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Patient Safety Learning

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  1. News Article
    A doctor in Cambridge is spearheading a project to help to reform "blunt" medical language that patients and their families can find upsetting. Ethicist Zoe Fritz said language that "casts doubt, belittles or blames patients" was long overdue for change. Sixteen-year-old Josselin Tilley from Wiltshire has charge syndrome that reduces her life expectancy. Her mother Karen said Josselin's death was often referred to in correspondence "like she's not a person. "It's not person-centred at all, it's like she's just nothing." The example she gave was an extract from a typical letter in November that she was copied in to by a community paediatrician addressed to colleagues. "Death below 35: On discussion with Josselin's mum early death has been discussed with her, and there is plan, discussed with Josselin's mother about a wishes document being done." Mrs Tilley, from Westbury, said she objected to the use of language that "very bluntly discusses Josselin's death like she's something going off in the fridge". Doctor Fritz said the reason she and doctor Caitriona Cox were running the campaign at Cambridge University was because they recognised language regularly used by clinicians was often problematic for anyone outside of medical practice. "Even just (the term) presenting [a] complaint. Patients coming into hospital with whatever's bothering them we [doctors] talk about as a complaint and I think that infantilises the patient. They're not complaining when telling us what's going on." Read full story Source: BBC News, 17 January 2023 Further reading on the hub: Presenting complaint: use of language that disempowers patients
  2. News Article
    The BBC has come under fire from scientists for interviewing a cardiologist who claimed certain Covid vaccines could be behind excess deaths from coronary artery disease. Experts have criticised Dr Aseem Malhotra’s appearance on the BBC's news channel last Friday, accusing him of pushing “extreme fringe” views, which are “misguided”, “dangerous” and could mislead the public. Scientists have described the doctor as “hijacking” an interview on statins to air his views, causing BBC staff to be “alarmed and embarrassed” by their booking. Malhotra recently retweeted a video by the MP Andrew Bridgen, who had the Tory whip removed on Wednesday after comparing the use of Covid vaccines to the Holocaust. After criticising new guidance on statins, he cited British Heart Foundation (BHF) figures that suggested there had been more than 30,000 excess deaths linked to heart disease since Covid first arrived. Malhotra, a cardiologist at ROC Private Clinic, claimed mRNA Covid vaccines play a role, saying his “own research” showed “Covid mRNA vaccines do carry a cardiovascular risk”. He added that he has called for the vaccine rollout to be suspended pending an inquiry because of the “uncertainty” behind excess deaths. Read full story Source: The Guardian, 13 January 2023
  3. News Article
    Two new nurses' strikes will be held on 6 and 7 February in England and Wales - unless there is movement on pay, the Royal College of Nursing says. The walkouts will be the biggest so far, with more than a third of NHS trusts in England and all but one Welsh health board affected. It comes as nurses prepare to walk out on Wednesday and Thursday, following the two strike days before Christmas. As required under trade union laws, emergency care will be covered. Most of the 73 NHS trusts involved in the new set of strike dates are hospitals. It means the biggest disruption is likely to be in pre-booked treatment such as hernia repair, hip replacements or outpatient clinics. Services such as chemotherapy, kidney dialysis and intensive care will be staffed, however, as part of the emergency cover. Read full story Source: BBC News, 16 January 2023
  4. News Article
    A group of transgender people have lost their legal case against NHS England over waiting times to get seen by a gender specialist. The two trans adults and two trans children had tried to get the wait times - more than four years in one of their cases - deemed illegal. But a High Court judge ruled on Monday the waiting times are lawful. The Good Law Project - which helped to bring the legal action - said it would seek permission to appeal. The four people brought the legal action against NHS England (NHSE) over the waiting time to get a first appointment with a gender dysphoria specialist. The claimants argued that NHS England was failing to meet a duty to ensure 92% of patients referred for non-urgent care start treatment within 18 weeks. They said the waiting times were discriminatory, arguing the delays faced by trans people were longer than for other types of NHS treatment. But the judge dismissed the claim on several grounds. Read full story Source: BBC News, 16 January 2023
  5. News Article
