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Patient Safety Learning

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  1. Patient Safety Learning
    A British mother-of-three has died just days after undergoing a Brazilian bum-lift operation in Turkey.
    Demi Agoglia, 26, of Salford, Greater Manchester, died from a heart attack caused by the operation just hours before she was due to return to Manchester from Istanbul where she had the operation, her family said.
    Ms Agoglia, who had a seven-month-old baby boy, went back to the clinic in Istanbul for a check-up but had a heart attack in a taxi on the way to the hospital as her partner, Bradley Jones, gave her CPR in a desperate bid to save her life.
    Her brother Carl, 37, said Ms Agoglia’s family and partner had tried to convince her not to go through with the bum-lift as they were concerned for her safety.
    Last year, a British surgeon warned of the dangers faced by Brits who fly to countries like Turkey for cheaper cosmetic surgery.
    “Many people fail to do their research and focus too much on money, rather than the quality or safety of the clinic,” Dr Ahmed Alsayed, who is lead surgeon and medical director at plastic surgery specialists Signature Clinic told HullLive.
    “Clinics in the UK have to adhere to the strictest levels of expertise, safety and cleanliness. You just can’t be sure you’ll get that from a cheaper option abroad,” Dr Alsayed said.
    Read full story
    Source: The Independent, 10 January 2023
  2. Patient Safety Learning
    The UK has some of the worst cancer survival rates in the developed world, according to new research.
    Analysis of international data by the Less Survivable Cancers Taskforce found that five-year survival rates for lung, liver, brain, oesophageal, pancreatic and stomach cancers in the UK are worse than in most comparable countries. On average, just 16% of UK patients live for five years with these cancers.
    Out of 33 countries of comparable wealth and income levels, the UK ranks as low as 28th for five-year survival of both stomach and lung cancer, 26th for pancreatic cancer, 25th for brain cancer and 21st and 16th for liver and oesophageal cancers respectively.
    The six cancers account for nearly half of all common cancer deaths in the UK and more than 90,000 people are diagnosed with one of them in Britain every year.
    The taskforce calculated that if people with these cancers in the UK had the same prognosis as patients living in countries with the highest five-year survival rates – Korea, Belgium, the US, Australia and China – then more than 8,000 lives could be saved a year.
    Anna Jewell, the chair of the Less Survivable Cancers Taskforce, said: “People diagnosed with a less survivable cancer are already fighting against the odds for survival. If we could bring the survivability of these cancers on level with the best-performing countries in the world then we could give valuable years to thousands of patients.
    “If we’re going to see positive and meaningful change then all of the UK governments must commit to proactively investing in research and putting processes in place so we can speed up diagnosis and improve treatment options.”
    Read full story
    Source: The Guardian, 11 January 2023
  3. Patient Safety Learning
    The family of an autistic teenager who died from an accidental overdose say they had to investigate the death themselves to find the truth of how he died.
    Will Melbourne, 19, was found dead at his Cheshire home on December 18, 2020 after he mistakenly had taken a strong synthetic opioid 100 times stronger than morphine he bought on the dark web.
    The inquest into Will's death took three years to come back and his family say had to investigate the matter themselves to find out what happened. 
    Sally and John Melbourne said their lives were put on hold during the long wait for the inquest to be completed and the family were told at the pre-inquest hearing that the court were short-staff and had a backlog of 500 cases.   
    Parents and friends of the teenager used a trail of digital "breadcrumbs" to uncover that Will had tried to buy oxycodone, a highly addictive opioid that helps with pain relief and anxiety, which turned out to be a synthetic opioid.
    The blue pills Will had bought on the darknet were found beside his body. 
    The family say the drugs were not tested until they raised it with the coroner's court a year after his death.
    Will's blood sample had also been destroyed after the company storing it went into administration. 
    The family said they were left traumatised by the time the inquest was concluded. 
    Mrs Melbourne said: "We thought the inquest system was there to give us answers. Instead, we felt blocked at every turn. 
    "It was outrageous that we had to take the investigation on ourselves."
