Patient Safety Learning

A struggling mental health trust is being prosecuted over accusations it failed to protect a teenager at a children’s inpatient unit. Tees, Esk and Wear Valleys Foundation Trust ran the former West Lane Hospital in Middlesbrough until the Care Quality Commission (CQC) closed it in 2019. The CQC is now prosecuting the trust, alleging it breached the Health and Social Care Act 2008 in relation to the death of Christie Harnett, who took her own life at the facility in June 2019. In a statement, the regulator claimed TEWV “failed to provide safe care and treatment” by exposing the patient to a “significant risk of avoidable harm”. A CQC spokeswoman added: “Our main priority is always the safety of people using health and social care services, and if we have concerns we will not hesitate to take action in line with our regulatory powers. We will report further as soon as we are able to do so.” Read full story (paywalled) Source: HSJ, 30 June 2022

A baby suffered brain damage and died due to failings at a hospital where her mother spent hours alone in pain and suffered crucial delays, according to her family. Dominic and Ewelina Clyde-Smith told The Independent their daughter, Amelia, was otherwise healthy and poor care led to her being starved of oxygen at birth. The couple said they experienced a series of failings at Jersey General Hospital in 2018, including a lack of a doctor during a difficult labour and staff taking “too long” to resuscitate their child. They believe Amelia suffered further harm when a ventilator was not plugged in properly during a transfer. Amelia was left with brain damage and died aged one month after being put into palliative care. Her parents said they have spent years trying to get justice through official channels but are now speaking out for the first time as they believe the standard of care received should be public knowledge. “It happened nearly four years ago,” Ms Clyde-Smith says, adding: “But the whole maternity unit just failed us completely.” Read full story Source: BBC News, 1 July 2022

The NHS is facing a shortage of laundry supplies that could have a “knock-on effect” on bed numbers, an industry leader has warned, with staff at one trust recently told to “only change linen if essential”. The Textile Services Association (TSA), which represents multiple laundry businesses that provide supplies to the NHS, said Brexit and the pandemic had caused large labour shortages which were making it difficult to meet demand across the healthcare and hospitality sectors. David Stevens, chief executive of TSA, told The Independent that “shortages of linen and laundry will have a knock-on effect on the provision of beds in trusts”, adding that the “bounce back post-Covid created a high demand for product and the supply chain was not able to deliver”. In an internal email circulated to staff last month at Oxford University Hospitals NHS Trust, one senior official said both the trust and the NHS were “currently experiencing severe issues with the supply chain for linen deliveries,” adding that the situation is “currently very serious”. The email reads: “Please follow good Infection Prevention and Control practices, but only change linen if essential. For example, always change bed linen between patients, but do not change inpatients’ bed linen daily if at all possible.” Read full story Source: The Independent, 30 June 2022

Trust boards should start scrutinising performance against new indicators set out by NHS England this month as part of a national push to iron out unwarranted variation in performance on key sepsis blood tests, according to an NHSE report. Blood cultures are the primary test for detecting blood stream infections, determining what causes them, and directing the best antimicrobial treatment to deal with them. However, it is too often seen as part of a box-ticking exercise, according to a report published by NHSE yesterday. Improving performance on this important pathway should be integrated into existing trust governance structures for sepsis, antimicrobial stewardship, and infection control “to help secure a ‘board to ward’ focus on improvement,” the report says. It says there is too much variation in how blood cultures are taken prior to analysis and sets out two targets for trusts to use to standardise their collection. The first is ensuring clinicians collect two bottles of blood, each containing at least 20ml for culturing. The more blood collected, the higher the rate of detecting bloodstream infections. Blood culture bottles “are frequently underfilled”. The second is ensuring blood cultures are loaded into an analyser as fast as possible, within a maximum of four hours, because delaying analysis reduces the volume of viable microorganisms that can be detected. Read full story (paywalled) Source: HSJ, 1 July 2022

The NHS is wasting time and money due to a ‘culture of overtreatment’ in cancer care, a report has revealed. An All-Party Parliamentary Group paper released on Tuesday on minimally invasive cancer treatments (MICTs) found only 10 per cent of cancer patients are offered non-invasive treatments. This is despite many of these treatments being recommended by the National Institute for Health and Care Excellence (NICE). And many doctors and patients remain in the dark about some of the newer treatments due to ‘a severe lack of education’ . The APPG, which is made up of different political parties and peers, was formed to drive awareness of Minimally Invasive Cancer Therapies - proven cancer treatments that provide similar outcomes to cancer surgery but are more targeted and less invasive than traditional surgery. Paul Sayer, founder of charity Prost8, which launched its ‘ONE in EIGHT’ campaign to help men with prostate cancer get better access to minimally invasive treatment, said: “The report has identified a culture of overtreatment even when it’s not the best or safest option. Read full story Source: The Independent, 29 June 2022

