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Patient Safety Learning

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  1. News Article
    The poor state of children’s teeth is a damning indictment of widening inequalities in child health in England, the president of the Royal College of Paediatrics and Child Health has said. In an interview with The BMJ Camilla Kingdon said that paediatricians were seeing the effects of longstanding health inequalities widening as the cost of living crisis affects the types of ill health that children are presenting with. She further told The BMJ, “There are lots of examples. One that we often forget about is oral health and the state of children’s teeth, which is actually a national disgrace. The commonest reason for a child having a general anaesthetic in this country is dental clearance. That’s a terrible admission of failure.” In her interview with The BMJ, Kingdon identified asthma and nutrition as other major areas of child health where the UK was failing. She said that these trends were partly being driven by social factors and expressed concern at the lack of focus in policy on fixing them. She warned, “Our worry, with the health disparities white paper being kicked into the long grass, is that without that intention, without a clear signal from the government that this is a priority, all these ideas [for tackling child health inequalities] just won’t be prioritised and we will miss an opportunity to really intervene.” Read full story Source: BMJ, 4 January 2023
  2. Content Article
    As the NHS crisis has deepened in recent weeks, frontline staff have posted vivid, troubling accounts on social media of what has been happening in their workplaces. Many have described the NHS, and often themselves too, as “broken”. They have related the difficulty of providing proper care, the impact of acute understaffing and their fears for the NHS’s future. In this Guardian article, read some of what doctors, nurses and other NHS staff have been saying.
  3. News Article
    A man turned up to an accident and emergency department in the Midlands complaining about ear wax on the day a hospital declared a critical incident, a nurse who works there has said. Lesley Meaney, a sister at University Hospitals of North Midlands (UNHM), said the patient presented to A&E with “no pain, no discomfort, just eat war wax!” Earlier on 30 December officials at the trust declared a critical incident, citing “extremely high demand for all of our services.” The disclosure by Ms Meaney underlines the scale of the challenge facing the NHS and staff working in hospitals across the country. Writing on Twitter, Ms Meaney added: “Seriously what is up with the general population? A major incident declared, ambulances queuing, and you decide to come to the emergency department on New Year’s Eve with ear wax.” Dr Matthew Lewis, medical director at UNHM, said: “The accident & emergency departments at UHNM are some of the busiest in the country so we would urge the public to only come to our Emergency Departments if it’s for serious, life-threatening conditions that need immediate medical attention, such as persistent severe chest pain, loss of consciousness, acute confusion, severe blood loss, serious burns, broken bones, suspected stroke. Read full story Source: The Independent, 4 January 2023
  4. News Article
    Mental health trusts will be expected to appoint a board member responsible for improving racial equality and to develop individual plans to eliminate systemic racism, according to new draft NHS England guidance seen by HSJ. The draft guidance says all providers will be required to draw up their own Patient and Carer Race Equality Framework by March 2024. These blueprints will outline how trusts plan to improve access, experience and outcomes for racialised communities, covering all services from talking therapies through to secure inpatient services. PCREFs were a key recommendation in the 2018 Mental Health Act review which identified disproportionate applications of the act in racialised groups and are part of NHSE’s wider mental health equalities strategy. Black people are 10 times more likely to receive a community treatment order after being an inpatient and their rate of detention under the act is four times as high as the rate for white people. The guidance follows HSJ last month revealing the “staggering” rise in restraints of black people in NHS care. Read full story (paywalled) Source: HSJ, 5 January 2023
  5. News Article
    Senior NHS staff have been advised by the Welsh government to discharge people who are well enough to leave, even without a package of care. But one GP called the announcement "terrifying" and warned that patients could deteriorate and end up back in hospital. The seven health boards in Wales have nearly 1,800 patients medically well enough to leave hospital. The Welsh government has called the NHS situation "unprecedented". The message comes after one health leader said the NHS was on a "knife-edge" in terms of its ability to cope. The letter from the chief nursing officer and the deputy chief medical officer to the health boards offered "support and advice to ensure patients are kept as safe as possible, and services are kept as effective as possible over the next period". Read full story Source; BBC News, 4 January 2023
  6. News Article
    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
  7. Content Article
    This briefing from the Centre of Mental Health summarises evidence from six studies on the use of digital and telephone technology to deliver mental health services. It finds that using remote technology can improve access to mental health support for rural communities, disabled people or people needing a specialist service far from home. It has the potential to increase access and choice in mental health care. But it also risks exacerbating inequalities for people who are digitally excluded.
