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Patient Safety Learning

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  1. Patient Safety Learning
    After receiving more than 12,000 complaints about Australia's Victorian mental health services, the state’s regulator has not taken compliance action against a single mental healthcare provider in seven years.
    This is despite the royal commission into the Victorian mental health sector last year finding systemic breaches of the law and human rights across the system.
    Annual reports from Victoria’s mental health complaints commissioner (MHCC) showed that in the seven years since it was first established in July 2014, it received 14,160 inquiries, of which 12,470 were complaints. Yet no compliance notices were issued, despite the MHCC having regulatory powers to compel providers to improve.
    The MHCC is an independent body that resolves complaints about Victoria’s public mental health services and makes recommendations for improvements.
    The MHCC’s service provider complaint reports, obtained under freedom of information, show that some mental health services do not hand over data on the outcomes of complaints, in breach of the state’s Mental Health Act (2014).
    The chief executive of Mind Australia – a community-based mental health provider, Gill Callister, said it was vital people with mental health concerns, their families and carers had access to “information about the performance and approach” of the mental health services they access.
    “For a lot of people, a lack of transparency reinforces the view that they’re sitting at the bottom of the pile in terms of priority even when seeking information about their own care,” she said.
    Read full story
    Source: The Guardian, 25 May 2022
  2. Patient Safety Learning
    Britain’s safety at work regulator refused to investigate reports from NHS trusts that 10 frontline staff had died as a result of catching Covid-19 during the pandemic.
    The Health and Safety Executive (HSE) declined to look into at least 89 dangerous incidents that NHS trusts said involved healthcare workers being exposed to Covid, including 10 deaths.
    The stance taken by the HSE, which oversees workplace health and safety and can bring prosecutions, is disclosed in freedom of information requests by the Pharmaceutical Journal. It has prompted concern that the regulator is too strict in its definition of workplace harm.
    It found that 173 trusts in England submitted at least 6,007 reports about employees’ exposure to Covid-19 in the course of their duties to the HSE between 30 January 2020 and 11 March 2022, under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR).
    They included 213 “dangerous occurrences”, which are incidents that have the potential to cause significant harm; 5,753 cases where a staff member had caught Covid-19; and 41 deaths among people who had been exposed to the disease at their workplace.
    However, the HSE refused to look into five Covid deaths reported under the RIDDOR scheme by the Yorkshire ambulance service (YAS) because of what it considered a lack of evidence.
    The regulator also decided not to look into the Covid deaths of five staff at University College London hospital acute trust, despite the trust’s belief they had caught it at work. “The HSE found that there was no reasonable evidence that the infection was contracted at work,” a trust spokesperson said.
    Shelly Asquith, the health, safety and wellbeing officer at the Trades Union Congress, said the HSE’s decisions and claimed lack of evidence was “really concerning”. It suggested a continued “element of denial about Covid being airborne and it not being possible to necessarily pinpoint where exactly somebody was exposed once it’s in the air”, she added.
    Read full story
    Source: Guardian, 26 May 2022
  3. Patient Safety Learning
    Four hospitals in Greater Manchester are struggling with a near ‘total IT failure’ which has forced staff in all key services to use handwritten lists and notes.
    The problems have affected multiple IT systems across Royal Oldham, Fairfield General, Rochdale Infirmary and North Manchester General hospitals.
    Staff at the sites are running theatre and emergency departments using handwritten patient lists and notes, while bloods and scan results are also being written by hand. Patient histories are largely unavailable.
    HSJ spoke to staff who said there are major concerns over patient safety, as the lack of digital systems increases the risk of errors, and also slows down multiple processes. They described the problems as a “total IT failure”.
    Chris Brookes, deputy CEO and chief medical officer, said: “Patient safety and maintaining essential services remains our priority. We are doing everything we can to fix the IT issues and to limit disruption to patients and our services."
