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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    A hospital trust has been fined £200,000 for putting four babies at "serious risk"of harm. Staff at Rotherham Hospital failed to spot non-accidental injuries during admissions, Sheffield Magistrates' Court heard. District Judge Naomi Redhouse criticised failures in the hospital's systems and processes. Health watchdog, the Care Quality Commission (CQC), had earlier highlighted problems with safeguarding training at the trust prior to the babies' admissions between January 2019 and February 2020. The court was told how one eight-day-old baby was brought into the hospital on 23 December 2019 suffering from breathing difficulties and bleeding from the nose and mouth. It was only on the child's fifth visit to hospital - after a GP raised concerns - that a child safety examination took place, revealing rib and leg fractures that were deemed non-accidental. Ms Redhouse also heard how a month-old baby brought in with a mouth injury on 20 January 2019 was on a child protection plan but this was not spotted by the paediatric nurse who examined the baby. This child was twice released from hospital, with no safeguarding concerns, before a scan and other examinations revealed multiple fractures, the court heard. Prosecutor Ryan Donohue said failings had been identified in areas including policy implementation, training, reporting, auditing and governance. Eleanor Sanderson, mitigating for the trust, said: "The trust wishes to express to the court its deep regret for the circumstances which gave rise to these offences and the risk posed to those who required safeguarding." Read full story Source: BBC News, 26 October 2022
  2. News Article
    Bosses at struggling trusts must sign new commitments to national leaders about how they are approaching the task of clearing their elective and cancer backlogs, under a new protocol drawn up by NHS England. National leaders have written to CEOs and chairs of trusts in NHSE’s bottom two “tiers” for elective and cancer performance, telling them they must fill out a new “board self certification” by 11 November. It requires them to sign that they have carried out a list of 12 separate actions to try to improve. In addition to some fundamental administrative requests, these include increased scrutiny around issues such as theatre productivity, list validation, especially for non-admitted lists, and cancer pathway redesign. Read full story (paywalled) Source: HSJ, 28 October 2022
  3. News Article
    Just a “fraction” of people with Long Covid is getting the help they need, with a third of them waiting more than three and a half months to be assessed after a GP referral, rising to almost half in some areas. More than 60,000 people in England had a first assessment for post-Covid syndrome in an NHS specialist service between July 2021 and August 2022. But the latest estimates released by the Office for National Statistics (ONS) show that about 277,000 people with Long Covid in England report that the disease has limited their day-to-day activities “a lot”. These are the people that experts would expect to be referred for an assessment; however, the numbers who have been seen are far lower. Dr Helen Salisbury, a GP and columnist for the BMJ, said: “A fraction of the people who have got this problem are actually being seen” within the existing services. She said reasons could include patients not realising that the help is available to them; GPs not recognising Long Covid in those who do not self-label as having the condition; and a lack of knowledge of, and local access to, specialised clinics. While Salisbury conceded that there was no current cure for long Covid, she added that patients require treatment that involves symptom management, psychology and knowing they are not alone in their diagnosis. Ondine Sherwood, a co-founder of the advocacy charity Long Covid SOS, said many people with long Covid “are struggling to get any healthcare. Many are not getting any treatment at all.” She said public misconceptions around long Covid made it harder for sufferers to ask for and get help. “There was a lack of preparedness for the potential long-term morbidity which was not conveyed to healthcare professionals and this has contributed to the lack of care for long Covid.” Read full story Source: The Guardian, 27 October 2022
  4. News Article
    Regulators have told the agency that supplies blood to the NHS to develop a more inclusive culture, after hearing multiple reports of ethnic minority staff being ‘disrespected’ and discriminated against. “Many staff” at NHS Blood and Transplant also expressed fear of reprisal for raising issues and concerns, the Care Quality Commission (CQC) said. The CQC carried out a “well-led” inspection of the agency over the summer, after receiving concerns about its culture and the behaviour of some senior leaders. Chief executive Betsy Bassis resigned after the inspection, although the CQC report does not refer to any specific allegations made against her. NHSBT has acknowledged it needs to improve its culture, particularly around diversity and inclusion issues. An internal memo sent to staff last week, seen by HSJ, said executives and board members would receive one-to-one training in “inclusive leadership and understanding racism”. Read full story (paywalled) Source: HSJ, 27 October 2022
  5. News Article
    Senior staff have questioned why a major hospital did not seek support from neighbours when emergency patients were left waiting more than 60 hours to be admitted to a bed. Cambridge University Hospitals Foundation Trust’s emergency department came under severe pressure last week, with patients being bedded down in corridors and facing very long waits to be admitted to a ward. Senior sources told HSJ there were two cases where patients were waiting more than 60 hours last Monday, and the trust declared an internal incident. But the sources felt the trust should have escalated its alert level to “Opel 4”, which prompts calls for external support when trusts are under the most severe levels of operational pressure. This can include diverting ambulances to other hospitals. The trust apologised to patients who had been kept “waiting for a long time” but that the required threshold for Opel 4 had not been reached. Read full story (paywalled) Source: HSJ, 25 October 2022
  6. Content Article
    Charlotte Augst, chief executive of National Voices, challenges system leaders to think differently about what is needed to repair the NHS. As next year is likely to be the most difficult people ever had to live through, since NHS’s inception, she urges leaders to stand together
  7. Content Article
    While many physicians may avoid discussing the subject, a study showed that who gets addressed with the honorific “Dr.” may depend on gender, degree and specialty.