    Read full story
    Source: Mail Online, 4 January 2023
  4. Patient Safety Learning
    More NHS managers support regulation of their roles than oppose it, despite many fearing its implementation will be unfair or disproportionate, a survey suggests. 
    The trade union Managers in Partnership surveyed NHS managers working at Agenda for Change band 8a and above throughout the UK late last year, collecting 291 responses.
    Asked whether they “in principle… support professional regulation of NHS managers”, 49% said they supported or strongly supported it. Just 19% said they opposed or strongly opposed, while the remainder were neutral.
    However, respondents – 22% of whom said they were already covered by a professional regulator, and likely to be nurses, doctors or finance or legal professionals – appeared sceptical about the benefits. 
    Asked whether they thought professional regulation of NHS managers would make processes for raising concerns/whistleblowing better or worse, only 26% said it would be better. 20% said these would get worse, and the remainder said it would be “about the same”. 
    Read full story (paywalled)
    Source: HSJ, 9 January 2023
  5. Patient Safety Learning
    The former nursing director at the hospital where Lucy Letby murdered seven babies will be among the 'core participants' of the Thirlwall Inquiry.
    The inquiry, chaired by Lady Justice Thirlwall, will investigate how Letby was able to commit the murders and attempt six others while she worked as a neonatal nurse at Countess of Chester Hospital NHS Foundation Trust in 2015 and 2016.
    This week, Alison Kelly, who was director of nursing and quality at the trust during the time of Letby's crimes, was announced as 1 of 10 core participants in the inquiry.
    Also named were former Countess of Chester chief executive Tony Chambers, former medical director Ian Harvey and former human resources director Sue Hodkinson.
    Ms Kelly and Mr Harvey were among the senior staff at the trust who were accused of failing to act when clinicians first raised concerns about Letby.
    How managers responded to such concerns is one of the areas due to be investigated by the Thirlwall Inquiry.
    A number of organisations are also on the list as core participants, including the Nursing and Midwifery Council (NMC), NHS England, the Royal College of Paediatrics and Child Health, the Department of Health and Social Care and Countess of Chester itself.
    Read full story
    Source: Nursing Times, 3 January 2024
  6. Patient Safety Learning
    The senior midwife tasked by the government and NHS to investigate serious maternity scandals has warned that new mothers are being driven to suicide and backed an MP’s review into birth trauma.
    Donna Ockenden said it was “appalling” that women who should be in the “happiest times of their lives” were taking their own lives, after it was found suicide was the leading direct cause of deaths up to 12 months after giving birth.
    Ockenden, who has exposed poor maternity care across the country, is preparing to give evidence to an inquiry launched by Theo Clarke, the Conservative MP for Stafford, on birth trauma.
    Clarke thought she was going to die after giving birth to her daughter Arabella last year, having suffered a third-degree tear.
    But it was the lack of help available that opened her eyes to the estimated 200,000 women a year who experience birth trauma.
    Ockenden told The Times she had “huge respect” for Clarke’s inquiry and said: “I think that this whole issue of maternal trauma, sometimes long-term psychological trauma for families as well post a difficult maternity experience, is not necessarily given enough air time.”
    Read full story (paywalled)
    Source: The Times, 8 January 2023
  7. Patient Safety Learning
    A former midwife has told the BBC she quit because she could not live with herself if she provided poor care.
    Hannah Williams says staff shortages meant she kept patients safe, but sometimes only "by the skin of her teeth".
    BBC Verify analysis shows that the number of full-time equivalent midwife posts in England has gone up by 7% in the last decade. In comparison, the overall NHS workforce has increased by 34%.
    The country has a shortage of about 2,500 midwives, and maternity units are struggling with safety concerns.
    BBC research has also found that some trusts have more than one in five midwife jobs unfilled.
    The Royal College of Midwives says staffing is the "most important issue" and the gap needs to close.
    Read full story
    Source: BBC News, 9 January 2024
  8. Patient Safety Learning
    A coroner overseeing a teenager's inquest has warned there will be more deaths unless mental health services improve for autistic people at risk of self-harm.
