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Patient Safety Learning

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  1. Patient Safety Learning
    We have been coughed on and shouted at by people refusing to wear face masks. We need more protection, says NHS paramedic Jake Jones.
    The outpouring of appreciation for NHS staff during the COVID-19 crisis has been extraordinary. Yet reports of a recent rise in attacks on emergency workers, including ambulance crews, in England and Wales suggests the Thursday evening applause was hiding a less positive reality. Abuse of emergency workers is a growing issue: a 2018 survey found that 72% of ambulance staff have been attacked on duty, and figures have repeatedly pointed to an upward trend. As an NHS paramedic for 10 years, this aligns with Jake's own experience.
    The consultation on increasing sentences for assaults on emergency workers seeks to discourage attacks on them. Jake's hope is that it will also challenge what has become an ingrained view – that being abused and assaulted somehow goes with the territory.
    Read full story
    Source: The Guardian, 1 September 2020
    Read Jake's book 'Can you hear me? An NHS paramedics encounters with life and death'
  2. Patient Safety Learning
    An 'expanded workforce' will be delivering flu and a potential COVID-19 vaccine, under proposals unveiled by the Government today.
    The three-week consultation also focuses on a proposal of mass vaccinations against COVID-19 using a yet-to-be-licensed vaccine, if one becomes available this year.
    The Department of Health and Social Care (DHSC) is hoping new legislation could come into effect by October, ahead of the winter season.
    The consultation proposes to amend the Human Medicine Regulations 2012 to "expand the workforce legally allowed to administer vaccines under NHS and local authority occupational health schemes, so that additional healthcare professionals in the occupational health workforce will be able to administer vaccines".
    It said this would include 'midwives, nursing associates, operating department practitioners, paramedics, physiotherapists and pharmacists'.
    The consultation said: "This will help ensure we have the workforce needed to deliver a mass COVID-19 vaccination programme, in addition to delivery of an upscaled influenza programme, in the autumn."
    The consultation also said that "there is a possibility that both the flu vaccine and the COVID-19 vaccine will be delivered at the same time, and we need to make sure that in this scenario there is sufficient workforce to allow for this". 
    Read full story
    Source: Pulse, 28 August 2020
  3. Patient Safety Learning
    Hundreds of NHS patients have received personal, specialised care thanks to a new service set up during the coronavirus pandemic.
    Stroke Connect, a partnership with the NHS and the Stroke Association provides stroke survivors with support and advice in the early days following hospital discharge, without having to leave the house.
    Experts have said that the new offer is providing a ‘lifeline’ during the pandemic and has helped more than 500 people to rebuild their lives after having a stroke since it launched last month.
    Patients are contacted for an initial call within a few days of discharge from hospital, from a trained ‘Stroke Association Connector’, an expert in supporting people after stroke.
    The connector provides reassurance, support with immediate concerns and links the stroke survivor to support they can access in the long-term as part of their recovery journey as well as signposting them to other sources of support. A further call is offered within the month to check in on the stroke survivor’s progress and identify any further support needed.
    The new service complements existing rehabilitation services and ‘life after stroke’ care, which has continued throughout the pandemic.
    Read full story
    Source: NHS England, 31 August 2020
  4. Patient Safety Learning
    A London acute trust has told its staff they may not be paid for time at home self-isolating if it transpires they were not wearing a mask near someone with coronavirus.
    Staff at Chelsea and Westminster Hospital Foundation Trust were told that if they have to stay at home self-isolating because they were not wearing a mask, that time would have to be taken as annual or unpaid leave.
    Chief executive Lesley Watts told all staff in an email today, seen by HSJ, that a worker had tested positive for COVID-19, and that four staff members had spent more than 15 minutes with them “without appropriate [personal protective equipment]” and must all now isolate themselves at home for 14 days.
    The trust considers it “a serious conduct issue not to wear a mask where you are putting colleagues or our patients at risk – this will be dealt with under our formal processes going forward”, Ms Watts said in the email.
    “If you are sent home to isolate for two weeks because you have not worn a mask, I am now informing you that you will be required to take this as annual or unpaid leave. The four staff members “would not be having to go home to isolate if the use of face masks and social distancing had been in place appropriately”.
    A Chelsea and Wesminster Hospital spokesman told HSJ: “The guidance around PPE has changed a number of times over the course of the pandemic and we felt it was important to be clear on the trust’s position and to reiterate how seriously we take staff and patient safety."