  8. News Article
    A medical expert has told the trial of nurse Lucy Letby how he noticed a "quite disturbing and quite unusual" pattern in the deaths of babies she is accused of murdering. Ms Letby is charged with killing seven babies and attempting to murder 10 others at the Countess of Chester Hospital in 2015 and 2016. Expert Dr Dewi Evans was approached by the National Crime Agency to review the case in 2017. Giving evidence at Manchester Crown Court, Dr Evans said: "The concern was that there had been a number of deaths in the Countess of Chester that had been unusual. "There were far more deaths than they would expect. There was collapses in babies that were otherwise quite stable, but in many of the cases resuscitation was not successful." It is alleged Ms Letby injected air into the bloodstream of a baby referred to in court as Child A, shortly after she came on shift in June 2015, just over 24 hours after his premature birth. The prosecution alleges she used the same method to attack his sister, Child B, on the following night shift. Dr Evans told the court that a review of Child A's records showed that the baby boy was in a "stable condition" before his collapse. He said: "He was as well as could be expected, all the markers of wellbeing were very satisfactory. Read full story Source: BBC News, 25 October 2022
  9. Content Article
    NHS England’s Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety.  A Patient Safety Specialist in the North East of England has shared their 'plan on a page’ with the hub to help others prepare for the implementation of PSIRF. You can download the attachment below. Further reading: Applying the After Action Review for the PSIRF – some real life examples
  10. Content Article
    Lucy is a world-leading authority on recovering from disaster. She has been at the centre of the most seismic events of the last few decades, advising on everything from the 2004 Boxing Day tsunami to the 7/7 bombings, the Christchurch earthquake in New Zealand, the Grenfell fire and the Covid-19 pandemic. In every catastrophe, Lucy is there to pick up the pieces and prepare for the next one. She holds governments to account, helps communities rally together, returns personal possessions to families, and holds the hands of the survivors.   In her moving memoir she reveals what happens in the aftermath and explores how we pick up and rebuild with strength and perseverance. She takes us behind the police tape to scenes of destruction and chaos, introducing us to victims and their families, but also to the government briefing rooms and bunkers, where confusion and stale biscuits can reign supreme. Telling her own personal story, Lucy looks back at a life spent on the edges of disaster, from a Liverpudlian childhood steeped in the Hillsborough tragedy to the many losses and loves of her career.
  11. Content Article
    This article* is an update from Dr Henrietta Hughes, Patient Safety Commissioner for England.
  12. Content Article
    On his last day in office at the Healthcare Safety Investigation Branch (HSIB), outgoing Chief Investigator Keith Conradi wrote to the Secretary of State for Health and Social Care reflecting on his time at HSIB. He outlined concerns about the approach of the Department of Health and Social Care (DHSC) and NHS England to patient safety work carried out by HSIB and the need to introduce a safety management system approach at all levels of healthcare. Patient Safety Learning also shared our thoughts on the issues raised in this letter and we were keen to explore these issues, and Keith’s experience as HSIB’s first Chief Investigator, in greater depth. Here, Patient Safety Learning provides an overview of the recent interview we had with Keith Conradi on this subject. The full transcript of the interview is available to download in the attachment at the end.
