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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    The Care Quality Commission has launched a review of leadership at an “outstanding”-rated specialist trust, after receiving multiple concerns from whistleblowers. The regulator is understood to have made an unannounced visit to The Christie Foundation Trust within the last week to inspect its medical services. The review will also cover the trust’s overall leadership. HSJ understands the review is, at least, partly in response to the regulator receiving a number of concerns from whistleblowers about the trust’s leadership culture and behaviour of senior staff. It comes after the trust came under scrutiny from NHS England last year, with independent reviews finding there had been multiple failings around the handling of a major research project. The reviews also criticised the trust’s reaction to staff who had raised concerns, but failed to answer a key accusation that was made about the detriment suffered by whistleblowers. Read full story (paywalled) Source: HSJ, 19 October 2022
  2. News Article
    NHS England has warned trusts that it is “essential” that elective procedures go ahead over winter, despite acknowledging hospital occupancy is running at an “all time high”. New winter planning guidance from NHS England, published today, says electives should go ahead “unless there are clear patient safety reasons for postponing activity,” and trusts considering cancelling significant levels of elective activity should escalate to their regional directors to mobilise mutual aid where possible. NHSE has said bed occupancy “continues to be at all-time highs” and encouraged systems to “take all opportunities” to maximise physical and virtual bed capacity, including the use of “previously mothballed beds”. Read full story (paywalled) Source: HSJ, 18 October 2022
  3. Content Article
    This report sets out the impact the Point of Care Foundation’s programmes have had on people who use and deliver health and care services, in its mission to humanise healthcare.
  4. Event
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    This winter the Patients Association is bringing patients, carers and healthcare professionals together to talk about patient partnership. It will look at some great examples of shared decision making, take a look at how the new Integrated Care Systems in England are working with patients and local communities, and we’ll showcase some of the great work we’ve done with our partners that has given patients and carers the opportunity to engage with the health and social care system. Special guest: As part of the week, Dr Henrietta Hughes, Patient Safety Commissioner for England, will be in conversation with our Chief Executive, Rachel Power on Wednesday November 30th. Webinars All the events, including the event with Dr Hughes will be held on Zoom. Here are the details if you’d like to save any of the dates. Registration some of the events are open now and the others, soon. Shared decision making – examples of great practice Monday November 28th 8am – 8.55am Aimee Robson, Deputy Director, Personalised Care, NHS England, & Duvie Dafinone, Patient and Public Voice Partner, on decision support tools launched this summer to support shared decision making. Dr Sam Finnikin, GP, Sutton Coldfield and clinical research fellow, University of Birmingham, on Our Health – Our Knowledge, a new resource designed to help people who are thinking about choices in healthcare. Registration has opened on Eventbrite for this event. Rachel Power in conversation with Dr Henrietta Hughes, Patient Safety Commissioner England Wednesday November 30th 9am – 10:00am Registration has opened on Eventbrite for this event. Partnering with patients and communities – what’s happening in ICSs Wednesday November 30th 12.30pm – 2:00pm Patients and industry working together – stories from our projects Thursday December 2nd 8am – 8.55am Register
  5. Event
    This national conference looks at the practicalities of serious incident investigation and learning from deaths in mental health services. The event will look at the development and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) which was published on 16 August 2022. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement, and updates from PSIRF early adopter sites in mental health. The conference will also examine how the new framework will fit with the Royal College of Psychiatrists Care Review Tool for mortality review. Register
  6. News Article
    Trusts need hundreds of millions of pounds to remediate dangerous roofs. A series of freedom of information requests submitted by New Civil Engineer has revealed five of the worst affected trusts have applied for £331.9m of additional funding to be spent on fixing reinforced autoclaved aerated concrete planks during the next three years. In response to NCE’s freedom of information investigation, Liberal Democrat deputy leader and health spokesperson Daisy Cooper said “patients are paying the price for years of neglect” by successive governments. “It is truly shocking that patients are being treated in crumbling buildings that could be at risk of collapse. The NHS is crying out for the funds to fix creaking roofs so that patients can be treated safely. The public needs to know that the funds to fix this are on the way as soon as possible.” Read full story Source: HSJ, 17 October 2022