    GPs whose patients want to stop taking antidepressants should reduce the dose of their medication in stages to lower the risk and severity of withdrawal symptoms, the medicines watchdog has said. About one in six (16%) adult Britons experience moderate to severe depression, according to the Office for National Statistics. In England alone, 21.4m antidepressant drugs were prescribed between July and September 2022, according to the NHS Business Services Authority. A new draft quality standard for the care of adults with depression from the National Institute for Health and Care Excellence (NICE) – the first update in 11 years – includes specific guidance to help adults come off antidepressant medication permanently. NICE’s independent advisory committee, which includes experts in treating adults with depression, recommends the staged withdrawal of antidepressants in patients who want to stop taking the drugs. A staggered reduction of medicine, known as tapering, helps to reduce withdrawal effects and long-term dependence on the medication, according to Nice. The committee said primary care and mental health professionals should follow the NICE guideline recommendations on stopping antidepressant medication, including agreeing with their patient whether it is right for them to stop taking the medication and, if so, the speed and duration of withdrawal from it. Read full story Source: The Guardian, 17 January 2023
  6. News Article
    An NHS trust declined to provide care for a vulnerable Black man days before he died in police custody while having a psychotic episode, The Independent has learnt. Godrick Osei, 35, died after being restrained by up to seven Devon and Cornwall Police officers in the early hours of 3 July 2022, after fleeing his flat and hiding in the cupboard of a care home in Truro. His family said he had been expressing “paranoid thoughts” and had called the police himself for help. He was arrested and died within an hour. Mr Osei had been diagnosed with anxiety and depression, had suspected post-traumatic stress disorder (PTSD) and was prescribed various medications to treat these conditions. He also intermittently used illicit drugs and had suffered alleged sexual assault in prison around 2013, according to a medical report from North East London NHS Foundation Trust (NELFT). In the days before his death, Mr Osei was in the care of NELFT’s community mental health team, whose caseworkers were concerned that he was exhibiting signs of a further severe illness – emotionally unstable personality disorder (EUPD) – and was a high risk to himself. However, Mr Osei was based outside the team’s catchment area, and NELFT asked the neighbouring Cornwall Partnership NHS Foundation Trust (CPT) to assess him instead. CPT refused without explaining why, according to a medical report seen by The Independent. Following Mr Osei’s death, an investigating officer from NELFT made multiple attempts to contact CPT to explore the possibility of a joint investigation into the matter, but didn’t receive a response. Read full story Source: The Independent, 16 January 2023
  7. News Article
    Child mortality from trauma and sudden unexpected death increased last year, according to figures highlighting the stark impact of poverty on child health. The analysis, which tracked all child deaths in England between 2019 and 2022, found overall mortality dipped during the pandemic due to a decrease in infectious illnesses, but that numbers of deaths have since returned to pre-pandemic levels. This included a 32% increase in trauma deaths and a 13% rise in sudden unexpected death in infancy or childhood (Sudic) last year compared with pre-pandemic rates. Prof Karen Luyt, the programme lead for the National Child Mortality Database, based at the University of Bristol, said the figures could be “the first mortality signal” from families struggling with the cost of living crisis. “This is worrying and I think we’re likely to see things getting worse,” she said. “Certainly for childhood illness and mortality, we know there’s a strong social gradient and we know that more families are now living in poverty.” Sudic deaths are defined as being unexplained and unexpected at the point death is registered, but may be subsequently found to be due to cardiac arrest after infection or an asthma attack, for instance. It is a broader category than sudden infant death syndrome (Sids), where the cause of death often remains a mystery even after postmortem examination. Read full story Source: The Guardian, 16 January 2023
  8. News Article
    Complications after a procedure to treat IBS left Jennifer Hill in pain – and fighting for compensation. Earlier this year, an NHS inquiry found surgeon Anthony Dixon had caused women to “suffer harm” as a result of the mesh operations he carried out between 2007 and 2017. Dixon, who is now banned from practising in the UK, carried out hundreds of laparoscopic ventral mesh rectopexy (LVMR) operations for both the North Bristol NHS Trust and privately at Bristol’s Spire Hospital. Mesh is used to repair the pelvic floor, but the inquiry concluded that women should have been offered alternative treatments first. Jennifer Hill, from Herefordshire, is one of those women. She wishes she could go back in time and not have her mesh operation, which took place in May 2012. “I was totally unaware of the controversy surrounding mesh,” she says. “I still kick myself that I didn’t get a second opinion or ask more questions.” Read full story (paywalled) Source: The Telegraph, 11 January 2023
  9. Content Article
    This study examined the risks and patterns of childhood deaths before and during the COVID-19 pandemic.  In this cohort study, there were 3409 childhood deaths from April 2019 to March 2020, 3035 deaths from April 2020 to March 2021, and 3428 deaths from April 2021 to March 2022. Overall risk of death was significantly lower from 2020 to 2021, but not from 2021 to 2022 when compared with the reference year of 2019 to 2020. These findings suggest that there was a significant reduction in all-cause child mortality during the first year of the COVID-19 pandemic (2020-2021), which returned to near prepandemic levels the following year (2021-2022).
