Jump to content
 View Profile  See their activity

  • Posts

    11,589

  • Joined

  • Last visited

Patient Safety Learning

Administrators

 Content Type 

News posted by Patient Safety Learning

  1. Patient Safety Learning
    Do-not-resuscitate orders were wrongly allocated to some care home residents during the COVID-19 pandemic, causing potentially avoidable deaths, the first phase of a review by England’s Care Quality Commission (CQC) has found.
    The regulator warned that some of the “inappropriate” do not attempt cardiopulmonary resuscitation (DNACPR) notices applied in the spring may still be in place and called on all care providers to check with the person concerned that they consent.
    The review was prompted by concerns about the blanket application of the orders in care homes in the early part of the pandemic, amid then prevalent fears that NHS hospitals would be overwhelmed.
    The CQC received 40 submissions from the public, mostly about DNACPR orders that had been put in place without consulting with the person or their family. These included reports of all the residents of one care home being given a DNACPR notice, and of the notices routinely being applied to anyone infected with Covid.
    Some people reported that they did not even know a DNACPR order had been placed on their relative until they were quite unwell.
    “There is evidence of unacceptable and inappropriate DNACPRs being made at the start of the pandemic,” the interim report found, adding that the practice may have caused “potentially avoidable death”.
    Read full story
    Source: The Guardian, 3 December 2020
  2. Patient Safety Learning
    Trusts have been urged to reflect on their disciplinary procedures, and review them annually where required, following the death of a senior nurse who took his own life after being dismissed.
    NHS England’s chief people officer Prerana Issar has written to trust leaders to highlight Imperial College Healthcare Trust’s new disciplinary procedures, which were put in place following Amin Abdullah’s suicide.
    Mr Abdullah, a senior nurse at Charing Cross Hospital in west London, was suspended in September 2015 before being let go from his job that December. He died in February 2016 after setting himself on fire.
    An independent investigation criticised both the trust and its staff and concluded he had been “treated unfairly”. The summary report produced by the trust was labelled a “whitewash”, which “served to reassure the trust that it had handled the case with due care and attention”, and the delay of three months between the events and hearing were “troubling”.
    The report, which also criticised the delays as “excessive” and “weak” in their justification, said Mr Abdullah found the delay “stressful” and caused him to become “distressed”.
    In the letter sent on Tuesday, seen by HSJ, Ms Issar said: “The shared learning from Amin’s experience has demonstrated the need for us to work continuously and collaboratively, to ensure that our people practices are inclusive, compassionate and person-centred, with an overriding objective as to the safety and wellbeing of our people… our collective goal is to ensure we enable a fair and compassionate culture in our NHS. I urge you to honestly reflect on your organisation’s disciplinary procedure…"
    Read full story (paywalled)
    Source: HSJ, 3 December 2020
  3. Patient Safety Learning
    Care homes will not receive the first batches of the Covid vaccine in Scotland because of problems transporting small doses around the country.
    The health secretary has said about 65,500 doses of the Pfizer vaccine will arrive in Scotland by next Tuesday. They will initially be stored in freezers in packs of 997 doses.
    The first people to receive the jab may have to travel to where the doses are being held.
    Health Secretary Jeane Freeman said that means care homes would have to wait until the issue of breaking down the vaccines packs into smaller doses is resolved.
    She told the BBC's Good Morning Scotland programme: "The doses come to us in packs of 997 and we need to know to what degree we can pack that down into smaller pack sizes. If we can't, then we absolutely need to bring those who need to be vaccinated to those freezers - to the centres - because there is a limit to how much you can transport the doses once you have defrosted them."
    "We don't want to waste any of this vaccine so it's not possible at this point to take it in smaller doses into, for example, care homes."
    Read full story
    Source: BBC News, 3 December 2020
  4. Patient Safety Learning
    Emergency medics are writing to hospital chief executives warning them that some trusts are being ‘complacent’ about crowding in A&E, they have told HSJ.