  7. News Article
    A woman says she was forced to pay around £25,000 for private healthcare to treat endometriosis after her symptoms were “overlooked” for eight years. Aneka Hindocha, 34, started voicing her concerns about painful periods when she was aged 25 but says she was initially told by doctors this was normal. Ms Hindocha, who described the pain of endometriosis as “someone ripping your insides out”, says the condition should have been diagnosed sooner but argued women’s pain often gets overlooked and ignored. Endometriosis is a very common chronic inflammatory condition, impacting an estimated 1.5 million women in the UK. An inquiry by the All-Party Political Group found that like Ms Hindocha, it takes an average of eight years to get a diagnosis. The condition sees tissue comparable to womb-lining grow in other places in the body - with symptoms often debilitating and spanning from infertility to painful periods, tiredness, pain while having sex, as well as depression and anxiety. “I was told painful periods were normal, which they are not, but I believed that at the time,” Ms Hindocha told The Independent. “I thought the issue was me. I thought I was being a hypochondriac.” Her health massively deteriorated in the summer of 2020 and she became bedbound for three days. “I needed someone to find out what was wrong with me,“ Ms Hindocha added. “I was crying I was in so much pain.” She says that two years later she still had not received her laparoscopy despite the fact her pain was getting more severe and so she ended up paying for a private scan. She finally got diagnosed with stage 4 endometriosis a week later. “By the time of having my surgery at the end of February 2022, it had been nearly two years on the NHS waiting list and I was still being told to wait.” Read full story Source: The Independent, 18 October 2022
  8. News Article
    Thousands of doctors are being prevented from working in overstretched GP surgeries across the UK because of unnecessary “red tape”, leaving NHS patients experiencing “unprecedented” waits for care, the head of the doctors’ regulator in the UK has said. Charlie Massey, the chief executive of the General Medical Council, said barriers that stopped medics from being deployed to meet areas of high demand, such as in primary care, must be removed urgently if the NHS workforce crisis was to be resolved and access to care improved. “Red tape is stopping the UK from making the most of many of its skilled and experienced doctors,” he said. “Without action, patients will suffer.” The regulator will on Tuesday call for a relaxation of rules so the fastest-growing part of the medical workforce – skilled doctors in non-training roles – can undertake a wider range of work beyond hospitals, such as in GP surgeries. “There are no easy answers to the challenges facing the NHS. There is no army of new doctors coming over the horizon, so part of the solution must be to make sure that we have more doctors in the places that patients need them,” Massey said. “The government should make a start immediately by changing the performers list criteria so more doctors are allowed to work alongside GPs. That needs to be done urgently. “But beyond technical changes there is also a need for fresh thinking in the way our health services are structured and in how teams of health professionals work together. We can’t keep doing things the same way they have always been done, or nothing will change." Read full story Source: BBC News, 18 October 2022
  9. News Article
    Doctors have criticised new health secretary Therese Coffey over reports that pharmacists will be allowed to prescribe antibiotics without the approval of a doctor. According to The Times, Ms Coffey’s “Plan for Patients” will give pharmacists the power to prescribe certain drugs, such as contraception, without a prescription in an effort to reduce the need for GP appointments and tackle waiting lists. Responding to reports of the plans, Rachel Clarke, an NHS palliative care doctor and writer, wrote on Twitter: “This is staggeringly irresponsible of Therese Coffey and will cause so much more harm than good. “Doctors do not – unlike Coffey – dish out spare antibiotics to our family and friends because we’re painfully aware of the harms of antibiotic resistance. Utter recklessness.” Stephen Baker, a professor at Cambridge University and an expert in molecular microbiology and antimicrobial resistance, branded the health secretary’s plans “moronic”. He told the newspaper that the more antibiotics were used “the more likely we are to get drug-resistant organisms”. He added that it was “nuts” to consider widening access to drugs, adding that resistance against antibiotics is “clearly one of the biggest problems humanity is facing in respect of infectious disease at the moment”. Read full story Source: The Independent, 17 October 2022
  10. News Article