    Morgan-Rose Hart, 18, who had ADHD, autism and a history of mental illness had been a patient at a unit in Harlow, Essex, for three weeks.
    An inquest jury concluded she died by misadventure contributed to by neglect.
    Ms Hart, from Chelmsford, died in hospital six days after she was found unresponsive in the bathroom of her mental health accommodation in the Derwent Centre in Harlow, Essex in July 2022.
    The inquest into her death heard staff observations were falsified and critical observations were missed.
    In her Prevention of Future Deaths report, Ms Hayes said: "There is a significant shortfall of appropriate placements for people with autism who have mental health and self-harm risks in Essex both inpatient and in the community."
    She added: "During the course of the inquest the evidence revealed matters giving rise to concern.
    "In my opinion, there is a risk that future deaths will occur unless action is taken."
    Read full story
    Source: BBC News, 8 January 2024
  9. Patient Safety Learning
    NHS England and government are set to raise their target for four-hour A&E performance, despite most hospitals failing to meet the current ask.
    HSJ understands officials are likely to use 2024-25 planning guidance to raise the “interim” target for four-hour performance from the 76% which trusts were asked to hit in 2023-24.
    A new objective of 80% by March 2025 has been discussed, several sources said, but is not confirmed.
    The 76% target has not been met during any month of 2023-24 so far, and most acute trusts are consistently falling well short of it.
    Well-placed sources told HSJ  the target was likely to be increased despite “some doubts” among senior NHSE officials. One senior NHSE source said: “The target should be increasing incrementally as overall NHS A&E performance improves, [but] it hasn’t really improved this year.”
    Read full story (paywalled)
    Source: HSJ, 5 January 2024
  10. Patient Safety Learning
    Patients' lives are being put at risk because it is too easy to buy prescription-only medicines from online pharmacies, a leading pharmacist says.
    A BBC investigation found 20 online pharmacies selling restricted drugs without checks - such as GP approval. In total, over 1,600 various prescription-only pills were bought during the investigation entering false information without challenge.
    Regulator the General Pharmaceutical Council says extra checks are needed when selling some drugs online.
    The BBC's findings highlight the "wild west" of buying medicines on the web, says Thorrun Govind, a pharmacist, health lawyer and former chair of the Royal Pharmaceutical Society.
    "The current guidance basically tells pharmacies to be robust, but do that in your own way, and we know that under this current system, patients have died," she says.
    The parents of a woman who died in 2020, after accidentally overdosing on medicines she bought online, are among those calling for stricter rules.
    Katie Corrigan, from St Erth in Cornwall, had developed an addiction to painkillers after experiencing neck pain.
    "Katie needed help, she didn't need more medication," says her mum, Christine Taylor.
    Her GP had stopped supplying the drug after realising she had been allowed to request new prescriptions prematurely and been prescribed too much.
    Instead, Katie, 38, was able to buy a painkiller and a drug used to treat anxiety from multiple online pharmacies without notifying her GP.
    The coroner at Katie's inquest confirmed her GP had not been contacted by any of the pharmacies to check the drug was safe for her. In his final report, he said the safety controls were inadequate.
    Read full story
    Source: BBC News, 5 January 2024
  11. Patient Safety Learning
    At least 38 babies died in the space of nine years after serious incidents in the country’s maternity units, it has emerged.
    The total is based on research of both media reports of inquests and settled claims.
    Before Christmas, a review by the  Irish Examiner  revealed 21 hospital baby deaths followed one or more serious incidents, between 2013 and 2021.
    However, further study in the same nine-year period shows the toll to be higher. The worst year was 2018, when not only did at least 10 babies die, but three of them died at the same Dublin hospital over a five-month period.
    In at least 18 of the 38 deaths, issues around foetal heartbeat monitoring (CTG) were raised either at inquest or in the High Court.
    At least 18 of the inquests resulted in a verdict of medical misadventure.
    As well as issues around heart monitoring, the Irish Examiner review shows that in at least seven of the 38 cases, maternity staff missed signs that a woman was in labour, leading to repeated recommendations around training.