    The Royal College of Emergency Medicine (RCEM) is sending a letter to trust chiefs today calling on them to urgently plan for how they will stop corridor waits and exit blocking ahead of January and February, typically the busiest months. It says some trusts were not treating emergency department crowding as a “high priority”, despite covid risks and pressures.
    It is also calling for overcrowding in the emergency department (ED) to be classed as a “never event” — a set of major safety risks.
    RCEM’s concern comes amid apprehension over long ambulance queues at hospitals across the UK, and difficulties enabling social distancing between patients in many EDs.
    Read full story (paywalled)
    Source: HSJ, 3 November 2020
  5. Patient Safety Learning
    Niamh McKenna, Chief Information Officer at NHS Resolution, hosted the recent digital focussed event, ‘2020: A Catalyst for Rapid NHS Digital Transformation’. Panellists from NHS England & Improvement, Health Education England, and Microsoft, looked to dissect the rapid acceleration of digitalisation in our NHS over the last twelve months, and what this means for our sector and our workforce.
    The two hour event hosted over 100 attendees and live-streamed on YouTube, allowing delegates to hear about the key considerations for the impact of a new digital-first way of working.
    Looking at the good and the bad from the last twelve months, the panellists shared insight into digital-first training, technology fatigue on the workforce, revolutionary digital approaches from case studies on COVID-19 wards, and much more.
    One important topic associated with digital is the role of learning for our NHS workforce, and Henrietta Mbeah-Bankas, Head of Blended Learning and Digital Literacy at Health Education England, raised some interesting opportunities, challenges, and considerations around digital learning for the workforce:
    “Properly defining digital literacy is one of the first vital steps for a digital transformation strategy to succeed, we can’t continue to make assumptions like ‘Millennials are digital-natives’."
    “There are three groups we need to consider to properly develop an inclusive digital transformation strategy that will be effective – the digitally engaged, digitally ambivalent, and those that say, ‘I don’t do tech’. For me there’s also a fourth group, those who are actually digitally excluded. Until you understand the barriers these people have and consider how they’ll approach digital solutions, you can’t begin to create an inclusive digital strategy that will ensure everyone comes on the journey with you."
    Niamh's key take-away from the event was that we need to make sure we continue to embrace rapid digital transformation, use it as a catalyst to get stuff done, improve work, improve lives, and improve patient care. We must use all this data available to us to understand the good and the not so good outcomes from the pandemic to shape initiatives for our new future.
    A recording of this event is now available to watch on demand here, along with downloadable supportive resources shared by the panellists.
    Read full story
    Source: Health Tech Newspaper, 30 November 2020
  6. Patient Safety Learning
    The UK has become the first country in the world to approve the Pfizer/BioNTech coronavirus vaccine for widespread use.
    British regulator, the MHRA, says the jab, which offers up to 95% protection against COVID-19 illness, is safe for rollout next week. Immunisations could start within days for those who need it the most, such as elderly, vulnerable patients.
    The UK has already ordered 40m doses - enough to vaccinate 20m people.
    Around 10m doses should be available soon, with the first 800,000 arriving in the UK in the coming days.
    It is the fastest ever vaccine to go from concept to reality, taking only 10 months to follow the same developmental steps that normally span a decade.
    Prime Minister Boris Johnson tweeted "It's the protection of vaccines that will ultimately allow us to reclaim our lives and get the economy moving again."
    Health Secretary Matt Hancock told BBC Breakfast that people will be contacted by the NHS when it is their turn for the jab.
    Read full story
    Source: BBC News, 1 December 2020
  7. Patient Safety Learning
    Trusts are carrying out harm reviews after a ‘contamination issue’ affecting hundreds of samples resulted in some staff and patients being wrongly told they had coronavirus, HSJ can reveal.
    The error happened in mid-October and involved swabs from five trusts in the South East region, which were being processed by the NHS-run Berkshire and Surrey Pathology Services.
    HSJ understands it is thought that around 100 people across several trusts were given false positive results, and subsequently tested negative.