    Imtiaz Fazil has been pregnant 24 times, but she only has two living children. She first fell pregnant in 1999 and, over the subsequent 23 years, has had 17 miscarriages and five babies die before their first birthdays due to a rare genetic condition. The 49-year-old, from Levenshulme in Manchester, told BBC North West Tonight her losses were not easy to talk about, but she was determined to do so, in part because such things remained a taboo subject among South Asian groups. She said she wanted to change that and break down the stigma surrounding baby loss. She said her own family "don't talk to me very much about the things" as they think "I might get hurt [by] bringing up memories". "It's too much sadness; that's why nobody approaches these sort of things," she said. Sarina Kaur Dosanjh and her husband Vik also have the hope of breaking the silence surrounding baby loss. The 29-year-olds, from Walsall in the West Midlands, have set up the Himmat Collective, a charity which offers a virtual space for South Asian women and men to share their experiences. The couple, who have had two miscarriages in the past two years, said the heartache was still not something that people easily speak about. "I think it's hidden," Sarina said. "It's really brushed under the carpet." Read full story Source: BBC News, 13 October 2022
  11. Content Article
    People who provide care unpaid for a family member or a friend due to illness, disability, or mental health provide a vital role bridging gaps in state-funded support. But despite the laudable policy statements in support of carers, this Nuffield Trust report looking at the policy history and latest data shows that the reality for unpaid carers has been one of diminishing help over time.
  12. News Article
    New patient data shows significant regional differences in the effectiveness of primary care in getting cancer sufferers diagnosed – with an even more alarming picture when the data is broken down by ethnicity. A survey of cancer patients asked how many times they had “spoken to a healthcare professional at [their] GP practice about health problems caused by cancer” before they were diagnosed, with a range between one and more than five times. The overall figure for five times or more in England was 7% – but all four cancer alliances in London scored significantly above this. Cancer Research UK said this could reflect the greater concentration of ethnic minority patients in the capital, and the data bore this out. Nationally, 6.6% of white cancer patients had seen five or more primary care staff before getting a diagnosis. This compared to 11.7% for Asian cancer patients and 12.9% for Black cancer patients. Read full story (paywalled) Source: HSJ, 18 October 2022
  13. News Article
    The grandfather of a baby who died at a hospital that was fined over failings in the delivery has spoken of his five-year fight for justice. Derek Richford was speaking as an independent report into baby deaths at the East Kent Hospitals Trust will be released this week. He said he "came up against a brick wall" while searching for answers over the death of grandson Harry Richford. An inquest into Harry's death at Margate's Queen Elizabeth the Queen Mother Hospital in 2017 found it was wholly avoidable and contributed to by neglect. Coroner Christopher Sutton-Mattocks said the inquest, which was finally held in 2020, was only ordered due to the family's persistence. The following year the trust was fined £733,000 after admitting failing to provide safe care and treatment for mother Sarah Richford and her son following a prosecution by the Care Quality Commission (CQC). Mr Richford said: "To start with we felt fairly alone and we felt like we were coming up against a brick wall. "The trust were refusing at that time to call the coroner. They were reporting Harry's death as 'expected'. "We didn't contact anyone other than the CQC just to say 'look there's been a problem here'." He said at a meeting with the trust, more than five months later, "we suddenly realised that there were a huge [number] of errors". Mr Richford told the BBC: "It took me about a year to come up with all the detail I needed and to speak to all the right people." He said the family then spoke to the Health Safety Investigation Branch who found there were issues. Mr Richford also tracked down a "damming" report by the Royal College of Obstetricians and Gynaecologists (RCOG). "In the end it was like peeling back the layers of an onion, and the more you took off, the more you found," he said. Read full story Source: BBC News, 18 October 2022
  14. Content Article
    The coronavirus pandemic had an unparalleled impact on NHS services and on the people who use them. In August 2022, the Parliamentary and Health Service Ombudsman (PHSO) carried out research to better understand what impact the pandemic had on public attitudes towards complaining about the NHS. They also asked respondents about: their attitudes to complaining about the NHS currently and during the pandemic how satisfied they were with the NHS organisations they used or had contact with during the pandemic. The results have now been published.
