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Patient Safety Learning

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  1. Event
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    The Covid-19 pandemic has had a profound impact on our lives, including in how we work. While incredible efforts of health and care staff and voluntary and community workers were rightly valued and celebrated at the start of the pandemic, the scale of the workforce crisis in health and care continues to present a significant challenge for staff and leaders. Collaborative and inclusive leadership is key to successfully delivering good-quality care, as underlined by the recommendations from the Messenger Review.  Bringing our humanity to the workplace can mean different things to different people, but a greater focus on developing relationships in teams and the practice of collaborative, inclusive and compassionate leadership will be critical in supporting people through recovery from the pandemic. But how can we encourage others to bring their full selves to work at a time of significant challenge?’ The King's Fund's tenth annual leadership and workforce summit provides an established forum for health and care leaders to come together to share their leadership and workforce challenges and to explore practical options to help address them. Register
  2. News Article
    Families whose loved ones’ bodies were sexually abused in a hospital mortuary have yet to receive any compensation, because the Department of Health and Social Care has not signed off a proposed framework. A family member involved in the case claimed the delay was due to a “chaotic, splenetic mess of a government… [which] can’t get an arse on a seat long enough to approve it”. Former hospital maintenance supervisor David Fuller is serving life sentences for the murder of two women, committed two decades before he went on to commit sexual offences against 101 dead women and girls in hospital mortuaries in Kent. He was given a total of 12 years, to run concurrently, for 51 sex offences when he was sentenced last December but recently pleaded guilty to 16 additional charges involving 23 bodies and will be sentenced for these next month. But the families of the women and girls involved have waited more than a year to receive any compensation for the emotional distress his actions caused. Read full story (paywalled) Source: HSJ, 16 November 2022
  3. News Article
    Women are four times as likely to die after childbirth in Britain as in Scandinavian countries, a study published in the BMJ has found. Researchers analysed data on the number of women who die because of complications during pregnancy in eight high-income European countries. They found that Britain had the second-highest death rate, with one in 10,000 mothers dying within six weeks of giving birth, only slightly less than in Slovakia, the worst performing. The study found that rates of “late” maternal death — when women die between six weeks and a year after giving birth — were nearly twice as high in Britain as in France, the only other country for which data was available. Heart problems and suicide were the main causes of death. Professor Andrew Shennan, an obstetrician at King’s College London, said: “Any death relating to pregnancy is devastating. Equally shocking are the avoidable discrepancies in worldwide maternal mortality. “Causes of [maternal] death are relatively consistent across the world, and largely avoidable. Most deaths are due to haemorrhage, sepsis and hypertensive disorders of pregnancy. “In Europe, non-obstetric causes of death have become proportionately more common than obstetric causes, including deaths from cardiovascular disease (23%) and suicide (13%); these should be prioritised.” Read full story (paywalled) Source: The Times. 17 November 2022
  4. Content Article
    Women are four times as likely to die after childbirth in Britain as in Scandinavian countries, a study published in the BMJ from Diguisto et al. has found. The authors compared maternal mortality in eight countries (France, Italy, UK, Denmark, Finland, the Netherlands, Norway, and Slovakia) with enhanced surveillance systems. They found that UK had the second-highest death rate, with one in 10,000 mothers dying within six weeks of giving birth, only slightly less than in Slovakia, the worst performing. Norway has the lowest maternal death rates in Europe, at one in 37,000. In Denmark, the second-best performing country, one in 29,000 died. In-depth analyses of differences in the quality of care and health system performance at national levels are needed to reduce maternal mortality further by learning from best practices and each other. Cardiovascular diseases and mental health in women during and after pregnancy must be prioritised in all countries.