    In at least seven cases, mothers’ concerns were ignored.
    Read full story
    Source: Irish Examiner, 29 December 2023
  12. Patient Safety Learning
    The NHS will start recording harm caused to patients during strike action where exemptions have been rejected by the British Medical Association (BMA).
    BMA council chair Phillip Banfield yesterday accused NHS England of the “weaponisation” of the strike “derogation” process, saying trusts had this week submitted more of the requests, which would permit some striking doctors to return to work, and were not providing information needed to determine if they were justified.
    NHS England wrote back to Professor Banfield, insisting it was only trying to prioritise safety, but also saying it would revise its own approach to derogation requests.
    This will include: asking trusts whose requests were rejected by the BMA “to compile a picture” of the impact on services; reinforcing requirements to report patient safety incidents during strikes and after mitigation requests, so “we can evidence harm and near misses which might have been avoided”.
    The letter says: “We have consistently asked local medical and other clinical leaders to consider applying to the BMA for patient safety mitigations where they have significant concerns for patient safety that cannot be mitigated through other options available to them, and where they can make a strong evidential case that the return of a limited number of junior doctors would address these risks.
    “We have done this, in part, because we have received a number of reports over previous periods of action that some teams have been put off seeking patient safety mitigations because of their prior experience of having applications rejected, or not receiving a response in time. We are sure you would agree that this is an unsatisfactory position, and that where patient safety concerns exist, these should always be escalated appropriately.”
    Read full story (paywalled)
    Source: HSJ, 4 January 2024
  13. Patient Safety Learning
    The Welsh Ambulance Service is struggling to cope as many A&E departments are full and some patients have reportedly been waiting to be offloaded from ambulances for as long as 15 hours. The service has issued a plea for the public to "use 999 responsibly" amid severe pressure.
    An employee of the service said: "Nearly every A&E department is at capacity. Patients have been on ambulances for the last 15 hours. The ambulance service is only responding to red [immediately life-threatening] calls."
    The service has received almost 13,000 calls to 999 since Boxing Day and there have been almost 36,000 calls to the NHS 111 Wales service.
    Lee Brooks, the ambulance service’s operations boss, said: “Pent-up demand from the Christmas and New Year period, coupled with the seasonal illnesses we see at this time of year, means there are lots of people across Wales trying to access health services currently. When hospitals are at full capacity, it means ambulances can’t admit their patients, and while they’re tied up at emergency departments, other patients in the community are waiting a long time for our help, especially if their condition isn’t life-threatening.
    “We’re working really hard as a system to deliver the best possible care to patients, but our ask of the public today – and in the coming days – is only to call 999 if they are seriously ill or injured, or where there is an immediate threat to someone’s life. That’s people who’ve stopped breathing, people with chest pain or breathing difficulties, loss of consciousness, choking, severe allergic reactions, catastrophic bleeding or someone who is having a stroke."
    Read full story
    Source: Wales Online, 3 January 2024
  14. Patient Safety Learning
    Trusts reduced the number of 65-week breaches by around 20% and cut the overall elective waiting list between October and mid-December, NHS England has said.
    The claim is based on provisional data published by NHSE on 2 January, which came with a warning of possible “significant issues regarding the quality and completeness”.
    The figures suggest the number of 65-week waiters fell from around 114,000 on 8 October to around 93,000 by 17 December. The last official “referral to treatment” figures were published last month (see table below). They reported there were around 107,000 65-week breaches in October.
    Sources familiar with the provisional data, from the “waiting list minimum data set”, said while it was not as accurate as official referral to treatment statistics, it gives an accurate picture of the direction of travel and overall performance.
    Read full story (paywalled)
    Source: HSJ, 3 January 2024
  15. Patient Safety Learning
    NHS England has been accused of bowing to political pressure and trying to “undermine” the junior doctors strike.
    British Medical Association council chair Philip Banfield tonight wrote to NHSE chief executive Amanda Pritchard accusing her organisation of the “weaponisation” of the process used to agree minimum services level during the strike.