  13. News Article
    A Harley Street doctor suspended for working while testing positive for Covid at the height of the pandemic has said that his patient’s cancer treatment took priority. Dr Andrew Gaya was found to have “blatantly disregarded” the rules by going to work at a centre for patients with brain tumours after he tested positive for the disease. The “highly regarded” consultant oncologist “dishonestly” misled colleagues that he was safe to work by keeping his positive test secret, a tribunal found. Dr Gaya, whose work is at the forefront of tumour care and has been described as “world class”, said he defied Covid-19 rules because he believed “the risk of harm to his patient” in delaying treatment was “greater than the risk he posed”. Now, the doctor of 27 years has been suspended for three months at a Medical Practitioners’ Tribunal. Read full story (paywalled) Source: The Times, 20 Ocotober 2022
  14. Content Article
    The failure to consider the needs of diverse groups of people badly impacts experience of care. Sarah Sweeney, Head of Policy at National Voices points out how the NHS needs to change the way it communicates with people regarding care.
  15. Content Article
    Healthcare professionals share their experiences of Long Covid with the Guardian.
  16. Content Article
    Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are used to assess the quality of healthcare experiences, focusing on patients. These measures help healthcare providers, commissioners and other stakeholders to make informed changes to their services. Showing the benefits of your intervention to the patient and healthcare delivery is important if you aim to have your digital product or service embedded within the healthcare system. The Office for Health Improvement and Disparities has collated guidance on how to use a patient-reported outcomes and experiences study to evaluate your digital health product.
  17. Content Article
    On 13 January 2018, a group of healthcare simulationists from around the world gathered at a summit held in Los Angeles, California to collaborate on a unifying code of ethics for healthcare simulation professionals. There are six aspirational values that are described in the Code of Ethics: Integrity Transparency Mutual respect Professionalism Accountability Results orientation
  18. Event
    until
    Chaired by Patient Safety Learning's Helen Hughes, and sponsored by BD, an expert panel will discuss what measures are needed to achieve transformational change in the way infection is detected, monitored, prevented, and managed across the NHS, healthcare systems and broader society. The session will touch on how industry, professional bodies and healthcare experts can work collaboratively to support the creation of a healthcare system which is resilient and mature in dealing with disease outbreak and pandemic preparedness, infection prevention, and rapid treatment of time-critical infection, ultimately delivering antimicrobial stewardship (AMS) and improved sepsis outcomes. What attendees will learn: Understand the current challenges and barriers to effective infection prevention. What the future of infection prevention and management looks like in a post-COVID-19 world. Collaboration between all stakeholders – industry, government and PAGs – will be critical in delivering a holistic solution and pathway to robust infection management. Register
  19. Event
    until
    NHS England & Improvement has asked all Integrated Care Systems to extend, or introduce for the first time, the Virtual Ward model. The guidance starts a two-year funded transformation programme to support the development of Virtual Wards, including Hospital at Home. In this free webinar an expert panel will discuss how Virtual Wards can support elective recovery and improve patient flow during the critical Winter period. Our panel will also focus on the practicalities of setting up, rolling out and managing Virtual Wards across multiple treatments and care pathways. Headline discussion points: NHS winter pressures and tools to support delivery. Setting up, rolling out and managing Virtual Wards. Impact of Virtual Wards on the Healthcare system. Hospital at home & community based care models. What attendees will learn: What is a virtual ward and what needs to be in place to make virtual wards work. Innovation and initiatives that have been used previously to support delivery. How virtual wards can be rolled out across a system and new treatments/pathways introduced within a virtual ward. Register
  20. News Article
    Indonesia has temporarily banned all syrup-based and liquid cough medicines after the death of nearly 100 children from acute kidney failure since the start of this year. Most of those affected are said to be below the age of six. Muhammad Syahril Mansyur, the country’s health ministry spokesman, said: “Until today, we have received 206 reported cases from 20 provinces with 99 deaths.” He added: “As a precaution, the ministry has asked all health workers in health facilities not to prescribe liquid medicine or syrup temporarily … we also asked drug stores to temporarily stop non-prescription liquid medicine or syrup sales until the investigation is completed.” The ban, announced by the health ministry on Wednesday, applies to prescription and over-the-counter medicines. It comes after nearly 70 children died of acute kidney failure this year in the Gambia, linked to four brands of paracetamol cough syrup manufactured by India’s Maiden Pharmaceuticals. Read full story (paywalled) Source: The Times, 20 October 2022
