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Patient Safety Learning

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  1. News Article
    A woman spent “four hours watching her mother dying on the floor waiting for an ambulance in a journey that should take just ten minutes”, the Irish Oireachtas Health Committee was told today. Committee deputy chairman Sean Crowe said the “woman died on her way to hospital”. Her bereaved daughter was left with the memory of her mother “gasping for breath”, he told Health Minister Stephen Donnelly. He said ambulance delays, compounded by them having to wait backed up for hours outside hospitals because of a lack of trolleys in emergency departments, were leading to serious consequences. In response the minister said: “The national ambulance service needs significant additional funding and that is happening now.” He said there is work under way to rebuild ambulance bases as well as add to the fleet, along with hiring more advanced paramedics. He added: “We need to recognise response times from ambulances are not where they need to be and vary around the country. It is not yet where it needs to be and some areas are worse than others.” Read full story Source: Independent Ireland, 30 November 2022
  2. Content Article
    An expert review of the clinical records of 44 deceased patients who had been under the care of neurologist Dr Michael Watt has found there were “significant failures” in their treatment and care. Dr Watt, a former Belfast Health and Social Care Trust consultant neurologist, was at the centre of Northern Ireland’s largest ever recall of patients, which began in 2018, after concerns were raised about his clinical work. More than 4,000 of his former patients attended recall appointments. At the direction of the Department of Health, in August 2021, the Regulation and Quality Improvement Authority (RQIA) commissioned the Royal College of Physicians to undertake an expert review of the clinical records of certain deceased patients who had been under the care of Dr Watt, with the intention to understand his clinical practice, to ensure learning for others and to help make care better and safer in the future.
  3. News Article
    The UK is not in a significantly better place to deal with a new pandemic, the former vaccine taskforce chief has said, as a leading public health expert suggested Covid infections may be on the rise again. Dame Kate Bingham, the managing partner at the life sciences venture capital firm SV Health Investors, headed the UK’s vaccine taskforce between May and December 2020. Speaking to a joint session of the Commons health and social care committee and the science and technology committee, about lessons learned during the pandemic, Bingham said many of the initiatives set up by the taskforce had been dismantled, while key recommendations it had provided had not been acted upon. “To begin with, I thought it was lack of experience of officials since we don’t have a lot of people within Whitehall who understand vaccines, relationships with industry, all of that, but actually, I’m beginning to think this is deliberate government policy, just not to invest or not to support the sector,” she said. Among her concerns, Bingham cited the failure to create bulk antibody-manufacturing capabilities in the UK and the proposed termination of the NHS Covid vaccine research registry through which the public could indicate their willingness to participate in clinical trials for Covid vaccines. The decision by the National Institute for Health and Care Research to close the registry was eventually reversed after Robert Jenrick, then a health minister, stepped in. “I am baffled as to the decisions that are being made,” she said. Bingham also raised concerns about the length of time it is taking to agree a contract with Moderna – a US-based company that produces mRNA Covid vaccines – to create a research and development, and manufacturing, facility in the UK. Read full story Source: The Guardian, 30 November 2022
  4. News Article
    A consultant surgeon refused to attend hospital to carry out urgent surgery at a trust which later had upper gastrointestinal surgery suspended after an unannounced Care Quality Commission visit. The CQC report into upper GI surgery at the Royal Sussex County Hospital in Brighton – based on an inspection in August – said incident reports revealed occasions when upper GI surgeons could not be contacted or refused to come into hospital to treat patients. In one case, a consultant would not come in to carry out urgent surgery, it added. Low numbers of surgeons meant the on-call rota for upper GI was shared with the lower GI surgeons. This meant an upper GI specialist was not always available immediately, despite guidance from a professional body that 24/7 subspecialty cover was needed at centres which carry out major resectional surgery. This surgery was suspended at the RSCH after the August inspection and has yet to be reinstated. Mortality at both 30 and 90 days for patients with oesophago-gastric cancer was twice the national average between 2017 and 2020 – though the trust was not an outlier – and there was an increasing number of emergency readmissions for patients who had undergone upper GI surgery, the report said. Read full story (paywalled) Source: HSJ, 1 December 2022