Patients with long-lasting symptoms from Covid will have access to more convenient tests and checks closer to home, under new NHS measures announced. Specialist clinics, dedicated to Long Covid, will now be able to send people for tests at local one stop shops and mobile clinics, rather than people going back to their GP practice for multiple different tests. Backed by an additional £90 million investment, the updated Long Covid plan includes ambitions for all patients to have an initial assessment within six weeks to ensure they are diagnosed and treated quickly. Latest estimates from the ONS show that around 1.6 million people in England are experiencing ongoing COVID symptoms lasting more than four weeks, with around one in five saying it has a significant impact on their daily life. The plan, which has been developed with expert insights from patients, clinicians and partners across the health and care system, shows the NHS has already made significant progress on delivering the 10 commitments it set out for Long Covid services just over one year ago. This includes establishing a nationwide network of 90 specialist long COVID clinics, 14 hubs for children and young people and investment in training and guidance to support GP teams in managing the condition. Dr Kiren Collison, GP and chair of the NHS long COVID taskforce said: “Long COVID can be devastating for those living with it, and while we continue to learn more about this new condition, it’s important people know they’re not alone, and that the NHS is here for them. “In just under two years, the NHS has invested £224m to support people experiencing long term effects from COVID – from setting up specialist clinics, hubs for children, and an online recovery platform, to providing training for GP teams. “Today’s plan builds on this world-leading care, to ensure support is there for everyone who needs it, and that patients requiring specialist support can access care in a timely and more convenient way.” Read full story Source: NHS England, 28 July 2022

Digital improvement will be added to the conditions which trusts and integrated care systems have to legally meet as part of their operating licence, the government has indicated. The move is part of a raft of actions unveiled by the Department of Health and Social Care which are intended to “modernise” the NHS. The Plan for Digital Health and Social Care states: “At present, there are limited formal mechanisms for overseeing delivery of NHS digital priorities. Digital does not yet feature in the provider licence, system oversight framework, or Care Quality Commission assessments.” It adds: “We are exploring options for filling this gap in discussions between NHS England and the CQC, and through a review and consultation with system leaders and frontline staff.” New “regulatory levers” will be used to: “signal that digitisation is a priority, identify the non-negotiable standards of digital capability, [and] explain how we will monitor and support compliance”. Read full story (paywalled) Source: HSJ, 30 June 2022

The privatisation of NHS care accelerated by Tory policies a decade ago has corresponded with a decline in quality and “significantly increased” rates of death from treatable causes, the first study of its kind says. The hugely controversial shakeup of the health service in England in 2012 by the health secretary, Andrew Lansley, in the Tory-Lib Dem coalition government, forced local health bodies to put contracts for services out to tender. Billions of pounds of taxpayers’ cash has since been handed to private companies to treat NHS patients, according to the landmark review. It shows the growth in health contracts being tendered to private companies has been associated with a drop in care quality and higher rates of treatable mortality – patient deaths considered avoidable with timely, effective healthcare. The analysis by the University of Oxford has been published in the Lancet Public Health journal. “The privatisation of the NHS in England, through the outsourcing of services to for-profit companies, consistently increased [after 2012],” it says. “Private-sector outsourcing corresponded with significantly increased rates of treatable mortality, potentially as a result of a decline in the quality of healthcare services.” Read full story Source: The Guardian, 29 June 2022

Women who underwent damaging surgery in Irish hospitals have accused health authorities of dragging them into a "nightmare" of "gaslighting, ignorance and disrespect". Having had vaginal mesh implants, the women told an Oireachtas committee that they were "maimed" and then led on "a fool's errand" when they sought support from the HSE. The Health Committee heard from members of Mesh Ireland and Mesh Survivors Ireland who represent around 750 women. While the HSE said that it would be "extremely difficult" to provide accurate figures, it estimates that around 10,000 women had this surgery in Ireland. More than one in ten have suffered complications, Dr Cliona Murphy, Clinical Lead for the National Women and Infants Health Programme, revealed. Mary McLaughlin, Mesh Ireland, said that at one point, "I lay in bed 16 hours a day", because of the pain she was in. She demanded dignity and respect for survivors in the face of this "global scandal". The women are calling for access to a US-based expert in complete mesh removal, to mirror schemes in Scotland and the Canadian state of Quebec. Read full story Source: RTE, 29 March 2022