  10. Content Article
    With the NHS under relentless pressure this winter and as records keep getting broken for all the wrong reasons, Helen Buckingham takes a closer look at why hospitals are so full, and emphasises the importance of supporting and helping the health service’s staff.
  11. News Article
    The deaths of two nurses from Covid-19 in the early days of the pandemic have been ruled as industrial disease. Gareth Roberts, 65, of Aberdare, and Domingo David, 63, of Penarth, were found to have been most likely to have contracted the virus from colleagues or patients while working for hospitals under the Cardiff and Vale University Health Board. The senior coroner Graeme Hughes concluded on Friday that although they were given appropriate personal protective equipment (PPE), Roberts and David were “exposed to Covid-19 infection at work, became infected and that infection caused” their deaths. He made a finding of industrial disease. Roberts’ family had argued for a conclusion of industrial disease, while the health board had made the case for ruling that both deaths were from natural causes. Unions are campaigning for Covid-19 to be considered an industrial disease by the UK government so workers affected by it would receive greater financial support. Read full story Source: The Guardian, 13 January 2023
  12. News Article
    Hospital staff have to complete 50 separate steps on average to discharge a patient, it has emerged, as the NHS grapples with a bed-blocking crisis. On average, around 14,000 patients deemed fit to leave hospital are stuck in beds every day, according to the latest official figures. The congestion is helping to fuel the backlog in accident and emergency (A&E) departments, where more than 55,000 patients waited 12 hours or longer last month. Steve Barclay, Health Secretary, announced an additional £250 million in funding last week to buy up care beds to help discharge thousands of patients. But doctors, social care experts and families have warned discharges are being delayed by NHS “bureaucracy” and excessive form filling. Dr Matt Kneale, co-chair of the Doctors’ Association UK and a junior doctor in Manchester, said patients are held up by “numerous bottlenecks” before being sent home. “While social care shortages are the predominant issue, smaller factors stack up to create a big problem,” he told The Telegraph. Many hospitals have limits on the times their pharmacies are open, he explained, meaning patients can often be stuck on the ward all day, or an extra night, waiting for their medication. Read full story (paywalled) Source: The Telegraph, 15 January 2023
  13. News Article
    There are 10 patients in the corridor and the nurses are about to go out to assess two more waiting in an ambulance outside. The senior sister, Susan Beswick, who has worked in the hectic and often stressful world of NHS accident and emergency for 30 years, says she has never seen anything like it. "The last six to 12 months have been more challenging than I have ever known," she says. "We have been exceptionally busy for quite a number of weeks now. We're running two to three times above our capacity continually and often more than that." Susan's whole nursing career has been at Royal Bolton Hospital, which, like many in the country, is facing overwhelming demand from a growing as well as ageing population and has out-of-date buildings that are not fit for purpose. A policy of cohorting, adopted by many hospitals, has been agreed between emergency-department staff and paramedics. One member of an ambulance team will be left to look after two or three patients in a corridor, allowing others to get back on the road more quickly. The problem is space. There are simply too many patients coming in to be accommodated, even with all the streaming initiatives. Read full story Source: BBC News, 13 January 2023
  14. Content Article
    This report considers the number of safety incidents in surgery occurring in the NHS since 2015 and calls for action to improve surgical safety. It also highlights the perceptions of patients from a survey of people who have had surgery in the last five years. It is authored by surgical care platform Proximie, with support from experts in the surgical space.