  5. News Article
    Parents of children under five are being urged to get them a flu vaccine after a 70% jump in hospitalisations. The UK Health Security Agency (UKHSA) said an 11% fall in the uptake of the vaccine among two and three-year-olds came as flu circulated at higher levels than in previous years. Anjali and Ben Wildblood from Bristol saw their two-year-old son Rafa become "very sick" with flu just days before he was due to have the vaccine. The pair, who are both NHS consultants, said their concerns prompted them to take him to A&E where he was treated and sent home. "But his condition got worse again, with a soaring temperature and exhaustion - he had no strength whatsoever and what was so extremely worrying was that he barely had the strength to breathe - every parent's worst nightmare," they said. After returning to hospital, Rafa was admitted to a paediatric intensive care unit where he was put under general anaesthetic and intubated. Covid restrictions have meant most young children have never encountered flu and have no natural immunity to the virus, the UKHSA said. This increased risk has coincided with the uptake of the flu vaccine among two-year-olds standing at 31% and 33% among three-year-olds. All children under five can get vaccinated at their GP surgery. Read full story Source: BBC News, 30 November 2022
  6. News Article
    More than 11,000 ambulances a week are caught in queues of at least an hour outside A&E units in England, a BBC News analysis shows. The total - the highest since records began, in 2010 - means one in seven crews faced delays on this scale by late November. Paramedics warned the problems were causing patients severe harm. One family told BBC News an 85-year-old woman with a broken hip had waited 40 hours before a hospital admission. She waited an "agonising" 14 hours for the ambulance to arrive and then 26 in the ambulance outside hospital. When finally admitted, to the Royal Cornwall Hospital, which has apologised for her care, she had surgery. Both ambulance response times and A&E waits have hit their worst levels on record in all parts of the UK in recent months. In Cornwall, patients facing emergencies such as heart attacks and strokes are now waiting more than two hours on average for an ambulance. The target is 18 minutes. They are thought to be among the worst delays in the country but none of England's ambulance services is close to the target, while Wales, Scotland and Northern Ireland are all missing their targets. Read full story Source: BBC News, 1 December 2022
  7. News Article
    In an eleventh-hour decision NHS England has halted the automatic, blanket roll-out of a scheme that would have given all NHS patients in England prospective online access to their GP-held records the day before it was due to come in. The high-profile scheme to enable patents to automatically view their GP records via the NHS app by 30 November, has been a key digital promise by successive Conservative health secretaries. The last-minute u-turn came following a series of talks between the British Medical Association (BMA) and NHS England, in which the BMA made clear many practices would not be ready to roll out the programme in a safe way for patients, and that it didn’t comply with their data protection obligations. The BMA says the decision is the ‘right thing to do’ for patient safety. The BMA said in a statement that while some practices were ready to implement this, many expressed concerns over safety aspects and that it wasn’t fit for purpose at the present time. Dr David Wrigley, deputy chair of GPC England at the BMA, said: “We’re pleased to hear that NHS England has decided to review the pace and timing of the automatic, mass roll-out of the Citizens’ Access programme. This is, without doubt, the right thing to do for patient safety. “We want patients to be able to access their GP medical records, but this must be done carefully, with the appropriate safeguards in place to protect them from any potential harm. “The deadline of 30 November was, for many practices, just too soon to do this, and removing it will come as a huge relief to GPs and their teams across the country.” Read full story Source: Digital Health, 30 November 2022
  8. News Article
    Brexit has worsened the UK’s acute shortage of doctors in key areas of care and led to more than 4,000 European doctors choosing not to work in the NHS, research reveals. The disclosure comes as growing numbers of medics quit in disillusionment at their relentlessly busy working lives in the increasingly overstretched health service. Official figures show the NHS in England alone has vacancies for 10,582 physicians. Britain has 4,285 fewer European doctors than if the rising numbers who were coming before the Brexit vote in 2016 had been maintained since then, according to analysis by the Nuffield Trust. In 2021, a total of 37,035 medics from the EU and European free trade area (EFTA) were working in the UK. However, there would have been 41,320 – or 4,285 more – if the decision to leave the EU had not triggered a “slowdown” in medical recruitment from the EU and the EFTA quartet of Norway, Iceland, Switzerland and Lichtenstein. The dropoff has left four major types of medical specialities that have longstanding doctor shortages – anaesthetics, children, psychiatry, and heart and lung treatment – failing to keep up with a demand for care heightened by Covid and an ageing population. Read full story Source: The Guardian, 27 November 2022