  5. News Article
    The plan to tackle long waits in hospital treatment and cancer care in England by 2025 is at serious risk, the spending watchdog says. The National Audit Office report warned inflation and other pressures on the NHS could undermine the push. These included a lack of staff and hospital beds, which was affecting productivity, the watchdog said. But NHS bosses said they could overcome the challenges and the health service was on track to hit its targets. NHS England and the government have set a series of targets over the next three years. They include: returning performance on the 62-day target for cancer treatment to pre-pandemic levels by March 2023 ending waits of over a year and a half for planned treatment, such as knee and hip operations, by April 2023 ending waits of over a year for planned treatment by March 2025 The NAO report comes as the chancellor prepares to set out his tax and spending plans in his Autumn Statement on Thursday. Cuts to public spending are likely but Health Secretary Steve Barclay has strongly hinted the NHS will receive more money. Read full story Source: BBC News, 17 November 2022
  6. News Article
    The health service’s independent data watchdog has issued a warning to local NHS bodies over concerns confidential patient information is being shared unlawfully with third parties, including for ‘population health’ analysis. In a letter to integrated care systems (ICSs), National Data Guardian Nicola Byrne and UK Caldicott Guardian Council chair Arjun Dhillon said they had both “been made aware that within some local record sharing programmes, organisations could be processing confidential patient information without ensuring that the processing does not breach confidentiality”. They added among the four areas of concern health and care staff had raised with them was that confidential patient information may be being transferred from local record sharing programmes to third party hosted secure data environments. Secure Data Environments are data storage and access platforms where organisations can apply to access data for planning and research purposes. It is not clear what kind of patient data may have been unlawfully shared. Read full story (paywalled) Source: HSJ, 17 November 2022
  7. News Article
    Doctors have warned of "unsafe" maternity services at a Sussex hospital in emails seen by the BBC. In the email chain between senior staff at the Royal Sussex County Hospital in Brighton, consultants wrote of "compromises" to patient care. One doctor said during a birth "we were one step away from a potential disaster". One senior doctor wrote in the exchange that "increasing workforce issues" had contributed to making the situation in the maternity unit "almost unmanageable at times". They added: "We are making compromises to patient care every day as a result." Another wrote that their workload was often "unmanageable, and obviously impacted by the staffing issues". A senior member of maternity staff said "we are delivering suboptimal care" and "we are one step away from potential disaster". A doctor also said staff were being "stretched", and that there were delays to women's care. Another consultant wrote: "We have an unsafe service and we have to strive for better than that." Read full story Source: BBC News, 16 November 2022
  8. Content Article
    Published on 19 October 2022, the report of the investigation into maternity and neonatal services at East Kent Hospitals NHS Foundation Trust revealed a series of serious patient safety failings between 2009 and 2020, which resulted in avoidable harm to patients and deaths. The investigation found that if nationally recognised standards had been followed, the outcome could have been different in 97 of the 202 cases reviewed. In this article, Patient Safety Learning analyses the findings of this report from a broad patient safety perspective, focusing on five key themes that are consistent with many other serious patient safety inquiries and reports in recent years. It sets these in their wider context and highlights the need for a fundamental transformation in our approach to patient safety if similar scandals are to be prevented in the future.