    The trusts involved are the Royal Surrey Foundation Trust, Frimley Health Foundation Trust, Royal Berkshire Foundation Trust, Ashford and St Peter’s Hospitals Foundation Trust and Berkshire Healthcare Foundation Trust.
    Frimley has completed a clinical review and found no harm had been caused, while Royal Berkshire, Ashford and St Peter’s and the Royal Surrey have reviews ongoing. The position for Berkshire Healthcare, a mental health trust, is not known.
    Read full story (paywalled)
    Source: HSJ, 2 December 2020
  8. Patient Safety Learning
    The Care Quality Commission (CQC) has raised serious concerns about a major teaching trust’s maternity services and taken action to prevent patients coming to harm.
    The watchdog has imposed conditions on the registration of Nottingham University Hospitals Trust’s maternity and midwifery services at Nottingham City Hospital and Queen’s Medical Centre and rated them “inadequate”. 
    Following an inspection in October, the CQC identified several serious concerns, including leaders lacking the skills to effectively head up the service, a lack of an open culture where staff could raise concerns, and staff failing to complete patient risk assessments or identify women at risk of deterioration. 
    In its findings, the CQC reported how “fragile” staff wanted to escalate their concerns directly to the regulator, particularly around the leadership’s response to the “verbal outcome of the inspection”. The regulator called this “further evidence of the deep-rooted cultural problems” and escalated these concerns directly to trust CEO Tracy Taylor, who would be “personally overseeing the improvement process required”.
    Inspectors also found the service did not have enough staff with the right skills, qualifications and experience to “keep women safe from avoidable harm”.
    The CQC also issued the trust a warning notice over concerns around documenting risk assessments and IT systems. The trust has three months to make improvements. 
    Read full story (paywalled)
    Source: HSJ, 2 December 2020
  9. Patient Safety Learning
    People with learning disabilities have been "at the back of the queue" during the coronavirus pandemic, a panel of MPs has been told.
    Those living in supported accommodation were left waiting weeks for guidance on testing and visits.
    MPs were also told long-term social factors were likely to be more important than biology when it came to ethnic divides in the virus's impact.
    The panel focused on what lessons could be learned.
    Read full story
    Source: BBC News, 1 December 2020
  10. Patient Safety Learning
    Cancer screening programmes designed to save hundreds of lives have been delayed by up to a year as services struggle with staff and equipment shortages, HSJ can reveal.
    Of the 14 Lung Health Check Programme sites announced last year, four — or just under a third — have either halted programmes they had started or delayed beginning them, with some now expected not to be operational until after March.
    The areas chosen for the scheme activities, which often involved mobile computed tomography units in vans, have high rates of late diagnosis lung cancer. A study published in the New England Journal of Medicine in February showed CT scanning of high risk groups led to a 26% reduction in deaths in men and between a 39 and 61% reduction in women.
    NHS England confirmed “activity had resumed” in nine areas while one has started this month, meaning four areas remain out of action. The organisation declined to answer HSJ’s questions on which services were not running and why. 
    Read full story (paywalled)
    Source: HSJ, 1 December 2020
  11. Patient Safety Learning
    The NIHR-supported PRINCIPLE trial is to start investigating the inhaled corticosteroid budesonide to find out if it can help treat COVID-19 in patients who aren’t in hospital. 
    Led by the University of Oxford, the PRINCIPLE is the UK’s national platform trial for COVID-19 treatments that can be taken at home. It is evaluating treatments that can help people aged over 50 recover quickly from COVID-19 illness and prevent the need for hospital admission. The study, funded by NIHR and UK Research and Innovation (UKRI) has so far recruited more than 2100 volunteers from across the UK with support from NIHR’s Clinical Research Network.
    Inhaled budesonide is often used to treat asthma and chronic obstructive pulmonary disease, with no serious side-effects associated with short-term use.
    In some patients with COVID-19, the body’s immune response to the virus can cause high levels of inflammation that can damage cells in the airways and lungs. Inhaling budesonide into the airways targets anti-inflammatory treatment where it is needed most, and can potentially minimise any lung damage that might otherwise be caused by the virus.