  9. News Article
    The NHS could be facing its largest maternity scandal to date as the review into services in Nottingham is now expected to exceed 1,500 cases, The Independent has learned. The probe began in 2021 after this newspaper revealed dozens of babies had died or been left with serious injuries or brain damage as a result of care at NUH, which runs Nottingham’s City Hospital and Queen’s Medical Centre (QMC). But the scope of the investigation has more than doubled, with Nottingham University Hospitals NHS Trust sending more than 1,000 letters to families to contact the independent inquiry, after 700 families previously came forward with their concerns. Of these, the number of families expected to be covered by the probe is more than 1,500 – surpassing the 1,486 examined during the UK’s current largest maternity scandal in Shrewsbury. Read full story Source: The Independent, 30 November 2022
  10. News Article
    A former chief executive of the NHS has said most data collected about hospital discharges by NHS England is ‘useless’ and biased against social care. Sir David Nicholson, who was chief executive of the NHS from 2006 to 2013, and of NHS England until 2014, has said “almost all” of the data around delayed discharges “is designed to show how bad social care is”. Sir David, who is now chair of Worcestershire Acute Hospitals Trust and Sandwell and West Birmingham Trust, added that data on the number of patients with the “right to reside” in hospital is “wholly useless” when trying to improve discharge rates. NHSE publishes figures on the numbers of patients who “no longer meet the criteria to reside” in hospital – and during the winter months will publish this every week. NHSE has said the data collected on discharges helps to improve patient care and flow. In an interview with HSJ editor, Sir David said: “The problem we have with a lot of the data we collect [is that] it is designed for accountability reasons, not operational reasons. “And if you want a good example of that, have a look at the debate around discharge at the moment. There is a myriad of data, almost all of it is useless […] and almost all of it is designed to show how bad social care is. It’s extraordinary". Read full story (paywalled) Source: HSJ, 30 November 2022
  11. News Article
    NHS England has acted unlawfully by making thousands of patients with gender dysphoria wait “extreme” periods of time for treatment, the high court has heard. Transgender claimants, who have suffered distress as a result of delays, want the court to declare that NHSE broke the law by failing to meet a target for 92% of patients to commence treatment within 18 weeks. NHSE figures show there are 26,234 adults waiting for a first appointment with an adult gender dysphoria clinic, of whom 23,561 have been waiting more than 18 weeks. The number of children on the waiting list is approximately 7,600, of whom about 6,100 have been waiting more than 18 weeks. In a witness statement, one of the claimants, Eva Echo, said she received a referral in October 2017 but had still not been given a first appointment, leaving her in “painful indefinite limbo”. A co-claimant, Alexander Harvey, who has been waiting for a first appointment since 2019, said the delay “means that I have to continue to live in a body which I don’t feel is mine and which does not reflect who I am”. He said he had twice tried to kill himself. In written submissions for Tuesday’s hearing, David Lock KC, representing the claimants, said delays to puberty-blocking treatment – the current waiting time for children to access services is more than two years – could cause “intense anxiety and distress” to adolescents as a result of them experiencing “permanent and irreversible bodily changes”. While NHSE accepts it has not met the 92% target across the cohort of patients for whom its health services are commissioned, it claims a breach does not give rise to enforceable individual rights. Read full story Source: The Guardian, 29 November 2022
  12. Content Article
    Vision-based patient monitoring systems (VBPMS) are assistive tools that enable staff to enhance and support patient safety in inpatient services by delivering non-contact measurement of physiological parameters such as pulse and breathing rate, some estimate of patient location, activity or behaviour data and some form of contextual video information (which may be blurred) either in real-time or through subsequent reviews. In some cases, a VBPMS can be classified as a medical device regulated by the Medicines and Healthcare products Regulatory Agency and have specific indications for use. Providers adopting the technology need to ensure users are appropriately trained.