    Read full story (paywalled)
    Source: HSJ, 28 August 2020
  5. Patient Safety Learning
    Trusts underperforming on leadership diversity should not be rated “good” or “outstanding” by the Care Quality Commission (CQC), the NHS Confederation chair has told HSJ.
    Victor Adebowale said he did not understand how organisations can achieve the top CQC ratings if they do not demonstrate sufficient diversity at senior levels.
    Lord Adebowale was speaking to HSJ alongside Marie Gabriel, following Ms Gabriel being appointed last month to chair the new NHS Race and Health Observatory, which is being hosted by the confederation.
    The influential peer’s comments also follow the new People Plan tightened criteria around equality, diversity and inclusion in the “well-led” aspect of the care quality regulator’s inspections.
    He said: “I struggle to see [how] any NHS trust that performs badly, [on] racial equality and leadership, can be considered to be good and outstanding. I don’t get it.
    “It seems to me there is enough regulation to take into account the requirement to lead all the people, all the time. But, obviously, if you’re not, then you shouldn’t be [getting] slaps on the back, and [be rated] outstanding or good in anything else.”
    Read full story (paywalled)
    Source: HSJ, 28 August 2020
  6. Patient Safety Learning
    Complacency over the flu jab risks overwhelming the NHS, experts warn, as data reveals the scale of the challenge in expanding the vaccination programme.
    Last month, the government announced plans to double the number of people who receive the influenza jab. But BBC analysis has found the take-up rate among people in vulnerable groups eligible for a free jab has declined.
    Health secretary Matt Hancock said he did not want a flu outbreak "at the same time as dealing with coronavirus".
    The government wants to increase the number of people vaccinated from 15 million to 30 million amid fears coronavirus cases will rise again in the autumn.
    Local authorities in England saw an average 45% of people with serious health conditions under 65 take up the offer of a free vaccine last winter, data shows. That represents a drop from 50% in 2015.
    The UK government has an ambition to vaccinate 55% of people in vulnerable groups, which includes people with multiple sclerosis (MS), diabetes or chronic asthma.
    The World Health Organization (WHO) has previously said countries should vaccinate 75% of people in "vulnerable" categories.
    Read full story
    Source: BBC News, 27 August 2020
     
  7. Patient Safety Learning
    Any new and effective Covid vaccine will be given emergency approval for use in the UK and an expanded workforce will be trained to give the injections to immunise as much of the population as possible quickly, the government has said.
    A change in the law will allow the UK regulator, the Medicines and Healthcare Products Regulatory Agency (MHRA), to grant temporary approval for a vaccine from October, before it has been given a licence by the European authorities, which would be the normal procedure. The UK will be out of the EU from January and will approve drugs and vaccines without Brussels’ involvement.
    Ministers say there will be no shortcut on safety or effectiveness, and that any vaccine will be approved for the UK only if it meets the highest standards.
    The deputy chief medical officer for England, Prof Jonathan Van-Tam, said: “We are making progress in developing COVID-19 vaccines, which we hope will be important in saving lives, protecting healthcare workers and returning to normal in future.
    “If we develop effective vaccines, it’s important we make them available to patients as quickly as possible but only once strict safety standards have been met. The proposals consulted on today suggest ways to improve access and ensure as many people are protected from Covid-19 and flu as possible without sacrificing the absolute need to ensure that any vaccine used is both safe and effective.”
    The MHRA has the power to grant an unlicensed medicine or a vaccine temporary authorisation where a product is proven safe and effective and in the best interest of the patient on the basis of available evidence.
    Read full story
    Source: The Guardian, 28 August 2020
  8. Patient Safety Learning
    Guidance to protect at-risk healthcare workers in Wales from coronavirus infection has been relaxed, the BBC has learned.
    A risk assessment tool initially recommended high-risk workers should not work in the parts of a hospital where infection was most likely. But it now says their personal protective equipment (PPE) should be reviewed or duties changed.
    The Welsh government says this reflects latest data and low infection rates. However, healthcare professionals say the change to the all-Wales COVID-19 workforce risk assessment tool was made without consultation, and are concerned it was done to prevent hospitals from losing frontline staff ahead of a potential second wave of the virus.
    Mr Amol Pandit, a urologist who helped to design the tool, has written to the Welsh government four times seeking clarity on the basis for the changes, and why no one was made aware of them before the tool was rolled out.