The shortage of GPs in England is set to become worse, with more than one in four posts predicted to be vacant within a decade, an analysis suggests. The Health Foundation study said the current 4,200 shortfall could rise to more than 10,000 by 2030-31. The think tank believes the government will struggle to increase the number of GPs, while demand will continue to rise - creating a bigger shortfall. The government has promised to recruit 6,000 extra GPs by 2024, but ministers have admitted they are struggling to achieve that. The analysis said the numbers entering the profession are on the rise, but this will be offset by GPs retiring or moving towards part-time working, according to current trends. The worst-case scenarios suggested more than half of GP posts could even be vacant. Anita Charlesworth, director of research at the Health Foundation, said: "It's sobering that over the next decade things are set to get worse, not better." "It's critical that government takes action to protect general practice and avoid it getting locked in a vicious cycle of rising workload driving staff to leave, in turn creating more pressure on remaining staff and fuelling even more departures." Prof Martin Marshall, chairman of the Royal College of GPs, said the predictions were "bleak" and the worst-case scenario would be a "disaster". "Our members have told us they lack the time to deliver the care that they want to deliver for patients - and that patients need," he said. Read full story Source: BBC News, 30 June 2022

A coroner has said Britain is failing young people and more will die because of under-resourced mental health services, as she ruled that neglect led to the death of a 14-year-old girl. Penelope Schofield, the senior coroner for West Sussex, said she would write to the health secretary, Sajid Javid, to raise concerns after the case of Robyn Skilton, who killed herself after being let down by “gross failures” in NHS mental health services. Robyn, from Horsham in West Sussex, disappeared from her family home and took her own life in a park on 7 May last year, her inquest in Chichester heard. Despite serious concerns about her mental health, Robyn did not get face-to-face consultations, was not seen by a child psychiatrist or assessed for mental health issues, and was discharged from an NHS service a month before her suicide though she was on its high-risk “red list”. Her father, Alan Skilton, told the inquest he pleaded for help, and he described the lack of care his daughter received as “astonishing”. He said he believed that if Robyn had been seen earlier, her mental health would have improved and she would not have killed herself. The coroner said: “As a society we are failing young people.” She said she was shocked to hear that the number of young people seeking mental health help had increased by 95%. “Trying to manage it without more resources means we are not providing the help that young people need. Robyn’s case is a testament to that. It’s a clear risk that more lives will be lost if we don’t address it.” Read full story Source: The Guardian, 29 June 2022

A review of the medical records of a small number of deceased patients of former neurologist Dr Michael Watt has been completed, the BBC has learned. The findings from the review, conducted by the Royal College of Physicians (RCP), are being shared with the families of the 44 deceased patients. In May 2018, the Department of Health commissioned the review. It asked regulator the RQIA to review the records of Dr Michael Watt's patients who died in the previous ten years. The Royal College of Physicians, which has been examining 44 deceased patients' records as part of phase 2 of the review, has provided the RQIA ( Regulation and Quality Improvement Authority) with its reports. Families who wish to receive details of the review of their loved ones' medical records are being offered an opportunity to discuss the findings. The RQIA has estimated there may be more than 3,000 deceased patients who were at some point under the care of Dr Watt in the 10-year period prior to May 2018. The 44 cases selected for review included deceased patients whose family members had approached the RQIA with concerns about their care. Read full story Source: BBC News, 29 June 2022