  13. Content Article
    How have the numbers of doctors in the NHS who come from the EU and the European Free Trade Association changed since the Brexit referendum in 2016? And do certain specialties face particular problems? Martha McCarey and Mark Dayan take a closer look at what’s happened since the vote.
  14. Content Article
    A recently published report highlights the shortcomings in care provided by the NHS. Peter Walsh, Joanne Hughes and James Titcombe emphasise how millions could be saved if people were empowered early on to have their needs met without the need to turn to litigation
  15. Event
    until
    The past couple of years have placed enormous pressures on the mental health and wellbeing of the population. The current cost of living crisis is having a significant impact on people’s state of mind with millions feeling stressed about rising food and energy prices as we head into winter. Delivered by Maximus, the Access to Work Mental Health Support Service, funded by the Department for Work and Pensions, can help employees and employers during this difficult time with their mental health. Completely confidential, the service is available at no charge to anyone with depression, anxiety, stress or other mental health issues, affecting their work. Remploy already helped thousands of people across England, Scotland and Wales, to remain in, or return to work, so our expertise speaks for itself. Led by Bethany Kimberley and Kaylena Mushen, this webinar will introduce the service, covering facts and statistics around mental health. It also looks at the service’s aims, eligibility criteria and referral process, plus what support and workplace adjustments are available at home, in an office, or other place of work. The session will also introduce and additional service, offering virtual one-to-one support appointments for employees. Learn how to gain access to fully-funded expert advice and support for up to nine months, which includes – A well being plan to help employees stay in, or attend work. Ideas for suitable workplace adjustments. Tailored coping strategies. Facts and statistics around mental health. Aims of the service. Details of the eligibility criteria and referral process. The support and interventions available. Register
  16. News Article
    Five-year-old Yusuf Nazir died from pneumonia on Monday. It is reported an infection had spread to his lungs and caused multiple organ failure, resulting in several cardiac arrests. His family said they struggled to get the poorly child admitted to hospital in the run-up to his death, as they were told there were not enough beds or doctors available. His uncle, Zaheer Ahmed, said he had “begged” Rotherham General Hospital to take his nephew in. He told ITV’s Good Morning Britain a GP said Yusuf had “severe tonsilitis” and needed intravenous antibiotics - but the doctor had been told not to refer anyone to the ward and they needed to go to A&E instead. Mr Ahmed said he rang the hospital himself. “I begged them. I begged them. I’ve never begged for anything in my life and I begged them to help him,” the tearful uncle said. He said he told them Yusuf needed treatment but was told there were no beds. He claimed he was told: “What do you want me to do? Just get a bed out of the air? We’ve got kids waiting.” They say they drove him to the emergency department of Rotherham General Hospital the next day when his condition did not improve. The family waited for hours before Yusuf was seen but he was sent home even though the doctor treating him had said “it was the worst case of tonsillitis he had ever seen”, according to Mr Ahmed. Yusuf’s condition worsened while he was at home and his parents called an ambulance and insisted he was taken to Sheffield Children’s Hospital, where he later died. Rotherham NHS Foundation Trust has launched an investigation into Yusuf’s care. Read full story Source: The Independent. 29 November 2022
  17. News Article
    NHS England has warned trusts not to compromise on fire safety when using corridor spaces to treat patients, amid growing pressure to accommodate more patients. It comes as emergency departments face increasing pressure from national and regional officials to find more space for patients this winter – even when they are deemed full to capacity – to reduce ambulance handover delays. The guidance, issued earlier this month, says trusts should complete new fire safety risk assessments before bringing any new part of a hospital into use for patient care, or extending the capacity of an existing area. It also said trusts have a legal duty to ensure escape routes are kept clear. It added: “As we continue to find extra capacity in the estate by newly using, or re-using, parts of hospitals for patient treatment or care, or increasing the capacity of existing areas, we would like to remind you of how any change of use of areas may affect fire safety requirements. “Under no circumstances must fire compliance be compromised on sites which have been changed.” Read full story (paywalled) Source: HSJ, 29 November 2022