  8. Content Article
    The NHS saved William Fear's life and inspired him to change career. But when William started as a healthcare assistant on a hospital ward for older patients, it was clear how bad things had got. This is his story, told to the Guardian, of a typical shift
  9. News Article
    The Northern Ireland Ambulance Service (NIAS) is investigating whether a delayed response contributed to the deaths of eight people in recent weeks. All eight deaths occurred between 12 December and the start of January. The NIAS is treating four of the deaths as serious adverse incidents, which is defined as an incident that led to unintended or unexpected harm. The remaining four deaths are being investigated to see whether they meet that criteria. The patients' identities have not been disclosed, but it is understood one of the eight people was a man who waited more than nine hours for an ambulance in mid-December. The man's condition deteriorated and he died before paramedics arrived. The delays are a cause of "great concern," but there is "no end in sight to the pressures we are facing," according to the ambulance service's medical director Nigel Ruddell. He said the ambulance service conducts an internal review whenever "there is a delayed response to the call and a poor outcome from the call" to see whether delays contributed to a death. "That process involves liaising with the family and being open and clear with them about what happened on the day - whether it was because of pressures and demand on the day or whether there was something that, potentially, we could have done better." Read full story Source: BBC News, 4 January 2022
  10. News Article
    Care workers are taking as little as three minutes to help vulnerable people in their own homes, the social care ombudsman has found, after discovering a council was allocating extremely short visits to hundreds of people. Amid chronic staff shortages and rising unmet care needs nationwide, a homecare worker commissioned by Warrington borough council sometimes stayed for just three minutes, despite the family paying for the full visit. The council was found to have allocated 15-minute care calls to more than 300 people in the region, despite national guidance stressing these were “not usually appropriate”. The Homecare Association, which represents care providers, said the number of short calls being commissioned was increasing more widely and said “15-minute visits are inappropriately short”, result in inadequate care and are stressful for workers placed under “unfair pressure”. The case that triggered the investigation involved a woman with dementia who was paying the full costs of her care under a plan devised by the council. In 15 minutes two agency care workers were expected to wake her, prepare a meal and a drink, ensure she ate and drank, administer her medication, change her incontinence pad, administer any personal care and tidy the kitchen. Electronic monitoring showed they regularly stayed less than 15 minutes and the ombudsman said it was probable her care needs were not met and her care was not dignified. Read full story Source: The Guardian, 5 January 2023
  11. News Article
    An acute trust has announced the ‘reluctant’ return of ‘corridor care’ – having previously eradicated the unsafe practice – due to extreme ambulance handover delays and other emergency pressures. Last year, University Hospitals North Midlands Trust chief executive Tracy Bullock said the trust had been “resisting” placing patients in corridors as it “brought significant patient safety and staff wellbeing issues”. This was despite the trust having large numbers of handover delays, being singled out for criticism by the ambulance service, and ‘corridor care’ being commonplace in many other acute hospitals amid severe bed pressures. The trust had successfully eliminated the practice several years earlier, because of these issues. However, at its board meeting today, the trust confirmed the practice was formally introduced at its Royal Stoke site on the day of the ambulance staff strike (21 December) because it was “holding more ambulances than we deem acceptable”. Read full story (paywalled) Source: HSJ, 4 January 2023
  12. News Article