  15. News Article
    Mental health professionals have unveiled a "toolkit" to help school nurses support pupils with eating disorders. Bath-based campaigner Hope Virgo developed the strategy with the School and Public Health Nurses Association (Saphna) after a rise in cases. The toolkit aims to equip school nurses with techniques to discuss eating disorders, and also "what not to say". Ms Virgo has called on the government to deal with the backlog those waiting for treatment, which totalled 1,946 at the beginning of March, data from eating disorder charity Beat shows. Sharon White, Saphna's chair, said the organisation had been promoting the toolkit among its members. "We can't solve the huge waiting lists and reduced services, but what we can do is inform ourselves better," she said. The toolkit provides "the hints, the tips, the language, the stock phrases, and importantly, what not to say", Ms White added. The Department of Health and Social Care has been supportive of the scheme, Ms White said, adding it may adopt it as part of its own guidance in future. Read full story Source: BBC News, 17 October 2022 Read a recent blog Hope Virgo wrote for the hub: People with eating disorders should not face stigma in the health system and barriers to accessing support in 2022
  16. News Article
    Angry exchanges between paramedics and A&E staff in Liverpool have broken out after new measures were deployed to hold and treat patients in the back of ambulances. Sources said there have been “Mexican standoff” situations at Aintree Hospital in recent days, after hospital staff insisted patients who had been brought inside should be returned to ambulance vehicles. Staff at North West Ambulance Service told HSJ they were informed of a new protocol last week, which said patients should be kept in the back of ambulances if the corridor of the emergency department is full with patients. There have been repeated orders from NHS England and the Care Quality Commission over the past year for hospitals to ensure patients can be offloaded by ambulance crews, even if they fear they do not have adequate staffing or beds to accept them. One senior source at NWAS said: “To see a new protocol like this is absolutely unprecedented. I very much doubt the execs had approved it. “We’ve had Mexican standoff situations over the weekend with crews who have brought patients into ED being told to take them back out to their vehicles, but they’ve refused to do this as it means they cannot cohort. “We completely accept that taking extra patients means the ED and hospital staff have to deal with additional and unacceptable risk, but holding ambulances is not the solution because the risks to patients out in the community are even greater. Despite repeated instructions from NHS England and the CQC this still doesn’t seem to be understood.” Read full story (paywalled) Source: HSJ, 17 October 2022
  17. News Article
    Jeremy Hunt believes spending on the NHS will have to rise and that the increase should be funded through higher taxation. Mr Hunt was speaking at an event less than 48 hours before the prime minister asked him to replace Kwasi Kwarteng as chancellor. In a discussion last Wednesday evening with HSJ editor Alastair McLellan and the audience at an event held as part of the Shoreham Literary Festival event, Mr Hunt also rejected the introduction of a social insurance model to fund the NHS and re-iterated the pressing need for the NHS to have a long-term workforce plan. Asked by HSJ if the voices in the Conservative Party calling for a change from the NHS to a social insurance model had gained ascendancy, Mr Hunt said: “The game is not up for the NHS – absolutely not. “We are all going to spend more on our health and care – if you’re in America you’re going to spend more through your insurance premiums – which are going to go up. If you’re in Holland and Germany you’re going to spend more through social insurance premiums. If you’re in Britain, Ireland or New Zealand you’re going to spend more through your taxes.” Read full story (paywalled) Source: HSJ, 17 October 2022
  18. Event
    The Convenzis Integrated Care Summit provides a secure and high-value platform for NHS Managers and leaders to meet, share practical insights, and listen to some of the sector's most reputable and thought-provoking experts. In support of the NHS, registration is complimentary and CPD accredited. NHS England explains that ICSs are partnerships of health and care organisations that come together to plan and deliver joined-up services, and to improve the health, of people who live and work in their area. Integrated care is about giving people the support they need, joining up across local councils, the NHS, and other partners. It removes traditional divisions between hospitals and family doctors, between physical and mental health, and between NHS and council services. ICSs (integrated care systems) are seen by NHS leaders as the future of health and care integration in England. The NHS Long Term Plan, and now the Government’s white paper on health and care reform, both place ICSs at the heart of the NHS. This upcoming event will provide NHS healthcare leaders from across primary, social and secondary care sectors with a secure and high-value platform to discuss the key challenges and benefits of the integrated care strategy. This event will showcase some examples of best practices from teams across the NHS and provide you with a platform to meet and engage with 5 commercial sectors thought leaders as they share innovative services and solutions with delegates across the day. Register