    Junior doctors walked out yesterday to begin a six day strike, the latest in their 10 month campaign and the longest in NHS history.
    Professor Banfield’s letter claims that NHSE is not respecting the terms of the voluntary agreement to provide “derogations”. These, says the letter, “allow for junior doctors to return to work in the event of safety concerns arising from ‘unexpected and extreme circumstances’ unrelated to industrial action”.
    The BMA accuses trusts of not providing the information the union needs to determine if the requests for derogations are justified. It said that the lack of information provided by trusts had led to it turning down 20 requests for derogations.
    The letter states: “We are increasingly drawing the conclusion that NHS England’s change in attitude towards the process is not due to concerns around patient safety but due to political pressure to maintain a higher level of service, undermine our strike action and push the BMA into refusing an increasing number of requests; requests, we believe, would not have been put to us during previous rounds of strike action.
    “The change in approach also appears to be politicisation and weaponisation of a safety critical process to justify the Minimum Service Level regulations.”
    Read full story (paywalled)
    Source: HSJ, 3 January 2024
  16. Patient Safety Learning
    People in some more rural areas are missing out on specialist treatments they should be getting, while Londoners are receiving a lot more than their “fair share”, new NHS England figures suggest. 
    NHS England has suggested the main cause is “systematic shortfalls in access [in] remote communities”, leaving “unmet need” for specialised services in these areas.
    However other factors, including coding and reporting practices, year-to-year fluctuation, and weaknesses in the formula, are also likely to be confusing the picture, sources said.
    The variation is being uncovered now because NHSE is preparing to fund many specialised services via allocations to integrated care boards. These allocations will be based on estimates of their populations’ healthcare needs, rather than NHSE negotiating payments directly with provider trusts – as it has since 2013.
    Read full story (paywalled)
    Source: HSJ, 3 January 2023
  17. Patient Safety Learning
    Almost one in four people have bought medicine online or at a pharmacy to treat their illness after failing to see a GP face to face, according to a UK survey underlining the rise of do-it-yourself treatment.
    Nearly one in five (19%) have gone to A&E seeking urgent medical treatment for the same reason, the research commissioned by the Liberal Democrats shows.
    One in six (16%) people agreed when asked by the pollsters Savanta ComRes if the difficulty of getting an in-person family doctor appointment meant they had “carried out medical treatment on yourself or asked somebody else who is not a medical professional to do so”.
    Ed Davey, the leader of the Liberal Democrats, said delays and difficulty in accessing GP appointments constituted a national scandal, and face-to-face GP appointments had become “almost extinct” in some areas of the country.
    He said: “We now have the devastating situation where people are left treating themselves or even self-prescribing medication because they can’t see their local GP.”
    Dr Richard Van Mellaerts, the deputy chair of the British Medical Association’s GP committee in England, said: “While self-care and consulting other services such as pharmacies and NHS 111 will often be the right thing to do for many minor health conditions, it is worrying if patients feel forced into inappropriate courses of action because they are struggling to book an appointment for an issue that requires the attention of a GP or a member of practice staff.”
    Read full story
    Source: The Guardian, 2 January 2024
  18. Patient Safety Learning
    Hundreds of children’s appointments – including for lifesaving operations and cancer treatments – have been cancelled on each day that NHS strikes took place over the last year, as hundreds of thousands of youngsters languish on the waiting list for treatment, The Independent can reveal.
    More than 20,000 paediatric treatments and surgeries were shelved because of the walkouts, while the families of 400 children were told that their lifesaving operations had been cancelled.
    With junior doctors due to stage the longest strike in NHS history this week – for six days, starting on Wednesday – the problem is set to get worse.
    Dr Camilla Kingdon, president of the Royal College of Paediatrics and Child Health, warned that long waits for children can be particularly damaging, and can have a lifelong impact as treatment is often time-critical.
    She said that children are seldom prioritised in national policy-making, and urged the government to put children’s needs “back on the agenda”.
