increased intraocular pressure in patients recently implanted with EyeCee One preloaded and EyeCee One Crystal preloaded intraocular lenses (IOLs), which are manufactured by NIDEK and distributed by Bausch + Lomb. The root cause has not been identified and further investigations are ongoing with the manufacturer.  Due to the potential risks for patient safety, you should stop using these IOLs and quarantine remaining stock immediately pending the results of further investigations. Additional communications will be issued shortly advising clinicians and affected patients on the next steps.
  13. News Article
    East Kent Hospital University Foundation Trust has been criticised for failures in services by the Care Quality Commission, after an unannounced inspection last month, years after major problems began to come to light. The Care Quality Commission has highlighted: Issues with processes for fetal monitoring and escalation at the William Harvey Hospital, Ashford. There had been “incidents highlighting fetal heart monitoring” problems in September and October, and the trust’s measures to improve processes were not “embedded and understood by the clinical team”; Slow maternity triage, due to staffing problems, and infection control problems at the William Harvey. The trust is reviewing how issues with infection prevention and control and cleanliness were not identified or escalated; and Fire safety issues at the Queen Elizabeth, the Queen Mother Hospital, in Thanet with problems linked to fire doors and an easily accessible secondary fire escape route. Three years ago issues with reading and acting on fetal monitoring were highlighted at the inquest into baby Harry Richford, whose poor care by the trust led to an independent inquiry into widespread failings in its maternity services, led by Bill Kirkup. Read full story (paywalled) Source: HSJ, 6 February 2023
  14. Content Article
    Mesh implantation for hernia repair has become standard practice for the majority of hernia repairs. Mesh-based hernia repairs have been shown to be a durable solution, however, postoperative complications, such as chronic postoperative pain, remain a concern. To date, there have been few investigations into the inflammatory response to mesh. In this study, Fadaee et al. present their experience in diagnosing and treating a subpopulation of patients who require mesh removal due to a possible mesh implant illness. They found predisposing factors include female sex, history of autoimmune disorder, and multiple medical and environmental allergies and sensitivities. Presenting symptoms included spontaneous rashes, erythema and oedema over the area of implant, arthralgia, headaches and chronic fatigue. Long-term follow up after mesh removal confirmed resolution of symptoms after mesh removal. The authors hope this provides greater attention to patients who present with vague, non-specific but debilitating symptoms after mesh implantation.
  15. News Article
    A draft NHSE statement suggests mental trusts could be asked to eradicate features of the ‘serenity integrated mentoring’ (SIM) care model from clinical practice, following a whirlwind of concerns in 2021 and an investigation by national clinical director Tim Kendall. A core feature of SIM is to place a police officer within a healthcare team charged with supporting patients who frequently attend emergency services in crisis, and creating crisis plans. The draft position statement produced by NHSE, which the regulator said is not its final version and is subject to changes, says SIM should not be used. It also proposes the eradication of the following practices from any equivalent care model: Police involvement in delivery of therapeutic interventions in planned, non-emergency, community mental healthcare; The use of coercion, sanctions (criminal or otherwise), withholding care and otherwise punitive approaches; and Discriminatory practices and attitudes towards patients who express self-harm behaviours, suicidality and/or those who are deemed “high intensity users”. The statement, which is the first indication of NHSE’s position on the SIM model but not its final stance, also suggests Professor Kendall will be seeking assurance from trust medical directors that SIM or similar models, and the above three features of concern, are no longer used. A full policy and public statement on the model is expected by the spring. The StopSIM coalition, whose campaigning prompted the NHSE review, said: “Unless and until the full policy is freely available to service users and the public, service users are not equipped to protect themselves against the dangers of SIM and similar approaches". Further reading on the hub: The High Intensity Network (HIN) approach and SIM model for mental health care and 'high intensity users' – views and discussion StopSIM: Mental health is not a crime
  16. News Article