    Patients taking part in the study will be randomly assigned to receive an inhaler in the post, alongside the usual care from their clinician. They will be asked to inhale two puffs twice a day for 14 days with each puff providing a 400 microgram dose of budesonide. They will be followed up for 28 days and will be compared with participants who have been assigned to receive the usual standard-of-care only.
    Read full story
    Source: National Institute for Health Research, 27 November 2020
  12. Patient Safety Learning
    Regulators have apologised to a health manager who went through “five years of hell” while being investigated for misconduct, before being told there was no case to answer.
    Debbie Moore was a senior manager at the former Liverpool Community Health Trust, where there was a major care scandal in the early 2010s.
    As head of healthcare at HMP Liverpool, where many of the most serious failings were identified, Ms Moore was suspended in 2014 and referred to the Nursing and Midwifery Council. She was accused of multiple failures to take action or escalate concerns, of failing to investigate deaths, and discouraging staff from reporting incidents. 
    However, in a first public interview about her experience, she told HSJ she was “scapegoated” for the problems at the prison, where she says she worked tirelessly to address the issues and had repeatedly flagged concerns to the LCH management team.
    External inquiries have found the trust would routinely downgrade risks escalated by divisional managers, as it sought to make drastic cost savings in pursuit of foundation trust status.
    Read full story (paywalled)
    Source: HSJ, 30 November 2020
  13. Patient Safety Learning
    Eleven patients have suffered harm after being kept waiting in ambulances outside accident and emergency departments, a review has found. 
    South East Coast Ambulance (SECamb) Service Foundation Trust launched the review after a specific incident at Medway Foundation Trust on Monday 16 November. Although details of the incident have not been released, HSJ has been told one patient waited for nine hours before being seen in the trust’s A&E department that day.
    The review covered all long waits across SECAmb’s area over the last few weeks. Out of 120 cases examined, 11 patients were found to have suffered some degree of harm, SECAmb’s executive director of nursing and quality Bethan Eaton-Haskins told Kent’s health overview and scrutiny committee last week. However, the trust has not revealed which hospitals were involved. 
    Ms Eaton-Haskins said the ambulance trust was “struggling significantly” with handovers and expecting the recent pressure experienced at Medway FT to affect the county’s other hospitals soon. However, she indicated some other trusts in Surrey and Sussex had also had long delays.
    Ambulance services have been concerned for some time that handover delays could pose significant problems this winter. They are thought to have contributed to the North West Ambulance Service Trust declaring a major incident earlier this month. HSJ has also been told of waits of several hours in other ambulance trusts.
    Read full story (paywalled)
    Source: HSJ, 1 December 2020
  14. Patient Safety Learning
    The safety of maternity services at a major north London hospital has been criticised by the care watchdog after an inspection prompted by the death of a woman.
    The Care Quality Commission (CQC) has issued the Royal Free Hospital, in Hampstead with a warning notice after inspectors identified serious safety failings in its maternity unit.
    An unannounced inspection of the hospital’s maternity service took place in October, following the death of Malyun Karama, in February this year.
    The 34-year-old died while giving birth to her stillborn baby. She suffered a ruptured uterus after being given an overdose of misoprostol to induce her labour.
    In a report following an inquest into her death Coroner Mary Hassell said: “Abnormal observations were relayed by a midwife to a senior registrar, but the doctor failed to attend Ms Karama and instead ordered fluids. The uterine rupture would have been life threatening whatever the care rendered to Ms Karama, but if the doctor had attended immediately and had reviewed and treated appropriately, the likelihood is that Ms Karama’s life would have been saved.”
    The CQC has yet to publish a full report on its inspection of the hospital but confirmed it had taken enforcement action and issued the trust with a warning notice.
    The concerns relate to the trust being too slow to investigate and make changes after incidents of harm. It’s understood a panel to investigate Ms Karama’s death did not meet until June this year.