    "The changes could have been made in order to keep as many healthcare workers on the frontline as possible, which is why I sent a specific list of questions to the Welsh government, so that I could have assurances that it wasn't done for that reason, but for clinical, evidence-based reasons," Mr Pandit said.
    Mr Pandit believes healthcare workers who fall into the high-risk category and work in environments where aerosol-generating procedures are performed - considered to carry a high risk of transmission of the virus - may not be fully protected by the current version of the tool if PPE supplies fall short and additional safeguarding measures aren't put into place.
    "The government needs to be absolutely sure that there is adequate PPE and that it is going to be available to everybody - we have to trust them on that," he said
    Read full story
    Source: BBC News, 27 August 2020
  9. Patient Safety Learning
    Nursing homes were put under “constant” pressure to accept patients with coronavirus while being regularly refused treatment from hospitals and GPs for residents who became ill at the height of the Covid crisis, a landmark study has found.
    The Queen’s Nursing Institute said homes were told hospitals had blanket “no admissions” policies during April and May while GPs and local managers imposed unlawful do not resuscitate orders on residents.
    The findings have emerged in a survey by the QNI, the world’s oldest nursing charity, which surveyed 163 care home nurses and managers working across the country.
    Carried out between May and June this year, the study establishes an evidence base of the impact on the sector from coronavirus, in addition to the official figures showing care home death rates.
    One nurse said they were under “constant pressure to admit people who were Covid positive” while another said: “The acute sector pushed us to take untested admissions. The two weeks of daily deaths during an outbreak were possibly the two worst weeks of my 35-year nursing career.”
    Read full story
    Source: The Independent, 22 August 2020
  10. Patient Safety Learning
    COVID-19 death tolls at individual care homes are being kept secret by regulators in part to protect providers’ commercial interests before a possible second coronavirus surge, the Guardian can reveal.
    England’s Care Quality Commission (CQC) and the Care Inspectorate in Scotland are refusing to make public which homes or providers recorded the most fatalities amid fears it could undermine the UK’s care system, which relies on private operators.
    In response to freedom of information requests, the regulators said they were worried that the supply of beds and standards of care could be threatened if customers left badly affected operators. The CQC and Care Inspectorate share home-by-home data with their respective governments – but both refused to make it public.
    Residents’ families attacked the policy, with one bereaved daughter describing it as “ridiculous” and another relative saying deaths data could indicate a home’s preparedness for future outbreaks.
    “Commercial interest when people’s lives are at stake shouldn’t even be a factor,” said Shirin Koohyar, who lost her father in April after he tested positive for Covid at a west London care home. “The patient is the important one here, not the corporation.”
    Read full story
    Source: The Guardian, 27 August 2020
  11. Patient Safety Learning
    England’s test-and-trace system has been hit with fresh problems after there were delays in contacting nearly 2,000 people infected with coronavirus, and one in seven home tests failed to produce a result.
    An internet outage meant nearly 3,000 more people than usual were transferred to the contact-tracing system after testing positive for COVID-19 in the week ending 19 August. Two-thirds of these people had been tested days or weeks earlier, meaning there was a delay in reaching them and their close contacts when they should have been self-isolating.
    The proportion of home tests kits failing to produce a result that week rose sharply, from 4% to 15% of the total, equating to more than 18,000 tests.
    The Department of Health and Social Care figures also show that test and trace failed for a ninth week running to reach its target of contacting 80% of close contacts of people who test positive for COVID-19.
    Matt Hancock, the health secretary, acknowledged on Thursday that the programme was “not quite there” in reaching that target. He told LBC radio: “One of the challenges is we want to get NHS test and trace up to over 80% of contacts, getting them to self-isolate – we’re at just over 75%, so we’re nearly there but not quite there.”
    Read full story
    Source: The Guardian, 27 August 2020
  12. Patient Safety Learning
    Women are forced to wait more than five times longer than men for a heart failure diagnosis, a new study has found.
    Researchers discovered women are 96 per cent more likely to get an incorrect diagnosis of heart failure than men – attributing sharp disparities to such problems being wrongly viewed as “a man’s disease”.
    The study, conducted by leading heart failure charity the Pumping Marvellous Foundation, found men said they waited an average of just over three and a half weeks to get a formal diagnosis after their first GP visit, but women waited just over 20 weeks instead.