  19. News Article
    In 2018 the British Association of Aesthetic Plastic Surgeons (www.baaps.org.uk) dissuaded all its members from performing Brazilian Buttock Lift (BBL) surgery, until more data could be collated. The decision was taken due to the high death rate associated with the procedure. Now, following an extensive four-year review of clinical data, new technology and techniques, BAAPS has published its Gluteal Fat Grafting (GFG) guidelines. Gluteal fat grafting is currently the procedure with the biggest growth rate in plastic surgery worldwide, with an increase of around 20% year-on-year). It has become the most popular means of buttock volume augmentation, overtaking gluteal augmentation with implants. In 2020, The Aesthetic Society statistics recorded 40,320 buttock augmentation procedures, which included both fat grafting and buttock implants. In 2015, there were reports of intraoperative mortality related to pulmonary fat emboli associated with BBL surgery and in 2018 with growing concern about the high mortality rate associated with this procedure BAAPS recommended it was not performed by its members. The development of the present guidelines and recommendations has been stimulated by the evidence that has emerged since 2018, based on scientific review and analysis. BAAPS guidelines now recommend that Gluteal Fat Grafting is safe to perform under two key conditions: Injection into the subcutaneous plane only - there is a plethora of evidence to suggest this significantly reduces mortality related to the procedure perhaps this needs to be changed to – the evidence shows that the only deaths from the procedure have been when fat has been injected into the deeper muscle layer. Intraoperative ultrasound must be used during the placement of fat in the gluteal area to ensure that the cannula remains in the subcutaneous plane – this is the only way that surgeons can be confident they are not in the muscle layer. Read full story Source: BAAPS, 17 October 2022
  20. Content Article
    The aim of community diagnostic centres (CDCs) is to deliver additional diagnostic capacity in England by providing quicker and more convenient access for patients and reducing pressure on hospitals.  The vision is for CDCs to be ‘one-stop shops for checks, scans and tests’, designed to achieve early diagnoses for patients and timely treatment and intervention, and are part of the offer of more place-based, person-centred approaches to care, removing some of the known barriers to access. But are CDCs living up to their promise?
  21. Event
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    The free, one-day, virtual conference will explore the themes and issues arising from the report recently published by the Authority, Safer care for all – solutions from professional regulation and beyond. It will be an opportunity to hear a range of views, debates and discussions about some of the issues in the report with the aim of moving towards solutions to support safer care for all. Safer care for all – solutions from professional regulation and beyond is the Authority’s contribution to the debate on some of the key patient and service user safety challenges within health and social care, drawing on insights from our role overseeing the ten health and care professional regulators and the Accredited Registers programme. Topics that we focus on within the report include: tackling inequalities regulating for new risks facing up to the workforce crisis accountability, fear and public safety. Register
  22. News Article
    Time is running out for hundreds of thousands of vulnerable people who are facing another winter shielding from Covid, campaigners have said. They are calling on the government to buy a drug called Evusheld to provide some protection against the virus. The government says it is not clear how long that protection will last when up against the Omicron variant. But patients, charities and health experts argue the protection offered is better than nothing. There are around 500,000 people in the UK with suppressed immune systems. That means their bodies struggle to produce antibodies, so the existing vaccines offer them little or no protection, leaving them very vulnerable to Covid. Blanche Hampton has lupus, a condition where her immune system has turned against her. The drugs she takes to control the lupus also suppress her immune system, meaning her body has no defences against Covid. Blanche has been shielding for two and a half years, but she believes Evusheld offers a chance for at least some kind of existence outside of her small flat in Inverkip, west of Glasgow. "Evusheld would give me a layer of protection, that is better than nothing. Because that's what I have currently - nothing." And Blanche, like many people who find themselves in the same situation, says she feels abandoned. Read full story Source: BBC News, 17 October 2022
  23. News Article