    A record number of eating disorder patients are not getting the life-saving treatment they need due to lengthy waits, leaked NHS data shows. More than 8,000 adults are waiting to be seen for therapy, according to internal figures from NHS England – the highest figure recorded since data collection began in 2019. In March 2021, there were around 6,000 adults waiting, while it was less than 2,000 in March 2019. One leading doctor warned that delays were leading to avoidable deaths, while multiple coroners investigating the deaths of nine patients since 2021 have repeatedly called on the NHS and ministers to improve services to prevent more. An investigation by The Independent can also reveal that long waits have led to a woman, 24, taking her own life while waiting two years for appropriate care, and patients being admitted to hospital because their conditions became so severe they developed life-threatening physical conditions. Dr Agnes Ayton, the Royal College of Psychiatrists’ lead for adult eating disorders, said long waits meant patients were “dying avoidably” because under-resourced services were forced to turn them away or leave them waiting for years. Anorexia has the highest morality rate of any psychiatric disorder. “One important thing is eating disorders are treatable, people can get better with time and treatment. We shouldn’t accept anorexia has the highest mortality rate because a lot of these deaths are avoidable and treatable. We should be aiming to provide high-quality care,” she said. Read full story Source: The Independent, 6 February 2023 Further reading on the hub: People with eating disorders should not face stigma in the health system and barriers to accessing support in 2022 Eating disorders: challenges of the pandemic
  17. News Article
    A health board has apologised to the family of a patient after medical staff failed to consult with them over a decision not to resuscitate her. While the decision was clinically justified, the public services ombudsman for Wales said Betsi Cadwaladr health board did not discuss it with the patient and her family. The ombudsman, Michelle Morris, also upheld a complaint by the patient's daughter, identified only as Miss A, that her mother's discharge from Ysbyty Gwynedd in Bangor was "inappropriate" and that insufficient steps were taken to ensure her needs could be safely met at home. The final complaint, which was also upheld, was that medics failed to communicate with the family about the deteriorating condition of the patient, identified as Mrs B, which meant a family visit was not arranged before she died. In her report she said the Covid pandemic had contributed to the failings, but added "this was a serious injustice to the family". As well as apologising to the family, she asked that all medical staff at Ysbyty Gwynedd and Ysbyty Penrhos Stanley be reminded of the importance of following the proper procedure when deciding when a patient should not be resuscitated. Read full story Source: BBC News, 6 February 2023
  18. News Article
    Rana Abdelkarim died at Gloucestershire Royal Hospital in March 2021 after suffering a bleed post-birth. The Healthcare Safety Investigation Branch (HSIB) found there were delays in calling for specialist help. Her husband, Modar Mohammednour, said that in March 2021 his wife attended the maternity unit at 39 weeks into her pregnancy for what she thought was a routine check-up. Mr Mohammednour said due to language barriers his wife thought she was going "for a scan and to check on her health" and then "come back home", but in fact she was being sent to be induced. "Immediately" after the labour, Ms Abdelkarim suffered heavy bleeding and her condition deteriorated - something Mr Mohammednour said he was "unaware of", until he was eventually called into the hospital to speak to a doctor. According to the investigation by the HSIB, the obstetric team of senior doctors were not told about the drastic change in her condition for almost 30 minutes. An investigation into her death by the HSIB found that once Ms Abdelkarim had been given a drip to speed up labour, regular support from midwives and assessments could not be given to her because the maternity ward was so busy. It also found there was a 53-minute delay from the point of bleeding to administering the first blood transfusion. HSIB also found Ms Abdelkarim was "uninformed" about the reason for her admission, "consent to induce labour was not given" and because she was thin and small, staff underestimated how much relative blood volume she was losing. Read full story Source: BBC News, 7 February 2023
  19. Content Article
    “Medical gaslighting” is a controversial term that has emerged to describe a phenomenon some people – women in particular – may recognise. It refers to a patient’s feeling that their symptoms are not taken seriously, or are being misdiagnosed by healthcare professionals. When she was 37, Eleanor presented at a hospital emergency department with severe chest pain. She was diagnosed with slightly high cholesterol and sent home. Three days later, she suffered excruciating pain and was taken to hospital in an ambulance. There, she was asked if she had suffered from panic attacks and was left overnight in a cubicle, before doctors realised she was having a heart attack. She needed eight cardiac stents. “I am sure no man would be asked if they suffer from panic attacks while they’re having a heart attack,” she says. This article in the Irish Times asks why women are more likely to feel their symptoms are not being taken seriously by doctors. Further reading on the hub: ‘Women are being dismissed, disbelieved and shut out’ Gender bias: A threat to women’s health Dangerous exclusions: The risk to patient safety of sex and gender bias