    Researchers warned such delays were linked to “poorer quality of life, financial losses, mental health issues and avoidable deaths” – adding that health professionals do not give heart failure the same attention and gravity as cancer and other diseases.
    "One of them [GP] actually said, your symptoms are probably not to do with your heart because you’re young and you’re female. Even though my father had a heart condition," says Sarah, who was diagnosed at the age of 42.
    Read full story
    Source: The Independent, 27 August 2020
  13. Patient Safety Learning
    The Care Quality Commission's chief executive Ian Trenholm has said he is sceptical about the need to appoint an NHS patient safety commissioner, one of the key recommendations of the recently published Cumberlege review.
    In a wide-ranging interview with HSJ, Mr Trenholm also revealed that he wants the Care Quality Commission to review the collaboration of every health system in England.
    Mr Trenholm told HSJ he is “not sure” a patient safety commissioner was needed and that it would need to perform a “role that was different from what’s already in place” for it to add value.
    He said: “If you look at the work we’re doing on patient safety, the work that HSIB are doing on patient safety, and then we’ve got people within the NHS itself doing work on patient safety, I think there are enough people playing. The question is, are we all working together as effectively as we possibly could be.
    “If another player helps that work [then] great, but I’m not sure that’s something that is necessary.”
    Read full story (paywalled)
    Source: HSJ, 24 August 2020
  14. Patient Safety Learning
    Women working in the NHS are suffering from serious stress and exhaustion in the wake of the coronavirus crisis, a troubling new report has found.
    Some 75% of NHS workers are women and the nursing sector is predominantly made up of women – with 9 out of 10 nurses in the UK being female.
    The report, conducted by the NHS Confederation’s Health and Care Women Leaders Network, warns the NHS is at risk of losing female staff due to them experiencing mental burnout during the global pandemic.
    Researchers, who polled more than 1,300 women working across health and care in England, found almost three quarters reported their job had a more damaging impact than usual on their emotional wellbeing due to the COVID-19 emergency.
    Read full story
    Source: The Independent, 25 August 2020
  15. Patient Safety Learning
    A nurse in the US sued Louisville, Ky.-based Kindred Healthcare this week, alleging the organisation fired him in retaliation for raising patient safety concerns.
    Sean Kinnie worked as an intensive care unit nurse at Kindred Hospital-San Antonio. Mr Kinnie claims he was suspended twice and then fired after leaders at the 59-bed transitional care hospital learned he anonymously reported patient safety concerns to The Joint Commission in November 2019 and January. 
    Mr Kinnie said issues related to inadequate staffing and unsanitary care environments put patients in "grave danger," according to the lawsuit. He also said the hospital created a culture in which employees were afraid to stand up for patients for fear of retaliation from management. 
    In January, Mr Kinnie told the hospital's chief clinical officer Sharon Danieliewicz that he was the staff member who reported the patient safety concerns to The Joint Commission. Mr. Kinnie claims he faced increased scrutiny after this disclosure and was ultimately fired Feb. 24 for violating facility policy.
    Read full story
    Source: Becker's Hospital Review, 24 August 2020
  16. Patient Safety Learning
    The Health Research Authority has launched a new strategy to ensure information about all health and social care research – including COVID-19 research - is made publicly available to benefit patients, researchers and policy makers.
    The COVID-19 pandemic has highlighted the importance of sharing details of research taking place - to understand the virus and find the tests, treatments and vaccines - so that results can inform best quality care and preventive measures. This also means researchers do not duplicate efforts and can build on each other’s work while the public can see what research is going on. Now the new Make it Public strategy aims to build on this good practice and make it easy for researchers to be transparent about their work.
    The strategy, delivered by the HRA in partnership with NHS Research Scotland (NRS), Health and Care Research Wales and Health and Social Care Northern Ireland, is about making transparency ‘the norm’ in research and making information more visible to the public. New measures set out in the strategy – will improve transparency and openness in health and social care studies, by:
    expecting researchers to plan how they will let research participants know about the findings of the study from the beginning introducing additional monitoring to check that researchers are reporting results and to collect information about study findings making information on individual research projects – and their transparency performance - available to the public introducing a system to consider past transparency performance when reviewing new studies for approval and in the future introducing sanctions. 
  17. Patient Safety Learning
    A home care worker who did not wear protective equipment may have infected a client with a fatal case of coronavirus during weeks of contradictory government guidance on whether the kit was needed or not, an official investigation has found.