  9. News Article
    Poison control centres in the USA have seen an increase in reports of children ingesting a type of prescription cough medicine, a study published by the Food and Drug Administration (FDA)found. From 2010 through 2018, reports of paediatric poisonings involving the drug, benzonatate, increased each year, the study found. Benzonatate, sold under the brand name Tessalon, is prescribed to treat coughs caused by colds or the flu. It is not approved for children younger than 10 years old. The findings, published in the journal Pediatrics, were based on more than 4,600 cases reported to poison control centres. The reports included children who were unintentionally exposed to the drug, as well as children who abused or misused it intentionally. The proportion of cases with serious adverse effects was low. However, accidental or inappropriate use of benzonatate, which comes in gel capsules, can lead to serious health problems in children, including convulsions, cardiac arrest and death. The findings should galvanise doctors to be more careful when they prescribe these kinds of medications, said study author Dr. Ivone Kim, a pediatrician and senior medical officer at the FDA. Cough medications "should be treated like any other medication that can have serious side effects," Ameenuddin said, "which means not giving it to children without specific medical direction." Read full story Source: NBC News, 15 November 2022
  10. News Article
    An orthodontist whose methods around shaping the jawline have gone viral advised treatment to young children that “carried a risk of harm”, a tribunal has heard. Dr Mike Mew, whose “mewing” techniques have racked up nearly 2 biillion views on TikTok, faces a misconduct hearing at the General Dental Council (GDC). Opening the hearing in central London on Monday, Lydia Barnfather, representing the GDC, said comments made by Mew, who claims to help “alter the cranial facial structure” on his YouTube channel, were “pejorative” about orthodontists. Barnfather told the professional conduct committee that Mew seeks to treat children with “head and neck gear” and “lower and upper arch expansion appliances” to help align teeth and shape the jawline. “The GDC alleges this is not only very protracted, expensive, uncomfortable and highly demanding of the child, but it carries the risk of harm", Barnfather said. It was heard that between September 2013 and May 2019, advice and treatment were provided to two children, referred to as Patient A and Patient B. Mew was accused of failing to “carry out appropriate monitoring” of their treatment and “ought to have known” this was liable to cause harm. Barnfather said: “The GDC allege you are not to have treated patients the way you did.” She argued that both children had “perfectly normal cranial facial development for their age” before treatment took place. She added that the treatment was “not clinically indicated” and that Mew “had no adequate objective evidence” it would achieve its aims. Read full story Source: The Guardian, 14 November 2022
  11. News Article
    Following the blistering verdict last week of the independent review into the General Medical Council's (GMC) handling of the notorious 'laptop' case, which highlighted the "worrying trend" of ethnic minority doctors facing disproportionate regulatory action, the GMC has launched a new resource 'hub' to support doctors facing racism at work. A new dedicated area on the GMC website offers advice on how to address racism in the workplace, and sits alongside its existing dedicated whistleblowing webpage as the latest of 12 areas in an 'ethical hub' that brings together resources on how to apply GMC guidance in practice, focussing on areas doctors often query or find most challenging, and helping to address important ethical issues. Announcing the launch, the GMC said: "Tackling discrimination and inequality continues to be an urgent priority for health services." It added: "The GMC has committed to working with organisations to drive forward change, setting targets on tackling inequality." Its equality, diversity, and inclusion targets set last year aimed, inter alia, "to eliminate disproportionate complaints from employers about ethnic minority doctors, by 2026, and to eradicate disadvantage and discrimination in medical education and training by 2031". In March this year it published its first progress report, which showed that the gap between employer referral rates for ethnic minority doctors and international medical graduates, compared with white doctors, had "reduced slightly". Read full story Source: Medscape UK, 15 November 2022
  12. Content Article
    Everyone has the right to come to work without fear of racism. This resource from the General Medical Council (GMC) provides advice on how our guidance principles on non-discrimination apply when tackling racism. Where racist behaviour occurs among colleagues and patients, we recognise the fear that many doctors have of reporting these incidents. It signposts a range of support channels and highlights the duties we expect of doctors in senior positions in tackling and rooting out discrimination where it arises. It includes case studies from doctors and others on their experiences, advice and best practice.
  13. Content Article
    The NHS and social care systems need more money. If there is anything else that they need as much, it is honesty from the government. Post-Covid, the UK’s health systems are in a perilously fragile state. As analysis by the Guardian showed this week, logjams created by delayed discharges appear to be getting worse. An average of 13,600 hospital beds in England are occupied by patients with nowhere else to go. As well as making new admissions impossible, unnecessarily long stays can make it harder for people to regain their independence after leaving. So far, a £500m emergency fund promised by ministers to ease the pressure has failed to materialise. It is a symptom of the social care crisis that hospitals find it so hard to discharge people who are well enough to leave.