    When Steve Parsons's grandfather collapsed at his Monmouthshire home, his family immediately dialled 999. However when they were told there were no ambulances available, they had to take measures into their own hands. In desperation, Mr Parsons drove and then carried the 83-year-old, who had suffered a cardiac arrest, into the Grange Hospital near Cwmbran, Torfaen. Aneurin Bevan University Health Board (ABUHB) and Welsh Ambulance Service Trust (WAST) admitted the incident did not match the service they wished to offer - but said it was indicative of the "unprecedented" pressures both organisations were under. Mr Parsons said: "It was horrible. They're on the phone, you're there and he's grey in the face and looks horrendous. You just panic." By the time Mr Parsons drove to the hospital, his grandfather had gone into cardiac arrest. He then carried his relative on his shoulder across the car park "yelling for help". A passing nurse heard his calls and was able to help save the 83-year-old's life using CPR. His grandfather is now recovering at Nevill Hall Hospital in Abergavenny, but Mr Parsons said his family has been traumatised. "It makes me feel angry," said the 31-year-old. "If my grandfather had that ambulance, had that oxygen, I fully believe he wouldn't have gone into cardiac arrest and my family wouldn't have gone through what they've gone through these past seven days." Read full story Source: BBC News, 4 January 2023
  13. News Article
    A shortage of cough and cold medicines in the UK is a result of ministers’ “lack of planning”, according to pharmacy leaders. Rishi Sunak’s Conservatives were accused of “being in denial” as supply chain problems worsen, with pharmacists reporting shortages of once-common cold and flu medicines. The Association of Independent Multiple Pharmacies said throat lozenges, cough mixtures and some painkillers are among the affected medicines, after issues with the supply of antibiotics and HRT last year. “Pharmacists are struggling to obtain the very basic, most common cold and flu medicine,” chief executive Leyla Hannbeck told the PA news agency. “This isn’t just the branded medicines, it is also simple things like throat lozenges, cough mixtures or painkillers – particularly the ones that are soluble. “The demand has been high because this season we’ve seen higher cases of colds and flu and people are obviously trying very hard to look after themselves and making sure that they use the relevant products to manage the symptoms. “And that has led to a shortage of these products in terms of us not being able to obtain them.” Read full story Source: The Guardian, 4 January 2023
  14. News Article
    Paramedics will only wait with patients for 45 minutes before leaving them on a trolley in A&E, one ambulance trust has said. One in five ambulances are waiting at least an hour outside accident and emergency departments to hand over patients, the latest data show, despite NHS standards stating it should only be 15 minutes. Now, London Ambulance Service (LAS) leaders have told hospitals their staff will only remain with patients for a maximum of 45 minutes for handover due to “the significant amount of time being lost” waiting in A&E departments. A leaked letter, seen by ITV News, from the LAS said: "From January 3 we are asking that any patients waiting for 45 minutes for handover... are handed over immediately to ED (emergency department) staff allowing the ambulance clinicians to leave and respond to the next patient waiting in the community. "If the patient is clinically stable the ambulance clinicians will ensure the patient is on a hospital trolley or wheelchair/chair and approach the nurse in charge of the emergency department to notify them that the patient is being left in the care of the hospital and handover the patient." The email added that if the patient was not clinically stable, ambulance crews would stay with the patient until handover is achieved but added that the clinical responsibility for the patient lied with the hospital. Read full story (paywalled) Source: The Telegraph, 3 January 2023
  15. News Article
    The Society to Improve Diagnosis in Medicine (SIDM) has announced that Congress in the final FY 2023 Omnibus spending bill has doubled dedicated federal funding for research to reduce patient harm from diagnostic error. Statistically, each of us is likely to experience a meaningful diagnostic error in our lifetime. The significant human and financial toll of diagnostic errors, which occur in all settings of care, was first highlighted in a landmark 2015 National Academy of Medicine (NAM) report, Improving Diagnosis in Health Care. The report found that missed, delayed, or un-communicated diagnoses result in more patient harm than all other healthcare-associated harms combined. The NAM report called diagnostic error "a blind spot" in health care quality and safety, and improving medical diagnosis a "moral, professional, and public health imperative." Since the release of the NAM report, SIDM has been working hard to educate policymakers about these issues and advocating for more research funding. SIDM has assembled a coalition of dozens of groups representing health systems, patients, clinicians, and others to raise awareness