    The government’s confusion about how much protection care workers visiting homes needed is detailed in a report into the death of an unnamed person by the Healthcare Safety Investigation Branch (HSIB), which conducts independent investigations of patient safety concerns in NHS-funded care in England. It was responding to a complaint raised by a member of the public in April.
    The report shows that Public Health England published two contradictory documents that month. One advised care workers making home visits to wear PPE and the other did not mention the need. The contradiction was not cleared up for six weeks.
    The government’s guidance had been a shambles that had placed workers and their vulnerable clients at risk, the policy director at the United Kingdom Homecare Association, Colin Angel, said on Wednesday. The association also accused the government of sidelining its expertise and publishing new guidance with little notice, sometimes late on Friday nights, meaning that it was not always noticed by the people it was intended for.
  18. Patient Safety Learning
    The Care Quality Commission (CQC) has taken immediate enforcement action at East Kent Hospitals University Foundation Trust citing “serious concerns” over patient safety.
    The regulator confirmed it was taking action today after inspectors visited on 12 August following concerns being raised about the standard of care and risk to patients.
    The CQC confirmed the action had been taken, but it said it could not comment further due to legal restrictions and the trust’s right to appeal the decision.
    HSJ understands the enforcement action was taken due to concerns over infection prevention control and the number of patients who have contracted COVID-19 in hospital. It is believed to be the first such action against a trust.
    Read full story (paywalled)
    Source: HSJ, 27 August 2020
  19. Patient Safety Learning
    Hospitals are not equipped to deal with the surge in screenings and tests as the health service restarts care – leaving patients facing delays in diagnosis and treatment for conditions including cancer, according to medical leaders.
    As the NHS tries to recover from the worst of the coronavirus crisis, more than a million laboratory samples from cancer screening services are expected in pathology labs, while as many as 850,000 delayed CT and MRI scans need to be carried out.
    But 97% of labs do not have enough pathologists to carry out the work – with staff already working unpaid hours to tackle the existing backlog – while the number of radiology posts nationally would need to be increased by a third to deal with the rise, experts say. Precautions to protect against the spread of coronavirus also limits the number of scans that can be carried out. The royal colleges of pathologists and radiologists warned that cancers would go undiagnosed and treatments for all patients across the NHS could be further delayed as a result.
    Read full story
    Source: The Independent, 27 August 2020
  20. Patient Safety Learning
    Obesity may double the risk of falling seriously ill with Covid-19 and increase the chances of dying by almost 50 per cent, according to researchers, who also warned any future vaccine may be less effective for the clinically overweight.
    Health issues caused by obesity include a number of pre-existing conditions known to exacerbate a Covid-19 infection – including heart disease, diabetes and high blood pressure.
    Now a global assessment of health data gathered since the start of the the pandemic by researchers at the University of North Carolina has found people with a Body Mass Index (BMI) of more than 30 were 113 per cent more likely to be hospitalised.
    Those admitted to hospital were found to be 74% more likely to be admitted to an intensive care unit, while the risk of death among obese patients increased by 48%.
    Read full story
    Source: The Independent, 26 August 2020
  21. Patient Safety Learning
    At least 6,500 health and care workers may have been infected with coronavirus through their work, including 100 who died, according to data from the Health and Safety Executive (HSE).
    The regulator told The Independent it was reviewing each case and could launch investigations under the Health and Safety at Work Act if hospitals or care homes are suspected of not taking adequate steps to protect staff from infection.
    This could result in a hospital or care home being prosecuted.
    The latest data from the HSE shows between 10 April and 10 August there were a total of 3, 382 healthcare workplace infections, including 50 fatal incidents. In residential care there were 3,168 infections reported to the watchdog with 48 fatal cases.
    The results of the review, first revealed earlier this month by The Independent, is being kept secret but where a medical examiner finds a worker may have died as a result of a workplace infection the death will have to be reported to the HSE for possible investigation. Coroners may also hold inquests into deaths.
    It will also make it easier for families to claim compensation from the government’s additional death in service payments of £60,000 which was announced by health secretary Matt Hancock in April.
    Read full story
    Source: The Independent, 25 August 2020
  22. Patient Safety Learning
    A clinical commissioning group (CCG) has ordered an independent review of its culture which it said was prompted by the “injustices experienced by black Asian and minority ethic colleagues” during the pandemic, HSJ has learned.