  18. News Article
    One in four 17- to 19-year-olds in England had a probable mental disorder in 2022 – up from one in six in 2021, according to an NHS Digital report. Based on an online survey, rates among teenage boys and girls were similar – but twice as high in 17- to 24-year-old women compared with men. The charity Mind said the UK government "will be failing an entire generation unless it prioritises investment in young people's mental-health services". Matthew Rimmington, 24, is working full-time after studying acting at university, but aged 18, he felt his life was falling apart. It started with symptoms of anxiety, which deteriorated until his feelings really started scaring him. Despite going to his GP and being referred to NHS mental-health services, Matthew received no early support. "I was put on one waiting list and then another one," he says. "It was a constant back and forth and we never got anywhere." Mind interim chief executive officer Sophie Corlett said funding should be directed towards mental-health hubs for young people in England, where they can go when they first start to struggle with their mental health. "The earlier a young person gets support for their mental health, the more effective that support is likely to be," she said. "Young people and their families cannot be sidelined any longer by the government, who need to prioritise the crisis in youth mental health as a matter of national emergency." Read full story Source: BBC News, 29 November 2022
  19. News Article
    Staff mistakes in a private laboratory may have caused 23 extra deaths from Covid-19. The UK Health Security Agency (UKHSA) made the claim in a report into errors at the Immensa lab in Wolverhampton. It said as many as 39,000 positive results were wrongly reported as negative in September and October 2021. The mistakes led to "increased numbers of [hospital] admissions and deaths", the report, published on Tuesday, concluded. Thousands of people, many in the South West, were wrongly told to stop testing after their results were processed by Immensa. The Wolverhampton laboratory was used for additional testing capacity for NHS Test and Trace from early September 2021, but testing was suspended on 12 October following reports of inaccurate results. Experts said high case rates in some areas were down to people unwittingly infecting others when they should have been isolating. UKHSA experts said the mistakes could have led to as many as 55,000 additional infections in areas where the false negatives were reported. "Each incorrect negative test likely led to just over two additional infections," the report said. "In those same geographical areas, our results also suggest an increased number of admissions and deaths." Read full story Source: BBC News, 29 November 2022
  20. Community Post
    Hi @Momof2 I have copied your post into our hysteroscopy thread. You'll find lots of information in there and there may be someone who can advise. Painful hysteroscopy
  21. News Article
    Plans have been drawn up to avoid the NHS being overwhelmed this winter by encouraging patients to “behave in ways they’ve not experienced before” and cut down on in-person GP visits, the Guardian can reveal. An advertising campaign devised by M&C Saatchi, awarded a contract by NHS England worth up to £28.6m, suggested ways people could be encouraged to settle for a virtual appointment or visit a pharmacist instead. To help reduce the mounting pressures facing medics, documents show the agency also advised patients should be told that seeking help via alternative routes instead of rushing to A&E would help the NHS “work better for everyone”. The three-year contract is for the ad campaign “Help Us Help You”, which seeks to change people’s behaviour when accessing healthcare to reduce pressures on the NHS and maintain capacity. Wes Streeting, Labour’s shadow health secretary, said patients were already cutting back on in-person GP appointments – “not because they don’t need them but they’re finding it impossible to get one”. He told the Guardian: “Among those millions of patients who can’t get an appointment when they need it, there will be problems which go undiagnosed until it’s too late". Read full story Source: The Guardian, 30 November 2022
  22. News Article