  15. Event
    This one-day virtual course is suitable those engaged or interested in patient safety, quality improvement & service delivery. On this interactive virtual course we will explore how human factors and ergonomics impact everyday working practices & patient safety. This material aligns with key focuses of the National Patient Safety Strategy, PSIRF & several domains of the National Patient Safety Syllabus 2.0. This course is equivalent to 6 hours of education. It will show you how to take a systems approach to respond to patient safety investigations using the SEIPS Model. Participants have the opportunity to practically apply SEIPS to a patient safety incident & explore contributory factors. We introduce methods such as observation & interview and consider how to generate areas for improvement and safety actions. Includes: A one-day healthcare focused course. Facilitated by experienced, doctors, nurses & educators. Small group work. Selected course materials. Membership of the Being Human in Healthcare Network. Register
  16. News Article
    Victims and family members affected by the contaminated blood scandal are calling for criminal charges to be considered as the public inquiry into the tragedy draws to a close. While the inquiry, which will begin to hear closing submissions on Tuesday, cannot determine civil or criminal liability, people affected by the scandal are keen for the mass of documents and evidence accumulated over more than four years to be handed over to prosecutors to see whether charges can be brought. About 3,000 people are believed to have died and thousands more were infected in what has been described as the biggest treatment disaster in the history of the NHS. The inquiry has heard evidence that civil servants, the government and senior doctors knew of the problem long before action was taken to address it and that the scandal was avoidable. But no one has ever faced prosecution. Eileen Burkert, whose father, Edward, died aged 54 in 1992 after – like thousands of others – contracting HIV and hepatitis C through factor VIII blood products used to treat his haemophilia, said the inquiry had shown there was a “massive cover-up”. She said: “In my eyes it’s corporate manslaughter. You can’t go giving people something that you know is dangerous, and they just carried on doing it. As far as my family’s concerned, they killed our dad and they killed thousands of other people and there’s been no recognition for him since he died, there’s been nothing. Read full story Source: The Guardian, 16 January 2023 See UK Infected Blood Inquiry website for further details on the inquiry.
  17. News Article
    The health secretary said "voluntary arrangements" for emergency cover during recent ambulance strikes could not "ensure patient and public safety". In a letter to the GMB, Steve Barclay acknowledged unions that walked out had agreed to answer the most serious category one 999 calls. But he said the lack of cover for category two calls, including strokes, in some areas put lives at risk. The GMB has accused the government of "demonising" its striking workers. In response, Mr Barclay wrote on Sunday that he recognised the right to strike and accepted "that a certain amount of disruption is inherent to any strike". He said he "greatly" valued the "vital work ambulance workers do" but criticised the "volatile" assurances given to him about cover by trade unions during December's industrial action. The government's anti-strike bill is due to be considered by MPs again on Monday. The legislation would set minimum service levels for fire, ambulance and rail services during industrial action and could leave unions at risk of legal action if they fail to comply. Read full story Source: BBC News, 15 January 2023
  18. News Article
    Staff at a maternity unit were exposed to almost 30 times the legal workplace exposure limit for nitrous oxide, documents have shown. Testing at Basildon Hospital revealed the levels more than 16 months before colleagues were informed. The Royal College of Midwives said its members there were considering legal action. Routine testing of the maternity suite in June 2021 revealed nine staff members had been exposed to excess nitrous oxide levels during the course of their shifts. Three had readings of more than 1,000 parts per million (ppm) of the gas, while a fourth recorded almost 3,000. The Workplace Exposure Limit is set at 100ppm. Trust management apologised after failing to notify staff at the unit until October 2022. A briefing seen by the BBC stated the issue was logged on the risk register, but "there has not been proper oversight of the problem and staff have not been informed". One person familiar with the situation, who did not want to be identified, said: "We had an email sent out that said 'emergency maternity staff briefing' and there was a Teams meeting. "The Teams meeting was very, very difficult to listen to. It was very emotive. People were angry understandably, but I feel like the executive who were on the call didn't handle it very well." Read full story Source: BBC News, 16 January 2023
  19. News Article
    Fewer women who gave birth in NHS maternity services last year had a positive experience of care compared to 5 years ago, according to a major new survey. The Care Quality Commission’s (CQC) latest national maternity survey report reveals what almost 21,000 women who gave birth in February 2022 felt about the care they received while pregnant, during labour and delivery, and once at home in the weeks following the arrival of their baby. The findings show that while experiences of maternity care at a national level were positive overall for the majority of women, they have deteriorated in the last 5 years. In particular, there was a notable decline in the number of women able to get help from staff when they needed it. Many of the key findings from the survey include a drop in positive interactions with staff and lack of choices about the birth. Just over two-thirds of those surveyed (69%) reported 'definitely' having confidence and trust in the staff delivering their antenatal care. Results were higher for staff involved in labour and birth (78%). In addition, while the majority of women (86%) surveyed in 2022 said they were 'always' spoken to in a way they could understand during labour and birth, this was a decline from 90% who said this in 2019. The proportion of respondents who felt that they were 'always' treated with kindness and understanding while in hospital after the birth of their baby remained relatively high at 71%, however had fallen from 74% in 2017. Just under a fifth of women who responded to the survey (19%) said they were not offered any choices about where to have their baby. Also, less than half (41%) of those surveyed said their partner or someone else close to them was able to stay with them as much as they wanted during their stay in hospital. Read full story Source: Medscape, 13 January 2023
  20. Content Article
    This survey from the Care Quality Commission (CQC) looked at the experiences of women and other pregnant people who had a live birth in early 2022.