Press release: 29 June 2022 Today, Dean Russell MP, a member of the Health and Social Care Select Committee, with the charity Patient Safety Learning and the Safety for All campaign, are hosting a Parliamentary reception with MPs, Peers and representatives of the wider patient safety and healthcare community. Each year in the UK thousands of people are killed and harmed as a result of unsafe care, costing the NHS billions of pounds for additional treatment, support, and compensation costs relating to litigation by those harmed. Following the unprecedented impact that the Covid-19 pandemic has placed on health and social care, both the public and the healthcare sector believe politicians must prioritise the improvement of both patient and healthcare worker safety. At this reception politicians and members of the wider healthcare community will discuss how we can harness the knowledge, enthusiasm and commitment of healthcare organisations, professionals and patients for system-wide change, to improve care and reduce avoidable harm to patients and healthcare workers. This event also marks the launch by the Safety for All campaign of a new guide for Staff directly involved in a serious safety incident. This step-by-step good practice guide sets out how to ensure we support staff involved in serious safety incidents better, so that these can be more effectively investigated and result in learning and improvement. It is also an opportunity to discuss the recently published report, Mind the implementation gap: The persistence of avoidable harm in the NHS, which highlights a patient safety implementation gap in the UK that results in the continuation of avoidable harm. Dean Russell MP said: “I am delighted to host this event to reinvigorate parliamentary action in improving patient and healthcare worker safety. The NHS estimates that there are 11,000 avoidable deaths in the UK each year due to patient safety incidents. We must look at the issue of patient safety holistically. If we can change blame culture and allow workers to be open and learn from mistakes, then we can reduce the number of serious safety incidents. Also, if we ensure, in the transition back normality following the pandemic, that the safety of healthcare workers is a priority this will also impact positively on patient safety.” Jonathan Hazan, Chair of Patient Safety Learning, said: “Patient Safety Learning is working to make patient safety the core purpose of health and social care, not just one of many priorities to be traded with others. We engage with politicians, healthcare organisations, professionals and patients to campaign for system change and we work together on projects to reduce harm to patients. Dean Russell MP and his colleagues in Parliament can play a major role in improving safety and we look forward to working with them.” Dr. Paul Grime, Chairman of Safer Healthcare Biosafety Network (SHBN), said: “Today’s reception is a chance for the patient safety and wider healthcare community to meet and discuss how we can harness the knowledge, enthusiasm and commitment of healthcare organisations, professionals and patients for system-wide change, to improve care and reduce avoidable harm to patients and healthcare workers. The Safety for All campaign will be pressing MPs and Peers here today and those in leadership roles within the NHS and social care to address these recommendations and lend their support to the campaign and the practical actions we are taking to deliver safety for all.” Ian Duncalf, Chair of Patient Safety Group at ABHI, said: “The Patient Safety group at the Association of British HealthTech Industries has been supporting and helping to deliver the patient and staff safety agenda for many years. The ABHI are very pleased to be supporting the work of the Safety for All campaign, which with Patient Safety Learning, is now implementing the practical plan, activities and deliverables of the campaign over the next year and beyond. I am delighted that I am joined today by members of the Safer Healthcare and Biosafety Network and the Safety for All campaign Industry Group who are committed to delivering improved patient and staff safety outcomes.” Notes to editors 1. Patient Safety Learning is a charity and independent voice for improving patient safety. We harness the knowledge, enthusiasm and commitment of healthcare organisations, professionals and patients for system-wide change and the reduction of harm. We support safety improvement through policy, influencing and campaigning and the development of ‘how to’ resources such as the hub, our free award-winning platform to share learning for patient safety. 2. The Safer Healthcare and Biosafety Network is an independent forum focused on improving healthcare worker and patient safety and has been in existence more than 20 years. It is made up of clinicians, professional associations, trades unions and employers, manufacturers and government agencies with the shared objective to improve occupational health and safety and patient safety in healthcare. COVID-19 pandemic has provided a stark reminder of the vital role healthcare professionals play in providing care to those in our society who need it most and this was recognized in the WHO Patient Safety Day in September 2020: only when healthcare workers are safe can patients be safe. In 2020, the Network launched a campaign called ‘Safety for All’ to improve practice in, and between, patient and healthcare worker safety to prevent safety incidents and deliver better outcomes for all. The Safety for All white paper is calling for improvements in, and between, patient and healthcare worker safety to prevent safety incidents and deliver better outcomes for all by: Improved understanding and advocacy of the mutual benefits to be accrued for patient safety by improving healthcare worker safety, and vice versa, and of the common risks, factors and interventions across patient and healthcare worker safety The application of shared learning and best practice between workplace and patient safety and, where appropriate, aligned or integrated synergistic solutions in safety systems, standards, governance and preventive measures Resources, leadership and staff committed to a stronger, reciprocal patient and workplace safety culture, with safety as a core purpose for both, underpinned by better education and training Greater support for staff, and for them to speak up, following patient safety incidents, including a safety care pathway for both patients and staff, and to ingrain a just culture Improved risk management and reporting of safety incidents, learning and communication across patient and healthcare worker safety 3. ABHI is the UK’s leading industry association for health technology (HealthTech). ABHI supports the HealthTech community to save and enhance lives. Members, including both multinationals and small and medium sized enterprises (SMEs), supply products from syringes and wound dressings to surgical robots and digitally enhanced technologies. We represent the industry to stakeholders, such as the government, NHS and regulators. HealthTech plays a key role in supporting delivery of healthcare and is a significant contributor to the UK’s economic growth. HealthTech is now the largest employer in the broader Life Sciences sector, employing 131,800 people in 4,060 companies, with a combined turnover of £25.6bn. The industry has enjoyed growth of around 5% in recent years. ABHI’s 320 members account for approximately 80% of the sector by value.