    Read full story
    Source: The Independent, 1 December 2020
  15. Patient Safety Learning
    COVID-19 could be causing lung abnormalities still detectable more than three months after patients are infected, researchers suggest.
    A study of 10 patients at Oxford University used a novel scanning technique to identify damage not picked up by conventional scans. 
    It uses a gas called xenon during MRI scans to create images of lung damage. Lung experts said a test that could spot long-term damage would make a huge difference to Covid patients. The xenon technique sees patients inhale the gas during a magnetic resonance imaging (MRI) scan.
    Prof Fergus Gleeson, who is leading the work, tried out his scanning technique on 10 patients aged between 19 and 69.
    Eight of them had persistent shortness of breath and tiredness three months after being ill with coronavirus, even though none of them had been admitted to intensive care or required ventilation, and conventional scans had found no problems in their lungs.
    The scans showed signs of lung damage - by highlighting areas where air is not flowing easily into the blood - in the eight who reported breathlessness.
    The results have prompted Prof Gleeson to plan a trial of up to 100 people to see if the same is true of people who had not been admitted to hospital and had not suffered from such serious symptoms. He is planning to work with GPs to scan people who have tested positive for COVID-19 across a range of age groups.
    The aim is to discover whether lung damage occurs and if so whether it is permanent, or resolves over time.
    Read full story
    Source: BBC News, 1 December 2020
  16. Patient Safety Learning
    The government has admitted the NHS in England does not have enough nurses and doctors to keep all its services running if there is a third spike in coronavirus cases as leaked figures show the number of staff off work because of the virus rising.
    An analysis of the impact of coronavirus, released by Downing Street on Monday, warned that even with a 6% growth in NHS staff since August 2019 and extra funding “there is a trade-off between the NHS’s ability to deliver COVID-19 and non-Covid-19 care in the event that COVID-19 hospitalisations rise”.
    It also warned of the psychological effects on staff saying: “It would be expected that higher rates of post-traumatic stress disorder (PTSD) would be seen amongst health and social care staff.”
    New leaked NHS data for England on Monday shows more than 82,000 NHS staff are absent from work with more than two-fifths, 42 per cent, linked to coronavirus either due to sickness or because they need to self-isolate.
    This includes almost 27,000 nurses and 4,000 doctors absent from NHS wards.
    Hospital leaders reiterated the strain the NHS was under in a briefing to MPs ahead of the vote on local tier restrictions today.
    Read full story
    Source: The Independent, 1 December 2020
  17. Patient Safety Learning
    Two hospitals in Cumbria must take "rapid" action "to keep people safe", the health watchdog has announced.
    There had been "escalating" concerns about Carlisle's Cumberland Infirmary and the West Cumberland Hospital in Whitehaven, the Care Quality Commission (CQC) said.
    North Cumbria Integrated Care (NCIC) has been issued with a warning.
    The trust, which was already rated as requiring improvement, admitted the pace of change had been "too slow". The warning notice requires the organisation "to take action to minimise the risk of patients being exposed to harm".
    During checks in August and September, inspectors found:
    Emergency department patients "were not always receiving timely and appropriate" treatment Significant delays in admitting people to wards "Insufficient numbers" of qualified, competent and experienced staff Professor Ted Baker, chief inspector of hospitals, said "rapid improvements" were needed.
    Read full story
    Source: BBC News, 27 November 2020
  18. Patient Safety Learning
    There are serious concerns over the funding and staffing numbers available for new ‘long-covid’ clinics, while patient groups ‘remain in the dark’ over their locations.
    Last month, NHS England announced there would be 40 clinics around the country, to start opening at the end of November, with £10m of funding to cover set-up and operational costs until March 2021.
    But several speakers at HSJ’s inaugural virtual respiratory forum last week said there were still uncertainties and concerns about the capacity to provide the clinics.
    Dr Jon Bennet, a respiratory consultant and chair of the British Thoracic Society, said staffing the respiratory rehabilitation services within the clinics would be challenging, as “there isn’t at the moment sufficient capacity”.