    The review at Surrey Heartlands CCG, due to report in the autumn, is being led by Duncan Lewis, emeritus professor of management at Plymouth University. He has led several major reviews into culture at NHS organisations, including one into bullying and harassment at South East Coast Ambulance Service Foundation Trust in 2017 and one into workplace culture at Whittington Health Trust in 2018.
    HSJ asked the CCG for the terms of reference of the review and the reasons why it felt it necessary to commission such an inquiry. It said the review’s scope would be determined by what staff felt was important regarding “our organisational culture, policy and practice – things we do well and things we need to improve”.
    It added in a statement: “We will listen to the findings of the review and we will make any changes that are necessary.”
    It is not yet clear if specific events within the organisation itself prompted the CCG to take the unusual step of commissioning the work. But the commissioner’s interim chief did say “feedback from staff” had been a driver.
    Read full story (paywalled)
    Source: HSJ, 26 August 2020
  23. Patient Safety Learning
    The US Food and Drug Administration (FDA) has approved convalescent plasma for emergency use in hospital patients with COVID-19.
    The announcement on 23 August said that the FDA had concluded that plasma from recovered patients “may be effective” in treating the virus and that the “potential benefits of the product outweigh the known and potential risks.” The move came despite the absence of results from randomised controlled trials, with only a preprint paper on the effects on hospitalised COVID-19 patients being published to date.
    Experts have warned that although these early findings show promise there is not enough evidence to show that it works.
    Plasma from recovered patients was approved on a case by case basis by the FDA for people critically ill with COVID-19 in March. Since then more than 70 000 patients have been treated with plasma. Emergency use approval allows clinicians to use unapproved medical products to diagnose, treat, or prevent serious or life threatening diseases or conditions when there are no adequate, approved, and available alternatives.
    The FDA’s commissioner, Stephen Hahn, said, “I am committed to releasing safe and potentially helpful treatments for covid-19 as quickly as possible in order to save lives. We’re encouraged by the early promising data that we’ve seen about convalescent plasma. The data from studies conducted this year shows that plasma from patients who’ve recovered from covid-19 has the potential to help treat those who are suffering from the effects of getting this terrible virus.”
    But Martin Landray, professor of medicine and epidemiology at the University of Oxford and lead researcher for the RECOVERY trial, which is comparing treatments for COVID-19, including convalescent plasma for hospital patients, urged caution. He said, “There is a huge gap between theory and proven benefit. That is why randomised clinical trials are so important. At present, we simply don’t know if it works."
    Read full story
    Source: BMJ, 25 August 2020
  24. Patient Safety Learning
    Theresa May has urged the government to consider “redress” for the victims of a hormone pregnancy test blamed for causing serious birth defects.
    The former prime minister said that while Primodos victims had received an apology, “lives have suffered as a result” of the drug’s use.
    In an interview for a Sky News documentary, she praised campaigners who had been “beating their head against a brick wall of the state” which tried to “stop them in their tracks”.
    A review in 2017 found that scientific evidence did “not support a causal association” between the use of hormone pregnancy tests such as Primodos and birth defects or miscarriage. But Ms May ordered a second review in 2018, because, she said, she felt that it “wasn’t the slam-dunk answer that people said it was”.
    “At one point it says that they could not find a causal association between Primodos and congenital anomalies, but neither could they categorically say that there was no causal link,” she said.
    The second review concluded last month that there had been “avoidable harm” caused by Primodos and two other products – sodium valproate and vaginal mesh.
    An interview for Bitter Pill: Primodos, which will air on Sky Documentaries, Ms May said: “I think it’s important that the government looks at the whole question of redress and about how that redress can be brought up for people.
    Read full story
    Source: The Independent, 28 August 2020
  25. Patient Safety Learning
    Safety inspectors have ordered a mental health trust to make immediate improvements after visiting two inpatient wards where three patients died inside six months.
    The Care Quality Commission this week warned Devon Partnership Trust it would take “urgent action” over “serious concerns about patients” unless the trust made the required improvements swiftly.
    The watchdog inspected the trust’s Delderfield and Moorland wards in June following concerns about three patient deaths in September, October and March, along with “a number of” patient safety incidents - including ligature incidents.
    The CQC also highlighted poor patient observation routines and a lack of learning from previous incidents, amid delays in completing investigations into safety incidents.
    Read full story
    Source: HSJ, 21 August 2020
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