  14. News Article
    Hundreds of mental health patients in England are sent to hospitals miles from home each month because of local bed shortages - more than a year after the NHS aimed to end the practice. NHS data shows that 630 patients were in inappropriate out of area placements (OAPs) at the end of August 2022. An inappropriate OAP is when someone is sent to a hospital in a different area because no beds are free locally. Of the 630 patients in inappropriate OAPs in August 2022, more than half were sent away that month. In 2019, Kelly was sectioned and - because no local bed was free - sent to a hospital 23 miles from her home. "I didn't have anything on me", she says, "I only had my phone and the clothes that I was in." With family members too far away to bring her possessions, the hospital provided basics: pyjamas, trousers, a T-shirt, one pair of socks and two pieces of underwear. "All I could wear were the pyjamas and the same top and trousers every day for three weeks," says Kelly. "It was just awful. When you're stuck in a strange place as it is... It's even more distressing not having your own familiar things to take comfort in." Shortly after her discharge, Kelly was sectioned again - this time closer to home. She says this made a "massive difference", adding: "When you're closer to home you've got your friends and your family coming to visit you and take you out for a walk." Paul Spencer, the charity Mind's head of health, policy & campaigns, describes OAPs as traumatic, isolating and costly to the NHS. He says that "people are cut off from their support networks right at the very moment they need them most". Read full story Source: BBC News, 16 November 2022
  15. News Article
    Far too many women were rushed into mesh sling surgery for stress incontinence after birth when pelvic floor physiotherapy could have fixed or eased the problem. In France, women are offered pelvic floor physiotherapy after childbirth as standard. A recent question to the Secretary of State for Health and Social Care asked what assessment the Department has made of the potential benefits of offering new mothers pelvic floor physiotherapy. This question was answered on 15 November 2022: "The National Institute for Health and Care Excellence’s guidance recognises that physiotherapy is important for the prevention and treatment of pelvic floor problems relating to pregnancy and birth. The NHS Long Term Plan committed to ensure that women have access to multidisciplinary pelvic health clinics and pathways in England. NHS England is deploying perinatal pelvic health services to improve the prevention, identification and access to physiotherapy for pelvic health issues antenatally and postnatally. Two-thirds of local maternity and neonatal systems are expected to establish these services by the end of March 2023, with full deployment in England expected by March 2024." Source: Parallel Parliament, 15 November 2022
  16. News Article
    All GP practices in England will be able to book cancer tests directly for their patients from later this month, NHS bosses say. The option of GPs booking CT scans, ultrasounds and MRIs has been gradually rolled out in recent years, as community testing centres have opened. NHS England chief executive Amanda Pritchard will announce later all GPs will now be able to do this. GPs have previously relied on referring on to specialist hospital doctors. Before referring, they have to identify clear symptoms the patient may have a specific type of cancer. But only one out of every five cancer cases is diagnosed through these urgent GP referrals. Patients with less clear symptoms face long waits for check-ups or are diagnosed only after presenting at an accident-and-emergency (A&E) unit or being referred to hospital for something else. And Ms Pritchard will tell delegates at the NHS Providers annual conference of health managers, in Liverpool, today, she hopes the new initiative will lead to tens of thousands of cancer cases every year being detected sooner. Read full story Source: BBC News, 16 November 2022
  17. News Article
    The national director for mental health has said she was shocked to discover how many ward managers do not work at weekends, adding this could contribute to abuse and poor care going undetected. Asked at the NHS Providers conference about recent reports into care scandals, NHS England’s director for mental health Claire Murdoch said it was crucial to listen to frontline staff, such as healthcare assistants, who spend most of their time with patients. But she added: “[It’s also] making sure your ward managers do work of a night and at the weekend. “I’ve been a bit shocked to hear that we’ve moved with agenda for change and quite often ward managers are Monday to Friday people.” Her comments come amid a string of high-profile care scandals, such as at the Edenfield Centre in Greater Manchester, as well as an ongoing debate around seven-day working across the NHS. It is understood Ms Murdoch is concerned managers are spending too much time on bureaucratic tasks, which typically happen during Monday to Friday shifts, meaning they are then not working night or weekend shifts. In September, the national director ordered all trusts to carry out safety reviews, warning in a letter they should leave “no stone unturned” in seeking to eradicate and prevent poor care. She also urged all boards to urgently review safeguarding of care in their organisations, and identify any immediate issues requiring action now. Read full story (paywalled) Source: HSJ, 15 November 2022