  21. News Article
    The families of three patients who all died after undergoing the same specialised endoscopy procedure have accepted damages from an NHS trust. The patients all died after a procedure called an endoscopic retrograde cholangiopancreatography (ERCP) at Nottingham University Hospitals NHS Trust. Following their deaths, a coroner issued a report calling for changes. The trust said improvements had been made. William - known as Bill - Doleman, 76, Anita Burkey, 85, Peter Sellars, 72, and Carol Cole, 53, died in the space of about six months after undergoing the procedures. An inquest found they died as a result of complications of the ERCP - where a tube is passed through a patient's throat to examine and treat possible gallstones and other conditions. The families said they had accepted undisclosed damages from the trust over the deaths. Read full story Source: BBC News, 21 October 2022
  22. News Article
    Parents are being told to urgently bring their children forward for flu vaccinations as new data reveals the rate of hospitalisation and ICU admission for people with the virus is rising fastest among those under five years old. New figures published in the UK Health Security Agency’s (UKHSA) National flu and Covid-19 surveillance report show that cases of flu have climbed quickly in the past week, indicating that the season has begun earlier than normal. According to the UKHSA, vaccination for flu is currently behind last season for pre-schoolers (12.1% from 17.4% in all two-year-olds and 12.8% from 18.6% in all three-year-olds). It has also fallen behind in pregnant women (12.4% from 15.7%) and under 65s in a clinical risk group (18.2% from 20.7%). Dr Mary Ramsay, director of public health programmes at the UK Health Security Agency, said: “Our latest data shows early signs of the anticipated threat we expected to face from flu this season. “We’re urging parents in particular not to be caught out as rates of hospitalisations and ICU admissions are currently rising fastest in children under 5. “This will be a concern for many parents and carers of young children, and we urge them to take up the offer of vaccination for eligible children as soon as possible.” Read full story Source: The Independent, 20 October 2022
  23. News Article
    A quarter of services the Care Quality Commission has recently inspected required enforcement action from the regulator, its chief executive has revealed. Speaking at the launch of the regulator’s annual State of Care report, Ian Trenholm called for a “long-term, sustainable funding solution” from the government to aid a service that was ”genuinely struggling to cope”. Mr Trenholm said “about a quarter of the services” the CQC has inspected in 2022 had resulted in it having to take “enforcement action”. Examples of action taken against NHS trusts in the last year included enforcement measures placed on Nottingham University Hospitals, University Hospitals Sussex, and Princess Alexandra Hospital. In response to a question from HSJ about the robustness of the CQC’s inspection regime following further care quality and safety scandals, Mr Trenholm said observers should not focus solely on the ratings given to trusts by the CQC as there was a lot ”work going on in the background, whether that’s enforcement or otherwise”. He added the CQC had significantly increased the amount of information it was gathering in relation to concerns about services. Read full story Source: HSJ, 21 October 2022
  24. News Article
    The “social prescribing” of gardening, singing and art classes is a waste of NHS money, a study suggests. Experts found that sending patients to community activity groups had “little to no impact” on improving health or reducing demand on GP services. The research calls into question a major drive from the NHS and Department of Health to increase social prescribing as a solution to the shortage of doctors and medical staff. In 2019 the NHS set a target of referring 900,000 patients for such activities via their GP surgeries within five years. Projects receiving government funding include football to support mental health, art for dementia, community gardening and singing classes to help patients to recover from Covid. However, the study, published in the journal BMJ Open, said there was “scant evidence” to support the mass rollout of so-called “social prescribing link workers”. Read full story (paywalled) Source: The Times, 18 October 2022
  25. Content Article
    Social prescribing is a way of linking people with complex needs to non-medical supports in the community. There are different models of social prescribing, ranging from online signposting services to individual support from a link worker to access community resource. The aim of this study from Kiely et al. was to establish the evidence base for the effects on health outcomes and costs of social prescribing link workers (non-health or social care professionals who connect people to community resources) for people in community settings focusing on people experiencing multimorbidity and social deprivation. The study found that there is an absence of evidence for social prescribing link workers. Policymakers should note this and support evaluation of current programmes before mainstreaming.
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