and spark action. "This funding is an important signal that Congress is becoming aware of the magnitude of the public health burden, both human and financial, associated with diagnostic error and intends to tackle it," says Jennie Ward-Robinson, CEO of SIDM. Citing diagnosis as "the next frontier of patient safety," the NAM report summarised what is known about factors that affect diagnostic safety and accuracy at the clinician, system, and policy levels, and made recommendations at each of those levels. A few promising interventions are already emerging for specific and commonly misdiagnosed conditions, as well as for specific systems-level problems, such as failure to "close the loop" on abnormal test results. But these initiatives are tiny compared the scope and scale of the issue. Read full story Source: CISION PR Newswire, 3 January 2023
  16. News Article
    Managers in an NHS area are considering using "field hospitals" to deal with the surge in patients. Sarah Whiteman, chief medical director of the Bedfordshire, Luton and Milton Keynes Integrated Care Board told colleagues the use of tents was a "real possibility". In an email, she also asked colleagues to sign temporary contracts to work in emergency departments. The board said the use of tents in hospital grounds was not imminent. Dr Whiteman's email, obtained by The Sunday Times and seen by the BBC, began with the statement: "Call to arms". It emphasised how busy the acute units were within her board's operational area, including Bedford, Milton Keynes and Luton and Dunstable Hospitals. In the message, she promised staff would receive training and induction if they stepped forward to support colleagues. Read full story Source: BBC News, 4 January 2023
  17. News Article
    People have been urged to wear face coverings and remain at home if feeling unwell, as an already crisis-stricken NHS faces down multiple waves of winter illnesses. With children returning to school at a time when high levels of flu, Covid-19 and scarlet fever are all being reported, the UK Health Security Agency (UKHSA) has issued fresh guidance in a bid to minimise the diseases’ spread. Parents have been urged to keep children at home if they are unwell and have a fever, with adults told to only go out if necessary and wear face coverings if they are ill and avoid visiting vulnerable people. While transport secretary Mark Harper said the advice was “very sensible”, Downing Street insisted that such guidance was “pretty longstanding”, stressing that it was “not mandatory” and remained a far cry from ministers “telling people what to do” at the height of the pandemic. The government has also reintroduced travel bans for those testing positive for Covid-19 in China from 5 January amid a mass outbreak there. It comes as pressure on the NHS continues to grow, but Rishi Sunak said he was “confident” the NHS has the funding it needs despite accusations from senior doctors his government is in denial about the scale of the crisis in the health service. Read full story Source: The Independent, 3 January 2023
  18. News Article
    NHS England has shelved priorities on Long Covid and diversity and inclusion – as well as a wide range of other areas – in its latest slimmed down operational planning guidance, HSJ analysis shows. NHSE published its planning guidance for 2023-24, which sets the national “must do” asks of trust and integrated care systems, shortly before Christmas. HSJ has analysed objectives, targets and asks from the 2022-23 planning guidance which do not appear in the 2023-24 document. The measures on which trusts and systems will no longer be held accountable for include improving the service’s black, Asian and minority ethnic disparity ratio by “delivering the six high-impact actions to overhaul recruitment and promotion practices”. Another omission from the 2023-24 guidance compared to 2022-23 is a target to increase the number of patients referred to post-Covid services, who are then seen within six weeks of their referral. Several requirements on staff have been removed, including to ”continue to support the health and wellbeing of our staff, including through effective health and wellbeing conversations” and ”continued funding of mental health hubs to enable staff access to enhanced occupational health and wellbeing and psychological support”. Read full story (paywalled) Source: HSJ, 4 January 2022
  19. Content Article
    NHS England has published its planning guidance for 2023/2023. The 2023/24 priorities and operational planning guidance reconfirms the ongoing need to recover our core services and improve productivity, making progress in delivering the key NHS Long Term Plan ambitions and continuing to transform the NHS for the future.