    Read full story
    Source: The Independent, 2 January 2024
  19. Patient Safety Learning
    An alarming number of Britons are turning into “DIY doctors” because of the struggle to get an NHS GP appointment in 2023, new polling has revealed.
    Some 23% of those surveyed said they could not get an appointment, while three in 10 (33 per cent) said they had given up on booking one altogether, according to a Savanta poll commissioned by the Liberal Democrats.
    Many said they had resorted to “DIY” medical care or gone to A&E instead. One in seven (14 per cent) said they had been forced to treat themselves or ask someone else untrained to do so, with the same proportion seeking emergency care.
    One in five people said they had bought medication online or at a pharmacy without advice from a GP, and one in three had delayed seeing a doctor despite being in pain, as pressure on the NHS mounts.
    Liberal Democrat leader Sir Ed Davey described the figures as “utterly depressing” and said they should serve as an “urgent wake-up call for ministers asleep on the job”.
    Read full story
    Source: The Independent, 1 January 2024
  20. Patient Safety Learning
    NHS bosses fear patient safety could be compromised during this week’s junior doctors strikes if medics do not honour an agreement to abandon picket lines if hospitals become overwhelmed during the winter crisis.
    Hospital bosses can ask the British Medical Association (BMA) to allow junior doctors to return to work to help if an emergency arises during their six-day strike starting on Wednesday.
    But there is concern among health trust leaders that the doctors’ union could reject such “recall requests” – or take worryingly long to consider them – despite “highly vulnerable” hospitals having too few staff on duty to cope with a surge in patient numbers.
    A spike in cases of flu, Covid and norovirus has left the NHS under intensifying strain in the first week of the new year, a period in which its winter crisis often bites.
    On the eve of the 144-hour strike – the longest in NHS history – the NHS Confederation, which represents trusts, urged the BMA to ensure the “recall system” worked reliably if it was triggered.
    “With the next round of junior doctors strikes coinciding with what is always an exceptionally busy week for the NHS, health leaders hope that escalation plans run smoothly and with a shared understanding that protecting patient safety is the most important priority,” Danny Mortimer, the confederation’s deputy chief executive, said.
    Read full story
    Source: The Guardian, 1 January 2024
  21. Patient Safety Learning
    Nurses are being put in increasing danger from shocking levels of violence and aggression by patients, a senior nursing leader has warned.
    Prof Nicola Ranger, the Royal College of Nursing’s (RCN) director of nursing, said the crisis in the NHS had fuelled bad behaviour by patients frustrated by worsening delays for treatment since the Covid pandemic.
    Ranger said the situation was contributing to an exodus of nurses from the NHS, amid a vicious cycle of staff shortages and rising violence.
    This meant that there were often not enough nurses on duty to keep colleagues safe, she added.
    Calling on the government to make tackling the abuse of nurses a priority, Ranger said there was a sense of despair in the profession about their deteriorating working conditions.
    “I think the public would be totally shocked if they knew how common it is for nursing staff to be on the receiving end of violence and aggression at work,” said Ranger. “Nurses are put in jeopardy, it’s become all too common for them to be threatened by patients on shift.
    “We genuinely have got a nursing crisis in the UK that doesn’t seem to be being acknowledged by our government at all. Being spat at, being hit, being punched, can for some nurses just literally be the final straw."
    Read full story
    Source: The Guardian, 1 January 2024
  22. Patient Safety Learning
    Stroke patients in England are waiting an average of almost seven hours for a specialist bed, double the wait reported before Covid.
    National performance against key measures collected by the Sentinel Stroke National Audit Programme has nosedived, with patients in England waiting an average of almost seven hours to be admitted to a specialist unit in 2022-23, compared to three and a half hours in 2019-20.
    NHS England guidance states that every patient with acute stroke should be given rapid access to a stroke unit within four hours. This time frame is considered critical, as patients can only be given clot-busting drugs, and treatments such as thrombectomy, which surgically removes a clot, within the first few hours of stroke onset.
    However, this was achieved in just 40% of cases last year (2022-23), down from 61% in 2018-19.