    NHS England has "never shown so much support" to stop children dying without explanation, a charity which works to prevent unexplained deaths has said. Sudden unexplained death in childhood (SUDC) is a rare category of death in which the cause remains unknown even after thorough investigation. Currently there is very little awareness or research into its causes. NHS England has said it will now begin a series of measures to change this, a move welcomed by the charity SUDC UK, including: Piloting systems to improve education of health professionals and gather data to help identify modifiable factors which will go on to establish processes to help manage the deterioration of children. Improve information given to families and professionals about SUDC. Separately, data from every child whose death has been put down as SUDC since 2019 will being reviewed by the National Child Mortality Database. Dr Nikki Speed, from the charity SUDC UK, described the plans as revolutionary. "This is such positive historic progress, a landmark moment. Never has the NHS shown such support to stop sudden unexplained death in childhood," she said. "Never has there been such a clear statement to review public information on SUDC, optimise data collection and learn how we could prevent future tragedies. "We finally have confidence that things will progress in our fight to stop SUDC." Read full story Source: BBC News, 15 October 2022
  24. News Article
    Staff at accident and emergency departments across Scotland have expressed “deep concern” at the daily “excessively long waiting times” that are forcing a record number of patients to wait more than 12 hours, according to a leading NHS consultant. Dr John-Paul Loughrey, vice-chair of the Royal College of Emergency Medicine Scotland national board, warned that while such long waits were once regarded as “never events,” they are now daily occurrences. Amid fears the delays will spike significantly over the winter months, especially with another wave of Covid-19 expected, Dr Loughrey said staff were already “burned out,” “exhausted,” and “overwhelmed with a system facing increasing strain.” The latest weekly data on A&E treatment shows that in the week ending 2 October, the number of patients waiting more than 12 hours had soared by 45% week-on-week. “There is deep concern among staff around the excessively long waiting times,” Dr Loughrey said. “The weekly data that show significant increases in long waits translates to real patients on the ground or in the community who are seeking urgent and emergency care. “The system is failing them. We know that long waiting times are associated with patient harm and even death. Staff face moral injury daily, but they are working incredibly hard and doing all they can to minimise this harm to patients.” Read full story Source: The Scotsman, 16 October 2022
  25. News Article
    Peter Duffy warned that there is a growing risk of electronic patient records and NHS staff communications being exposed to tampering efforts in disputes with managers and executives. The surgeon, who now practices on the Isle of Man, made the comments during talks given in September – to the Association for Perioperative Practice (AfPP) and at the Royal College of Surgeons Ireland (RCSI) in Dublin. He told audiences that “there is increasing potential for electronic tampering” of NHS IT records, holding serious implications for patient safety reporting and disputes with government and health service bodies. The consultant medic, who says he was driven out of UHMBT in 2016 after blowing the whistle on dangerous practices and uninvestigated cases of harm within the trust’s urology services, won a constructive dismissal claim against his ex-employer in 2018. Duffy now alleges that emails concerning the care of a patient at the centre of his whistleblowing were forged and backdated by senior UHMBT staff, several years after his employment claim against the trust had ended. The emails were not disclosed during the tribunal – despite a court order having been issued to release all communications concerning the care of the patient in question, the late Peter Read, who died in early 2015 – and are understood to have surfaced during the course of an external review into UHMBT’s urology services carried out between late 2019 and 2021. Niche Consult, a private firm commissioned by NHS England/Improvement (NHSE/I) to investigate Duffy’s patient safety disclosures alongside broader concerns regarding the trust’s urology department, determined that the emails in question were not fakes. Duffy told the AfPP and RCSI audiences that, during the Niche review of UHMBT’s urology services in 2020, he was “abruptly told that two entirely new, never-seen-before emails had suddenly, unexpectedly appeared”. The emails appear to partly implicate him in the series of clinical errors and missed care opportunities that contributed to Read’s death. Duffy described the allegedly falsified emails as being part of “an executive vendetta” waged against him in retaliation for his whistleblowing activity and negative publicity surrounding it, as UHMBT was seeking to cultivate the image of a “turnaround” trust in the years following a major maternity scandal between 2004 and 2013. Read full story Source: Computer Weekly, 28 September 2022
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