    Read full story (paywalled)
    Source: HSJ, 29 November 2020
  19. Patient Safety Learning
    Nearly 100 trusts have no ‘very senior managers’ (VSM) who are declared to be from a black, Asian or minority ethnic background, HSJ analysis has revealed.
    According to data obtained from every NHS provider in England, 96 out of 214 (45%) did not have any VSMs declared as being from a BAME background.
    This includes several large providers, such as The Newcastle upon Tyne Hospitals Foundation Trust — where around 9 per cent of the workforce and 15 per cent of the city’s population are BAME — and Liverpool University Hospitals FT.
    Jon Restell, chief executive of the Managers in Partnership trade union, said the underrepresentation of BAME staff in leadership positions has “dangerously damaged” the NHS’ response to coronavirus, labelling it the “ultimate wake-up call”.
    Read full story (paywalled)
    Source: HSJ, 30 November 2020
  20. Patient Safety Learning
    New Covid guidance for hospitals could see more patients receiving face-to-face visits from loved ones.
    NHS Wales has given health boards and hospices flexibility to allow visits based on local levels of COVID-19. Until now accompanying people to medical appointments and hospital visits have not been allowed, with a few exceptions. 
    It also allows for pregnant women in low Covid rate areas to take their partners to maternity appointments.
    The Welsh Government said the new flexibility was "due to the changing picture of coronavirus transmission across Wales, with significant variations in community transmission across different parts of the country and differences in the rate of nosocomial transmission".
    Read full story
    Source: BBC News, 30 November 2020
  21. Patient Safety Learning
    Mistakes by Great Ormond Street contributed to the death of a five-year-old boy, the children’s hospital has admitted – just months after it concluded a legal case with his family in which it denied responsibility.
    The world-renowned children’s hospital failed to flag results of a crucial blood test, showing that Walif Yafi had a dangerous infection, to doctors at King’s College Hospital where he had been receiving treatment. He died a few weeks later, in September 2017.
    In September this year, Walif’s parents agreed an out-of-court settlement with Great Ormond Street, which admitted negligence but denied liability for the boy’s death. However, this week the hospital admitted an expert had reviewed the case ahead of the settlement and concluded its actions did contribute to Walif’s death. The hospital said it had been under no duty to share these results with Walif’s parents at the time.
    Walif had a liver transplant in 2012 after suffering cancer shortly after his birth, and was being overseen by Great Ormond Street as an outpatient, as well as by the transplant team at King’s College Hospital, in south London. 
    On 24 August 2017, he had a routine blood test at Great Ormond Street, which showed he had an adenovirus infection – something that is common in children whose immune system is being suppressed by drugs, as Walif’s was because of his transplant. If untreated, the infection can be deadly.
    But the blood test result was not communicated to the team at King’s College Hospital. Shortly afterwards, Walif’s health deteriorated and he was admitted to hospital. He was transferred to King’s College Hospital a week later, and it was not until 7 September that the infection was confirmed. 
    By this stage, he was severely unwell and, though he began anti-viral therapy, Walif suffered multiple organ failure from the spread of the infection. On 30 September, he suffered cardiac arrest and died.
    It was only when approached by The Independent this week that the trust revealed its expert had, in the course of negotiating the settlement with Walif’s parents, determined the hospital did materially contribute to the child’s death.
    Read full story
    Source: The Independent, 29 November 2020
  22. Patient Safety Learning
    Health inspectors in England have been moving between care homes with high levels of COVID-19 infection without being tested, raising fears they have put more residents at risk of catching the virus, leaks to the Guardian have revealed.
    In recent weeks all care home inspections carried out in the north of England have been of infected homes, including a facility where 38 of the 41 people receiving care and 30 staff – almost half of the workers – had tested positive, internal documents from the Care Quality Commission (CQC) show.
    Over the last two months inspectors have been checking infection control procedures and care standards in up to 600 care homes, many of which were dealing with outbreaks of COVID-19, but the Department of Health and Social Care (DHSC) has yet to provide testing. The CQC said on Friday it was expecting to start testing inspectors “in the coming weeks”.