    Read full story (paywalled)
    Source: HSJ, 25 May 2022
  4. Patient Safety Learning
    Covid-19 vaccination is effective for cancer patients but protection wanes much more rapidly than in the general population, a large study has found.
    Vaccine effectiveness is much lower in people with leukaemia or lymphoma, those with a recent cancer diagnosis, and those who have had radiotherapy or systemic anti-cancer treatments within the past year, according to the research published in Lancet Oncology.
    The authors of the world’s largest real world health system evaluation of Covid-19 in cancer patients highlighted the importance of booster programmes, non-pharmacological strategies, and access to antiviral treatment programmes in order to reduce the risk that Covid-19 poses to cancer patients.
    Peter Johnson, professor of medical oncology at the University of Southampton and joint author of the study, said, “This study shows that for some people with cancer, covid-19 vaccination may give less effective and shorter lasting protection. This highlights the importance of vaccination booster programmes and rapid access to covid-19 treatments for people undergoing cancer treatments.”
    Study leader, Lennard Lee, department of oncology, University of Oxford, said, “Cancer patients should be aware that at 3-6months they are likely to have less protection from their coronavirus vaccine than people without cancer. It is important that people with a diagnosis of cancer are up to date with their coronavirus vaccination and have had their spring booster if they are eligible.”
    Read full story
    Source: BMJ, 24 May 2022
  5. Patient Safety Learning
    Violence against healthcare workers has become a “global crisis”, with 161 medics killed and 188 incidents of hospitals being destroyed or damaged last year, according to a new report.
    Data collected from 49 conflict zones by the Safeguarding Health in Conflict Coalition (SHCC), also found that 320 health workers were wounded in attacks, 170 were kidnapped and 713 people were arrested in the course of their work.
    The US-based group said on Tuesday that, although the total number of attacks was similar to those recorded in recent years, there had been an increase in violence in areas of new or renewed conflict in 2021, “underlining the fact that attacks on healthcare are a common feature in many of today’s conflicts”.
    Christina Wille, director at Insecurity Insight, which led the data collection and analysis, said: “Violence against healthcare resulted in widespread impacts on public health programmes, vaccination campaigns and population health, contributing to avoidable deaths and long-term consequences for individuals, communities, countries and global health writ large.”
    Read full story
    Source: The Guardian, 24 May 2022
  6. Patient Safety Learning
    A struggling ambulance trust could face a ‘Titanic moment’ and collapse entirely this summer if the region’s worsening problems with hospital handover delays are not taken more seriously, its nursing director has told HSJ.
    Mark Docherty, of West Midlands Ambulance Service (WMAS), said patients were “dying every day” from avoidable causes created by ambulance delays and that he could not understand why NHS England and the Care Quality Commission were “not all over” the issue.
    He revealed that handover delays at the region’s hospitals were the worst ever recorded, that rising numbers of people were waiting in the back of ambulances for 24 hours, and that serious incidents have quadrupled in the past year, largely due to severe delays.
    More than 100 serious incidents recorded at WMAS relate to patient deaths where the service has been unable to respond because its ambulances are held outside hospitals, according to the minutes of the trust’s March quality and safety committee.
    "Around 17 August is the day I think it will all fail,” he said. “I’ve been asked how I can be so specific, but that date is when a third of our resource [will be] lost to delays, and that will mean we just can’t respond. Mathematically it will be a bit like a Titanic moment.
    ”It will be a mathematical certain that this thing is sinking, and it will be pretty much beyond the tipping point by then.”
    Read full story (paywalled)
    Source: HSJ, 25 May 2022
  7. Patient Safety Learning
    RaDonda Vaught has spoken out about her criminal case for the first time last week in an exclusive interview with ABC News.
