Patient Safety Learning

GP leaders have urged the government to put out clearer advice for parents about when to seek help over potential strep A infections. Prof Kamila Hawthorne, of the Royal College of GPs, said many surgeries were struggling with the extra demand on top of existing pressures. The government should consider "overspill" services for surgeries unable to cope, she said. Since September, 15 UK children have died after invasive strep A infections. This includes the death of one child in Wales, and one in Northern Ireland. There have been no deaths confirmed in Scotland. The UK Health Security Agency figures (UKHSA) show there have also been 47 deaths from strep A in adults in England. Most strep A infections are mild, but more severe invasive cases - while still rare - are rising. Prof Hawthorne, said: "We do not want to discourage patients who are worried about their children to seek medical attention, particularly given the current circumstances. "But we do want to see good public health messaging across the UK, making it clear to parents when they should seek help and the different care options available to them - as well as when they don't need to seek medical attention." Read full story Source: BBC News, 8 December 2022

Two clinicians who say they lost their jobs at Berkshire Healthcare NHS Foundation Trust after raising patient safety concerns claim the trust’s legal team brought a five-figure costs threat against them to prevent witnesses from giving evidence in a tribunal. The threat of costs liability, intended to bring the case to a halt, was made halfway through the hearing – less than 48 hours before witnesses for the trust were due to give evidence. One of the claims put forward at the tribunal hearing was that the trust had destroyed crucial evidence by deleting the email account of a former staff member. The clinicians – Samir Lalitcumar and Ahmed Ghedri – brought allegations of poor practice against current and former staff at the trust. Berkshire NHS trust claimed their allegations, including claims that the trust had deleted email evidence, were “without merit”. A fortnight into the tribunal hearing, both out-of-work medics were threatened with costs liability, known as a “drop-hands offer”, totalling more than £300,000, had they opted to proceed with their case and lost. Lalitcumar and Ghedri had brought claims of whistleblowing detriment against their former employer, Berkshire Healthcare Trust. They say they were “victimised” and unfairly dismissed as a result of having blown the whistle on dangerous care within the trust’s geriatrics services – potentially affecting upwards of 2,000 patients. Read full story Source: Computer Weekly, 7 December 2022

Patients will be encouraged to choose private hospitals for NHS care under plans to help clear backlogs of routine operations through outsourcing more treatment. A task force of private healthcare bosses and NHS chiefs met in Downing Street for the first time yesterday in an effort to find more capacity for hip replacements, cataracts and other routine procedures in the independent sector. NHS bosses are hopeful of meeting a target to eliminate waits of more than 18 months by April, but there is increasing concern in government about whether one-year waits can be eliminated by 2025 as planned. Private hospitals say they have spare capacity that could help bring down waits but NHS bosses have been sceptical. Patients have long had a legal right to choose where they are treated but ministers are planning a fresh push for GPs to offer them the choice of having NHS treatment in private hospitals, in a revival of a Blair-era scheme. Steve Barclay, the health secretary, said he wanted to “turbocharge our current plans to bust the backlog and help patients get the treatment they need”. Read full story (paywalled) Source: The Times, 8 December 2022

Lying on a trolley in a hospital corridor in pain from a broken hip, Anne Whitfield-Ray could not believe she was in the care of the NHS. "It was absolute chaos - like something out of a third world country," said the 77-year-old from Worcestershire. "The staff were rushed off their feet, paint was peeling off the walls and patients were being squeezed in everywhere they could - in makeshift bays, in corridors and side rooms. It was horrific." Anne spent 15 hours in that position until a bed could be found for her. Such delays used to be the exception, something that happened on the odd occasion in the depths of winter. Now they are commonplace. Latest figures show nearly 40% of A&E patients who need admitting face what is called a trolley wait - a delay of four hours or more waiting for a bed to be found. These are the sickest and frailest patients - the ones who cannot be sent home immediately after treatment. Research has linked delays like this with longer hospital stays and even a higher risk of death. By the time patients get to this point, they may have already faced hours of waiting in A&E or, increasingly, stuck outside A&E in the back of an ambulance, as was the case for Anne. She is now back home recovering after surgery, a few days after her fall in October. She said that despite her experience she cannot fault the staff: "They are doing the best they can. But this is not what should be happening in the NHS". Read full story Source: BBC News, 8 December 2022