    Weekly Covid deaths in care homes have been rising. In the week to 20 November, 398 people were notified to the CQC as having died from Covid, up from 138 a month earlier. The death toll remains lower than at the peak of the pandemic, when more than 2,500 people were dying a week in late April.
    The situation has sparked “very real anxieties about contracting the disease” and spreading it between infected homes, the leaked memos reveal. One inspector described work to his managers as like “going into the eye of the storm”.
    Read full story
    Source: The Guardian, 27 November 2020
  23. Patient Safety Learning
    A mother fighting for a public inquiry into the death of her son and more than 20 other patients at an NHS mental health hospital in Essex has won a debate in parliament after more than 100,000 people backed her campaign.
    On Monday, MPs in the House of Commons will debate Melanie Leahy’s petition calling for a public inquiry into the death of her son Matthew in 2012, as well as 24 other patients who died at The Linden Centre, a secure mental health unit in Chelmsford, Essex, since 2000.
    The centre is run by Essex Partnership University NHS Trust which has been heavily criticised by regulators over the case.
    A review by the health service ombudsman found 19 serious failings in his care and the NHS response to his mother’s concerns.
    This included staff changing records after his death to suggest he had a full care plan in place when he didn’t.  
    Matthew was detained under the Mental Health Act but was found hanged in his room seven days later. He had made allegations of being raped at the centre, but this was not taken seriously by staff nor properly investigated by the NHS.
    The trust has admitted Matthew’s care fell below acceptable standards.
    In November, it pleaded guilty to health and safety failings linked to 11 deaths of patients in 11 years.
    Read full story
    Source: The Independent, 29 November 2020 
  24. Patient Safety Learning
    The Care Quality Commission (CQC) has criticised a new trust’s leadership after issuing it with a warning notice to improve care in its two emergency departments.
    The watchdog warned North Cumbria Integrated Care Foundation Trust that patients were not always receiving timely and appropriate care, while delayed transfers of care had “resulted in significant delays in admitting patients on to wards”.
    The CQC — which carried out focused inspections at the trust in August and September after concerns were raised about risks to patient and staff safety — added there was evidence of “insufficient numbers of suitably qualified, skilled, competent and experienced clinical staff”.
    The CQC also said there was a lack of an effective system to mitigate risks, including infection control in the emergency department escalation areas and on some medical wards.
    Of the trust’s Cumberland Infirmary and West Cumberland hospitals, the CQC said: “People could not access the urgent and emergency care and medicine service when they needed them and often had long waits for treatment.”
    The CQC’s inspection report, published today, also said the trust had an “inexperienced leadership team” which “did not always have the necessary skills and abilities to lead effectively”. It added there were “few examples of leaders making a demonstrable impact on the quality or sustainability of services”.
    Read full story (paywalled) 
    Source: HSJ, 30 November 2020
  25. Patient Safety Learning
    The death of a premature baby in 2001 led to a "20-year cover-up" of mistakes by health workers, an independent inquiry has found.
    Elizabeth Dixon, from Hampshire, died due to a blocked breathing tube shortly before her first birthday. The government, which ordered the inquiry in 2017, said the mistakes in her care were "shocking and harrowing".
    The inquiry report by Dr Bill Kirkup said some of those involved had been "persistently dishonest".
    Elizabeth, known as Lizzie, died from asphyxiation after suffering a blockage in her tracheostomy tube while under the care of a private nursing agency at home.
    Dr Bill Kirkup, who was appointed by the government to review the case, said her "profound disability and death could have been avoided".
    He said: "There were failures of care by every organisation that looked after her, none of which was admitted at the time, nor properly investigated then or later."
    "Instead, a cover-up began on the day that she died, propped up by denial and deception."
    Read full story
    Source: BBC News, 26 November 2020
    Patient Safety Learning's statement on the Dixon Inquiry report
×
×
  • Create New...