  21. News Article
    The intense pressure on the NHS in recent weeks has left hospitals unable to cope, patients at risk and staff in despair, writes an A&E doctor in this Guardian article. "I’ve worked in the NHS for over 10 years and I’ve never known it as bad as it is now. A&Es are swamped and primary care is swamped too. It’s a very sorry of state for all concerned. The last few weeks have been beyond dreadful and it was all predicted by those on the ground months ago". We’re now in a position in our A&E where we are looking after a ward and a half of admitted patients, who take up the bedded spaces, while simultaneously running an emergency department out of the corridor and waiting room. Having to manage the very sick in inappropriate areas is now becoming the norm. An emergency department (ED) is not a safe place. It’s filled with some of the sickest people in a hospital, in a chaotic environment. There are lots of comings and goings, with patients being moved frequently and staff looking after multiple patients. It’s a recipe for things getting missed. If you add in the fact that ED personnel work a shift rota, so new staff come on duty every few hours and they don’t necessarily know the patients, there is more scope for potentially vital information being lost. "As ED doctors, we have always tried to give the dying a place of privacy, where loved ones can be with them in some relative peace. I would hope that same degree of compassion was present in all A&Es, but it’s becoming more challenging to provide." Read full story Source: The Guardian, 12 January 2023
  22. News Article
    Patients with emergencies such as heart attacks and strokes in England had to wait more than 90 minutes on average for an ambulance at the end of 2022. It came after a sharp deterioration in 999 response times in December - they were nearly twice as bad as November. Record worst waits were also recorded for life-threatening cardiac arrests, while A&E waits of over four-hours reached their highest level ever. Patient groups warned the delays would be leading to real harm. Combined, the data - released by NHS England - represents the worst-ever set of emergency care figures since modern records began in 2004. The figures show: Average waits of more than 90 minutes to reach emergency calls such as heart attacks - five times longer than the target time - with waits of over 150 minutes in some regions. Response times for the highest priority calls, such as cardiac arrests, taking close to 11 minutes - 4 minutes longer than they should. More than a third of patients in A&E waiting longer than 4 hours. One in seven patients waiting more than 12 hours for a bed on a ward when they need to be admitted. But there has been some progress with the waiting list for routine treatment falling slightly, to 7.19 million by the end of November. Read full story Source: BBC News, 12 January 2023
  23. Content Article
    In this article, HSJ's Annabelle Collins reflects on the increasing number of NHS staff quitting their jobs and the risk to patient safety of 'corridor care'.
  24. News Article
    Health secretary Steve Barclay has privately conceded that he will have to offer a higher pay rise to NHS staff. Mr Barclay has admitted that more than one million NHS staff members deserve more money despite previously insisting that existing pay increases were all the government could afford. But, he also made clear that any new pay rises would come from the current health budget meaning potential cuts to key services, according to The Guardian. His U-turn comes in advance of nurses in England staging two more strikes next week, which is likely to force hospitals to again work at a reduced capacity following previous industrial action. Read full story Source: The Independent, 13 January 2023
  25. News Article
    ADHD awareness hassoared among women in the UK in the past year, but waiting times and the dearth of clinical awareness are leaving people awaiting diagnosis in a perilous position, leading experts have warned. Dr Max Davie, a consultant paediatrician and co-founder of ADHD UK, said that people talking openly about their diagnoses – including a number of high-profile celebreties – had led to more people seeking referrals for the condition. However, while awareness is increasing many trusts and private providers have shut waiting lists because of demand. “I think it’s probably as big a year as we’ve ever had. We are seeing a lot more people from all walks of life seeking a diagnosis later in life, particularly women,” Dr Davie said. “At the same time waiting lists have gone through the roof. NHS services have been swamped for a while and private providers are also closing their lists – there are wildly inadequate services for ADHD diagnosis, particularly for adults.” Dr Tony Lloyd, the chief executive of the ADHD foundation, said its own figures suggested a 400% increase in the number of adults seeking a diagnosis since 2020, adding that prescription volumes did not take account of those who do not use medication. “ADHD remains significantly under-diagnosed and under-treated in the UK – at great cost to public services and to the individual and the workforce,” he said. "Stigma around the condition, which the charity says affects one in 20 people in the UK, resulted in negative outcomes for individuals and high costs to the economy. Dismissing ADHD as a cultural construct and undeserving drain on finite NHS resources only adds to the enduring stigma and stereotyping of those with ADHD,” Read full story Source: The Guardian, 13 January 2023
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