    Juliet Bouverie, CEO of the Stroke Association, urged ministers to give trusts what they needed to reverse the decline, saying: “Stroke is a medical emergency and every minute is critical.
    “We are very concerned to see that, far from improving over the last year, the proportion of stroke patients being admitted to a stroke ward within the timescale for thrombolysis has continued to decline. This is putting patient recoveries at risk and strain on the rest of the health system.
    “We believe that early supported discharge, when done correctly, with adequately resourced community teams, can help to alleviate capacity pressures in acute stroke units. However, this is not a silver bullet. There are longstanding workforce issues which are affecting patient flow in, through and out of stroke units and we call on DHSC to properly address these in the workforce plan.”
    Read full story (paywalled)
    Source: HSJ, 2 January 2024
  23. Patient Safety Learning
    Patients who feel fortunate to get a doctor's appointment then find they are in and out of the GP surgery in less than five minutes.
    A fifth of the consultations in England last year were done within that time.
    Dennis Reed, of the Silver Voices campaign group for over-60s, said: "It is hard enough to get a face-to-face appointment with a GP these days, without being shown the door before you have had a chance to take your coat off.
    "The public wants the family doctor back, who knows your family history and has the time to chat about your general health and wellbeing.
    "A revolving door policy, with the patient exiting after a couple of minutes clutching a prescription, is not the way to run a primary care service."
    Research from the House of Commons Library, commissioned by the Lib Dems, found 22% of GP appointments between January to October 2023 lasted five minutes or less.
    Lib Dem MP Wera Hobhouse said: "Seeing a GP is the most vital contact for people to address their health concerns, seek help and start treatment.
    "Not having quick and easy access to a GP and not having sufficient time for patients during an appointment leads to huge problems later on, let alone the anxiety and additional pain people suffer because of delays."
    Read full story
    Source: The Express, 31 December 2023
  24. Patient Safety Learning
    Hospital admissions from a winter virus could be reduced by more than 80% if babies are given a single dose of a new antibody treatment, a study says.
    Respiratory syncytial virus (RSV) usually causes mild, cold-like symptoms, but can lead to bronchiolitis and pneumonia.
    More than 30,000 under fives are hospitalised with RSV in the UK annually, resulting in 20 to 30 deaths.
    One British parent said her son getting RSV was "very scary" as a first-time mother.
    Lorna and Russell Smith's eldest son, Caolan, got the virus when he was eight months old and was admitted to hospital twice - each time requiring oxygen.
    Now aged two, he has made a full recovery.
    "I hadn't heard of RSV and wasn't sure what to do. He had laboured breathing due to high temperature and was quite lethargic. It brought a lot of anxiety and stress," Lorna said.
    The Harmonie study involved 8,000 children up to the age of 12 months, with half receiving a single dose of the monoclonal antibody treatment nirsevimab.
    The results, published in the New England Journal of Medicine, showed that RSV-related hospitalisation was reduced by 83% in those receiving the jab and admissions for all chest infections were cut by 58%.
    Side effects were similar in both groups and mostly mild.
    Read full story
    Source: BBC News, 27 December 2023
  25. Patient Safety Learning
    Hospital neglect contributed to the death of a two month old baby after staff turned off emergency alarms, a coroner has ruled.
    Louella Sheridan died at Royal Bolton Hospital in on 24 April 2022 after she was admitted with bronchiolitis to the hospital’s intensive care unit before later dying from Covid and a related heart condition.
    Four alarms on a monitoring machine were silenced and then switched off before the baby collapsed in a high dependency unit, it has been found.
    On Wednesday coroner John Pollard ruled neglect by staff had contributed to Louella’s death after staff switched off the alarms on the monitors attached to her during the night.
    Summing up his conclusion Coroner Pollard reportedly said there was a “gross failure “ to provide basic medical care to Louell and that had care been given, had the alarms been switched on to alert staff her life may have been extended at least for a short period of time.
    He said turning off the alarms was a gross type of conduct.
    Read full story
    Source: The Independent, 22 December 2023
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