  20. News Article
    Mental health and wellbeing hubs for NHS and social care staff could be axed within months, as national funding for them is likely to be cut, HSJ has learned. NHS England and the Department of Health and Social Care are understood to be close to ending ring-fenced national funding for the 41 hubs, which were set up in February 2021, at the peak of acute covid pressures and concern about the impact on staff. Sources told HSJ discussions were ongoing, but that it is likely integrated care systems would need to find funding themselves if they are to continue. Amid tight local finances, it is expected many will be wound down or closed. This is despite problems with low staff morale, high absence rates and with large numbers of experienced staff thought to be leaving the service. Read full story (paywalled) Source: HSJ, 4 January 2022
  21. News Article
    A record number of "foreign objects" have been left inside patients' bodies after surgery, new data reveals. Incidents analysed by the PA news agency showed it happened a total of 291 times in 2021/22. Swabs and gauzes used during surgery or a procedure are one of the most common items left inside a patient, but surgical tools such as scalpels and drill bits have been found in some rare cases. A woman from east London described how she "lost hope" after part of a surgical blade was left inside her following an operation to remove her ovaries in 2016. The 49-year-old, who spoke to PA on condition of anonymity, said: "When I woke up, I felt something in my belly. "The knife they used to cut me broke, and they left a part in my belly." She added: "I was weak, I lost so much blood, I was in pain, all I could do was cry." The object was left inside her for five days, leading to an additional two-week hospital stay. Commenting on the analysis, Rachel Power, chief executive of the Patients Association, said: "Never events are called that because they are serious incidents that are entirely preventable because the hospital or clinic has systems in place to prevent them happening. "When they occur, the serious physical and psychological effects they cause can stay with a patient for the rest of their lives, and that should never happen to anyone who seeks treatment from the NHS. "While we fully appreciate the crisis facing the NHS, never events simply should not occur if the preventative measures are implemented." Read full story Source: Sky News, 4 January 2022
  22. News Article
    A combination of Covid, flu, and Strep A has seen more than a dozen trusts and ambulance services declare critical incidents in recent days. NHS patients are sleeping in their cars outside hospitals, as the chaos engulfing the health service is set to last until Easter. Some 13% of hospital beds in England are filled with people with Covid or flu, NHS England figures show, with the treatment backlog also at a record high of 7.2 million. But Matthew Taylor, the chief executive of the NHS Confederation, which represents health service managers, said no reprieve is expected until April. "It seems likely that the next three months will be defined by further critical incidents needing to be declared and the quality of care being compromised," he told the Guardian. Read full story (paywalled) Source: The Telegraph, 3 January 2023
  23. Content Article
    In this blog, Matthew Wain highlights how NHS organisations can support staff with patient safety investigations, and more generally, in the face of increased pressure. He looks at missed learning opportunities, psychological impact, and the support tools and programmes available for staff. Further reading: Patient Safety Learning's Staff Support Guide: a good practice resource following serious patient harm
  24. News Article
    There were more than 3,700 patients a day in hospital with flu last week - up from 520 a day the month before, the latest data from NHS England shows. Of these, 267 people needed specialised care in critical care beds last week. NHS England warns pressures on the health service continue to grow as viruses like flu re-circulate after a hiatus during the pandemic. Prof Sir Stephen Powis, NHS national medical director, said: "Sadly, these latest flu numbers show our fears of a 'twindemic' have been realised, with cases up seven-fold in just a month and the continued impact of Covid hitting staff hard, with related absences up almost 50% on the end of November." He warned this was "no time to be complacent" with the risk of serious illness being "very real" and encouraged those eligible to take up their flu and Covid jabs as soon as possible. Admissions among children under 5 have been high this flu season, as well as among older people. Read full story Source: BBC News, 30 December 2022
  25. News Article
    Police have carried out more than 5,500 investigations into patients who have been reported missing from NHS facilities in Scotland since 2019. The figures were outlined in a written response from Keith Brown, the justice secretary, to Jamie Greene, the Conservative MSP. Greene, who is the justice spokesman for the Conservatives, said the figures gave serious cause for concern. He said that the complete figure could be much higher because the data provided only included those reported to police. He urged Brown and Humza Yousaf, the health secretary, to provide adequate resources for policing and the health sector to ensure vulnerable patients were not slipping through the cracks. Greene said: “These figures are deeply alarming. Relatives expect their loved ones to be safe while they are staying, or being treated in, an NHS facility. It gives serious cause for concern that over 200 investigations have had to be launched in just the last few years to determine the whereabouts of young people who went missing from NHS grounds.” Read full story (paywalled) Source: The Times, 3 January 2023
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