  18. News Article
    Directors of a major hospital have ordered their accident and emergency staff to continue receiving ambulance patients into their department “in all instances”, following angry exchanges with paramedics. Hospital staff and ambulance crews have clashed at the new Royal Liverpool Hospital since its opening last month, after ambulance crews were prevented from bringing patients inside accident and emergency department when it was deemed to be full to capacity. The problems were escalated to hospital directors and North West Ambulance Service Trust earlier this month, resulting in new instructions being issued to the emergency department. In a letter to managers in A&E and the other divisions, seen by HSJ, the three most senior directors at the Royal Liverpool, wrote: “As you are aware we are currently experiencing long delays in accepting handover of patients from ambulance crews. “This phenomenon is not unique to us at the Royal Liverpool, nor is it particularly new, but our recent challenges have undoubtedly been exacerbated due to teams still familiarising themselves with working in a new environment and the patient flow challenges we have been experiencing on site. “However, what has changed has been the extent to which we have managed these pressures by continuing to hold patients in the back of ambulances, which we collectively agree is an unacceptable situation. Whilst providing corridor care is not what any of us would aspire to, we have to recognise and respond to the risk of patients awaiting response in the community. “We have therefore today met with NWAS colleagues and agreed that, with immediate effect, we will, in all instances, continue to receive crews from NWAS into the hospital building.” Read full story (paywalled) Source: HSJ, 16 November 2022
  19. News Article
    Experts have warned that Europe faces a “cancer epidemic” unless urgent action is taken to boost treatment and research, after an estimated 1m diagnoses were missed during the pandemic. The impact of Covid-19 and the focus on it has exposed “weaknesses” in cancer health systems and in the cancer research landscape across the continent, which, if not addressed as a matter of urgency, will set back cancer outcomes by almost a decade, leading healthcare and scientific experts say. A report, European Groundshot – Addressing Europe’s Cancer Research Challenges: a Lancet Oncology Commission, brought together a wide range of patient, scientific, and healthcare experts with detailed knowledge of cancer across Europe. One unintended consequence of the pandemic was the adverse effects that the rapid repurposing of health services and national lockdowns, and their continuing legacy, have had on cancer services, on cancer research, and on patients with cancer, the experts said. “To emphasise the scale of this problem, we estimate that about 1m cancer diagnoses might have been missed across Europe during the Covid-19 pandemic,” they wrote in The Lancet Oncology. “There is emerging evidence that a higher proportion of patients are diagnosed with later cancer stages compared with pre-pandemic rates as a result of substantial delays in cancer diagnosis and treatment. This cancer stage shift will continue to stress European cancer systems for years to come. “These issues will ultimately compromise survival and contribute to inferior quality of life for many European patients with cancer.” Read full story Source: The Guardian, 15 November 2022
  20. Content Article
    Cancer research is a crucial pillar for countries to deliver more affordable, higher quality, and more equitable cancer care. Patients treated in research-active hospitals have better outcomes than patients who are not treated in these settings. However, cancer in Europe is at a crossroads. Cancer was already a leading cause of premature death before the COVID-19 pandemic, and the disastrous effects of the pandemic on early diagnosis and treatment will probably set back cancer outcomes in Europe by almost a decade. Recognising the pivotal importance of research not just to mitigate the pandemic today, but to build better European cancer services and systems for patients tomorrow, the Lancet Oncology European Groundshot Commission on cancer research brings together a wide range of experts, together with detailed new data on cancer research activity across Europe during the past 12 years.