Press release: London, UK, 8 December 2022 A new report published today has highlighted serious safety concerns relating to the misdiagnosis of pulmonary embolisms.[1] It states that there was a minimum of 400 deaths attributable to pulmonary embolism misdiagnosis from March 2021 to April 2022 in England and Wales, with deaths in some regions almost three times the national average. This research has been carried out by Tim Edwards, an expert in risk management, and published by the charity Patient Safety Learning. Tim started this review following the premature death of his mother, Jenny Edwards, from a pulmonary embolism. He was concerned about the low quality of the investigation which took place following her death and the lack of assurance he received that any learning would be taken from this event. The report highlights clear safety issues in relation to staff, training, and equipment. Concerns around resource gaps have also been expressed by the Royal College of Radiologists and its members.[2] The report also highlights evidence that the NHS is not applying pulmonary embolism guidance considered best practice in comparable European countries and sets out nine calls for action to improve pulmonary embolism care. Tim’s concerns were also highlighted in a House of Commons debate led by Halen Hayes, MP for Dulwich and West Norwood, on the 30 November 2022.[3] Commenting on the report, Tim Edwards said: "My research found that there are hundreds of people who, like my mother Jenny, died from pulmonary embolism following misdiagnosis. It is vital we learn from these deaths, and the errors that have occurred, so we can take action to improve pulmonary embolism care. By publishing this report, I hope to start a dialogue that leads to positive change, so others do not suffer the loss of a loved one as we have." Helen Hughes, Chief Executive of Patient Safety Learning said: “This new report highlights serious patient safety concerns relating to the diagnosis of pulmonary embolisms. Urgent action is now needed to ensure that guidelines and diagnostic processes are up to date and that clinicians have the resources they need to deliver safe and effective care. It is also vital that we increase awareness of the key symptoms of pulmonary embolisms among both healthcare professionals and the wider public. Patient Safety Learning are proud to be supporting Tim and his campaign for improvement in pulmonary embolism care and to reduce avoidable deaths.” Notes to editors: 1. Independent Review of pulmonary embolism fatalities in England and Wales: Recent trends, excess deaths, their causes and risk of management concerns. 2. The Royal College of Radiologists report that 41% of clinical radiologists do not have the equipment they need, and that the UK has fewer scanners than most comparable OECD countries - 8.8 per million of population in the UK compared to 18.2 in France and 35.1 in Germany. They also raise that there is a high vacancy rate of clinical radiologists, 8%, with over 50% of vacancies unfilled for over a year. Data extracted from The Royal College of Radiologists. Clinical Radiology UK Workforce Census 2021 report. London: The Royal College of Radiologists, 2022. 3. Helen Hayes, MP for Dulwich and West Norwood, led an Adjournment Debate in the House of Commons on Wednesday 30 November 2022 highlighting patient safety concerns relating to the diagnosis of pulmonary embolisms. This was formally responded to by Helen Whately MP, Minister for Social Care at the Department of Health and Social Care. The full transcript can be found here. 4. Patient Safety Learning is a charity and independent voice for improving patient safety. We harness the knowledge, enthusiasm and commitment of healthcare organisations, professionals and patients for system-wide change and the reduction of harm. We support safety improvement through policy, influencing and campaigning and the development of ‘how to’ resources such as the hub, our free award-winning platform to share learning for patient safety.

NHS England is raiding a national fund earmarked for improvements in cancer, maternity care and other priority services by up to £1bn this year, to pay for deficits elsewhere, and will cut it by a similar amount in 2023-24, HSJ has learned. The “service development fund” is allocated at the beginning of the year for priority service areas also including primary care, community health, mental health, learning disabilities and health inequalities. Several NHSE directors said it was being tightly squeezed this year, amid major cost pressures from inflation, a pay deal unfunded by government, and higher than expected covid-related costs. One well-placed source said the fund this year was required to underspend by about £1bn against what had been planned, which will help balance overspends elsewhere in the NHS. The cuts are likely to be linked to ministers’ view that the NHS should focus on “core” priorities and cut other activities, including reducing NHSE national programme work which is typically linked to SDF budgets. Patricia Hewitt is looking into giving integrated care systems more “autonomy” from NHSE to set their own priorities. Read full story (paywalled) Source: HSJ, 8 December 2022