  20. News Article
    The government has rejected an urgent call by MPs to bring in a new licensing regime for non-surgical procedures such as Botox injections, chemical peels, microdermabrasion and non-surgical laser interventions. Ministers also rejected recommendations by the House of Commons Health and Social Care Committee to make dermal fillers available as prescription only substances—as Botox is—and to bring in specific standards for premises that provide non-surgical cosmetic procedures. The government also rejected several recommendations aimed at tackling obesity—including a dedicated eating disorder strategy, annual health and wellbeing checks for every child and young person, and restrictions on buy-one-get-one free deals for foods and drinks high in fat, salt, or sugar. Read full story Source: BMJ, 2 February 2023
  21. Content Article
    Simple, and relatively inexpensive, steps to implement care bundles can have a dramatic impact on rates of surgical site infection. The Burden of Infection Symposium provided an insight into the latest evidence and guidance around best practice, as well as offering expert advice on ‘overcoming the challenges of change’. Read a summary of the symposium published in the Clinical Services Journal.
  22. Content Article
    In this study, Hawkins and Morse explored nurses’ work in the context of medication administration, errors and the organisation. Secondary analysis of ethnographic data included 92 hours of non-participant observation, and 37 unstructured interviews with nurses, administrators, and pharmacists. Think-aloud observations and analysis of institutional documents supplemented these data. Findings revealed the nature of nurses’ work was characterised by chasing a standard of care, prioritising practice and renegotiating routines. The rich description identified characteristics of nurses’ work as cyclical, chaotic and complex, shattering studies that explained nurses’ work as linear. A new theoretical model was developed, illustrating the inseparability of nurses’ work from contextual contingencies and enhancing our understanding of the cascading components of work that result in days that spin out of the nurses’ control. These results deepen our understanding why present efforts targeting the reduction of medication errors may be ineffective and places administration accountable for the context in which medication errors occur.
  23. Content Article
    Ten years ago today, a public inquiry concluded that patients were subject to shocking levels of neglect at Stafford Hospital - putting it among the worst care scandals in NHS history. A young local reporter, Shaun Lintern – now The Sunday Times' health editor – helped expose the scandal. With the NHS again under huge pressure, can we be sure the same failings won't happen again? In this podcast, part of the Stories of our Times podcast series, Shaun speaks to the barrister who chaired the inquiry.
  24. News Article
    Deadlock over NHS pay is putting patients in danger and risks hardening the position of unions, 10 chief nurses have warned. Unions have warned that the government is making no moves towards resolving the strikes, with one general secretary accusing the government of lying about the state of negotiations. In a joint statement shared with the Guardian, chief nurses from 10 leading hospitals known as the Shelford group highlighted their concern that patients’ health could suffer as a direct result of the increasing disruption the stoppages are causing. Tens of thousands of nurses and ambulance workers in England will stage what will be the biggest strike in the NHS’s 75-year history on Monday. In a plea to the government and health unions, but especially ministers, the 10 Shelford group chief nurses stress that they want both sides to end their standoff as a matter of urgency “because of the impact on the patients and communities we serve. “Industrial action means appointments cancelled, diagnostics delayed [and] operations postponed. The longer industrial action lasts, the greater the potential for positions to harden, waits for patients to grow, and risks of harm to accumulate.” This week will see just one day – Wednesday – when there are no NHS strikes. Nurses will strike again on Tuesday, physiotherapists will stage their second walkout on Thursday and ambulance personnel will stage a further stoppage on Friday. Read full story Source: The Guardian, 5 February 2023
  25. News Article
    Staff at the Royal London are proud of their work but don’t know how long they can continue as waiting times grow and patients suffer. Read full story (paywalled) Source: The Times, 6 February 2023
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