  21. Event
    Developing a culture of continuous improvement is an imperative as healthcare organisations face unprecedented challenges and strive for sustainability. Join an executive leadership panel for a virtual roundtable discussion and learn about crucial lessons from Warwick Business School's recently published independent study of the NHS-VMI partnership. The research reveals the effectiveness of applying a systems approach to learning and improvement across five NHS trusts in partnership with NHS Improvement. It will explore crucial lessons for leaders as they work to improve patient outcomes, population health, access, equity, and the overall patient experience, even during disruptions like the Covid pandemic. This includes: Leadership models, behaviours and practices that were observed to be essential components of leading change in organisations. How to enable “partnership” ways of working through practices and mechanisms that foster and maintain collaborative ways of working. Cultural elements necessary for the successful adoption of an organisation-wide improvement programme. Register
  22. Content Article
    NHS chiefs and regulators have written to hospital bosses admitting winter could be so bad NHS staff may have to "depart from established procedures" to care for patients. Letter says regulators will take the challenging situations into context...
  23. News Article
    A large study today from Germany shows that children and adolescents are at the same relative risk of experiencing COVID-19 symptoms 90 days or more after acute infection as adults are, according to findings in PLOS Medicine. Though kids and adolescents have far fewer deaths or severe outcomes from COVID-19 infections compared to adults, little is known about Long or post-Covid symptoms in this age-group, or symptoms that persist for more than 12 weeks after acute infection. Researchers from the Technical University of Dresden, Germany, used data from half of the German population to determine that kids and adults have the same relative risk of experiencing post-Covid symptoms at 90 days following infection. Martin Roessler, the lead author of the study, said there were significant symptom overlap among kids and adults who experienced symptoms 90 days or more after acute infection. "We found 5 identical outcomes among the 10 outcomes with the highest relative risk among children/adolescents and adults. These symptoms are cough, fever, headache, malaise/fatigue/exhaustion, throat or chest pain," he told CIDRAP News. Other symptoms were more commonly seen in adults, but not kids. Those included a loss of taste or smell, fever, and shortness of breath. Daniel Blatt, MD, a pediatric infectious disease physician at the post-COVID clinic at Norton Children's Hospital in Louisville, Kentucky, said he was not surprised by the study's findings. "It's unclear if Long Covid is the same in children and adults, in terms of pathophysiology, but it's just as real," he said. Blatt, who was not involved in the study, said his clinic also collects data on children and Long Covid. He said the most common symptoms reported in his patients are fatigue, anxiety, and "brain fog," followed by some shortness of breath or muscle pain. "The good news is kids tend to get better, regardless of what intervention is needed," Blatt said. As in adult Long Covid, there's no one-size-fits-all approach for pediatric Long Covid patients. "Some need reassurance; some need a graduated exercise program." Read full story Source: CIDRAP, 10 November 2022
  24. News Article
    GP surgeries across Scotland are at risk of collapsing because of staff shortages and increased demand, a senior doctor has warned. Dr Andrew Buist, chairman of the British Medical Association's (BMA) Scottish GP committee, told the BBC many practices were at "tipping point". More than a third of surveyed surgeries reported at least one GP vacancy – up from just over a quarter last year. About half of the GP surgeries in Scotland took part in the BMA survey. It showed 81% of practices said demand was exceeding capacity - with 42% saying demand substantially exceeded capacity. Dr Buist told BBC Scotland: "I worry that we're reaching a tipping point for some practices. "They lose one or maybe two doctors out of three, and the remaining doctors cannot continue so they return the contract and the practice may cease to exist. "That is a real concern in some parts of Scotland that that is happening and it's going to happen increasingly as the situation develops over this winter." Read full story Source: BBC News, 15 November 2022
  25. Content Article
    Long-term health sequelae of COVID-19 are a major public health concern. However, evidence on Long Covid is still limited, particularly for children and adolescents. Using comprehensive healthcare data on approximately 46% of the German population, Roesller et al. investigated post-COVID-19-associated morbidity in children/adolescents and adults.
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