As the US Congress convenes, the American Hospital Association are turning up the pressure to secure additional support for hospitals and the patients and communities they serve. Specifically, they are asking Congress to: Prevent any further damaging cuts to health programmes, including stopping the forthcoming 4% Statutory Pay-As-You-Go (PAYGO) sequester. Establish a temporary per diem payment targeted to hospitals to address the issue of hospitals not being able to discharge patients to post-acute care or behavioural facilities because of staffing shortages. Increase the number of Medicare-funded graduate medical education positions to address the workforce need for additional physicians in the USA. Extend or make permanent the Low-volume Adjustment and the Medicare-dependent Hospital programmes — critical rural programmes that are due to expire on 16 December. Make permanent the expansion of telehealth services and extend the hospital-at-home programme. Finalize Senate passage of the Improving Seniors’ Timely Access to Care Act, which streamlines prior authorisation requirements under Medicare Advantage plans. Create a special statutory designation for certain hospitals that serve marginalised urban communities. Read full story Source: American Hospital Association, 2 December 2022

Ambulance staff across most of England and Wales will go on strike on 21 December in a dispute over pay. The coordinated walkout by the three main ambulance unions - Unison, GMB and Unite - will affect non-life threatening calls only. But it could mean people who have had trips and falls not being responded to. Members of GMB, which represents nearly a third of the 50,000-strong workforce, will then follow that up with another walkout on 28 December. It comes as Royal College of Nursing members are also preparing to go on strike on 15 and 20 December in parts of England, Wales and Northern Ireland. The walkouts will involve paramedics as well as control room staff and support workers, with the military on standby to help out. The only service which will be completely unaffected, however, is the East of England. Under trade union rules, life-preserving care has to be provided so the two highest category calls - covering everything from heart attacks and strokes to major trauma - will still be responded to. But Matthew Taylor, of the NHS Confederation, which represents health managers, said he was worried the action would "undoubtedly" affect patient care and how quickly ambulance services could respond and may even deter people from seeking help. "The prospect of industrial action over Christmas is very concerning," he added. Read full story Source: BBC News, 6 December 2022

NHS managers will be held accountable for failings at an overcrowded hospital where patients were put at risk of “serious harm” and some were left waiting up to 25 hours for a bed, ministers have warned. Forth Valley Royal Infirmary’s A&E was operating at two and a half times capacity during a visit by Healthcare Improvement Scotland (HIS) in September. Inspectors said that patients were at risk because of poor handling of medicines and unsafe working conditions at the hospital, which was placed in special measures by the Scottish government last month. The Times reported last month that the hospital had been declared “unsafe” by staff after five consultants resigned following severe criticism of the hospital’s leadership. They described it as a “war zone” and told of fire-fighting to cope with patient numbers while working in a “toxic” environment. Read full story (paywalled) Source: The Times, 6 December 2022

The ‘special measures’ label unquestionably hurts staff morale, according to the chief executive of a trust that is hoping to move out of the highest level of oversight for the first time in five years. Peter Reading, CEO of Northern Lincolnshire and Goole Foundation trust, told HSJ that targeted support from NHS England had brought “strong benefits” but said: “The label of special measures is one that hurts people, and so we are very keen to shed that label. I think I speak on behalf of all of our staff in that respect. “It doesn’t help morale and there’s no question about it, if you give people a bad name, even when they’re actually delivering generally very good care, and they’re working their socks off, and the label does not help.” Read full story Source: HSJ, 5 December 2022

A consultant orthopaedic surgeon who carried out double the average number of knee and hip operations over a three year-period is facing a tribunal over alleged misconduct and more than 100 legal cases lodged by former patients, HSJ has been told. Jeremy Parker, who performed hundreds of operations at Colchester Hospital and the private Oaks Hospital until his suspension in 2019, is currently appearing before a misconduct hearing. The tribunal is investigating allegations that between August 2015 and November 2018, Mr Parker failed to provide good clinical care to six patients. It has also been alleged that Mr Parker performed surgery in breach of restrictions on his clinical practice between October 2018 and January 2019 and that his actions were dishonest. The trauma and orthopaedic surgeon is also facing allegations that he added pre-typed operation notes to approximately 14 patients’ records ahead of an invited review into his clinical practice by the Royal College of Surgeons, without indicating they had been made retrospectively. Read full story (paywalled) Source: HSJ, 5 December 2022

Antibiotics could be given to children at schools affected by Strep A to stop the spread of the infection, schools minister Nick Gibb has said. Mr Gibb told Sky News that the UK Health and Security Agency (UKHSA) is "working closely with the schools involved and giving very specific advice to those schools which may involve the use of penicillin". He added that health officials will "have more to say about that". "They're providing more general advice to parents, which is to look out for the symptoms - so, sore throat, fever, high temperature and also a red or raised rash on the skin are symptoms of this invasive Strep A outbreak." His comments came after the ninth death of a child from the infection. Read full story Source: Sky News, 6 December 2022