    Patients who underwent brain operations at a West Midlands NHS trust suffered unnecessarily because of poor surgical outcomes, a report has found. More than 150 deep brain stimulation surgery cases at University Hospitals Birmingham (UHB) trust are now being investigated and surgery is suspended. There were unacceptable delays responding to patient concerns, the independent review also said. The investigation recommended indefinitely suspending the service at the NHS trust until it is safer. Deep brain stimulation (DBS) for movement disorders is used on patients with conditions including Parkinson's disease and dystonia, where medication is becoming less effective. The independent review, carried out by medics from King's College Hospital, was ordered by UHB after a serious incident investigation of a patient who underwent DBS for Parkinson's disease. One of those 21 people, Keith Bastable, 74, from Brierley Hill, had DBS in May 2019 for his Parkinson's disease and the review found his probes were placed too far away to be acceptable. Due to the misplacement, one was never switched on and the other probe had to be switched off as he suffered slurred speech and other side effects. They were removed and new ones recently reinserted in Oxford after he was referred to a hospital trust there. Mr Bastable said he had felt abandoned in the time it had taken to get resolved. Read full story Source: BBC News, 29 November 2022
  23. News Article
    A review of the clinical records of 44 patients who died under the care of former neurologist Michael Watt has found "significant failures in their treatment" and "poor communication with families". While this review looked at a sample of cases in which people died, potentially thousands more could be affected. The review arises from a 2018 recall of 2,500 outpatients who were in Dr Watt's care at the Belfast Health Trust. About one in five patients had to have their diagnoses changed. This separate review into 44 deaths was conducted by the Royal College of Physicians at the request of the regulator, the Regulation and Quality Improvement Authority (RQIA). It highlighted concerns over clinical decision-making, prescribing and diagnostics. It reveals a misdiagnosis rate of 45% among this group of patients, twice that for living patients. Speaking to BBC News NI, the RQIA's chair, Christine Collins, said the outcome of the review was "shocking and gut-wrenching as so many had experienced unpleasant deaths which they ought not to have done". Read full story Source: BBC News, 29 November 2022
  24. News Article
    With flu cases rising, UK Covid scientists are turning their attention to finding the best life-saving drugs to fight the winter virus. A trial will run across 150 hospitals this year and next, recruiting thousands of patients. Flu vaccines help prevent infection but each year some people become very sick. And antiviral tablets - given within a couple of days of symptoms developing - are designed to reduce the severity of these bad infections. One of the pills the Imperial College London team will be testing is oseltamivir, or Tamiflu. It is recommended to treat severe flu - but whether it saves lives is unclear. Funded by the National Institute for Health and Care Research, the Randomised, Embedded, Multi-factorial, Adaptive Platform Trial for Community-Acquired Pneumonia (Remap-Cap) will study how good the treatments are at reducing deaths and intensive care admissions. Chief investigator Prof Anthony Gordon told BBC News: "We want to learn at pace what works, just like we did during Covid. "We'll test multiple treatments in different combinations. Some are antivirals that stop the virus, others are steroids or other treatments that work on how the body responds to infections. "We hope that our trial will help to find urgently needed flu treatments rapidly. Our Covid trial changed clinical practice globally and we hope we can impact flu treatment and reduce winter pressures on the NHS in the same way." Read full story Source: BBC News, 29 November 2022
  25. Content Article
    Keeping patients safe during their care and treatment should be at the heart of any health system, including the NHS. Yet avoidable harm still occurs every day, around the world. There have been major efforts to prioritise patient safety in England, but the pandemic has shone a light on areas of care where progress has stalled, or safety has deteriorated. This report by Imperial College London's Institute of Global Health Innovation, commissioned by Patient Safety Watch, brings together publicly available data to present a national picture of patient safety in England. 
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