    Ms. Vaught, 38, was sentenced to three years of supervised probation on 13 May. She was convicted of criminally negligent homicide and abuse of an impaired adult for a fatal medication error she made in December 2017 after overriding an electronic medical cabinet as a nurse at Vanderbilt University Medical Center in Nashville, Tenn. The error, in which vecuronium, a powerful paralyser, was administered instead of the sedative Versed, led to the death of 75-year-old Charlene Murphey. 
    "I will never be the same person," Ms. Vaught told ABC News, "It's really hard to be happy about something without immediately feeling guilty. She could still be alive, with her family. Even with all the system errors, the nurse is the last to check."
    Ms. Vaught immediately took responsibility for the medication error after it occurred but contends that her actions alone did not cause the error. Her case has spurred an outcry from nurses across the country, many of whom have expressed concerns about the likelihood of similar mistakes under increasingly difficult working conditions. 
    "So many things had to line up incorrectly for this error to have happened, and my actions were not alone in that," Ms. Vaught said. 
    When Ms. Pilgrim asked her if she felt like a scapegoat, Ms. Vaught said, "I think the whole world feels like I was a scapegoat."
    "There's a fine line between blame and responsibility, and in healthcare, we don't blame," she said. "I'm responsible for what I failed to do. Vanderbilt is responsible for what they failed to do."
    Read full story
    Source: Becker's Hospital Review, 23 May 2022
  8. Patient Safety Learning
    The parents of a girl who died after failings by NHS 111 said they were horrified to learn coroners had already warned about similar shortcomings.
    Hannah Royle, 16, died in 2020 after the NHS phone service failed to realise she was seriously ill.
    BBC News found concerns had been raised about the call centre triage software in 2019 after three children died.
    The NHS said it had learnt lessons from each case, but said it had not established a link between the deaths.
    Hannah, who was autistic, had a cardiac arrest as she was driven to East Surrey Hospital by her parents. She had suffered a twisted stomach, but call handlers believed she had gastroenteritis.
    A coroner's report said NHS 111 staff failed to consider her "disabilities and inability to verbalise" when using the triage software.
    Known as NHS Pathways, the algorithm relies on answers being given over the phone to a set series of questions. The system guides call handlers, who are not medically qualified, to direct patients to other parts of the NHS for further assessment and treatment.
    In 2019, three coroners issued reports "to prevent future deaths" after serious abdominal illness in Myla Deviren, Sebastian Hibberd, Alexander Davidson and were missed by NHS 111.
    In all cases, coroners raised concerns about the ability of children to understand call handlers' questions or articulate their symptoms.
    Read full story
    Source: BBC News, 24 May 2022
  9. Patient Safety Learning
    A two-year-old with a twisted bowel died despite her mother telling NHS non-emergency services about "blue lips and breathlessness", a coroner said.
    Myla Deviren's mother spoke to a series of NHS 111 and out-of-hours service advisors, but none "appreciated" her symptoms and she later died. A coroner said with earlier hospital transfer and appropriate treatment Myla probably would have survived.
    The 111 provider said it had made a number of changes since Myla's death.
    In a prevention of future deaths report, Rosamund Rhodes-Kemp, assistant coroner for Cambridgeshire, said after Mylabecame unwell in the early hours of 27 August 2015 her mother rang 111. During the call the health assistant "did not appreciate the significance of key symptoms", Ms Rhodes-Kemp said. 
    Ms Rhodes-Kemp said that further steps in the 111 and out-of-hours services should be taken, including mandatory annual training for all call staff and having a "suitably-qualified" paediatric specialist clinician available. She added the "default position and precautionary advice should be - if in doubt call an ambulance".
    Read full story
    Source: BBC News, 7 November 2019
     
  10. Patient Safety Learning
    NHS Scotland is to change the way women are called to breast cancer detection appointments after major recent errors in the screening programme.
    Some eligible for screening were not invited because they had moved between GP practices or were aged over 71 by the time their practice was called.
    Women aged 50 to 70 are invited for appointments once every three years, based on their GP practice.
    It emerged hundreds of women in NHS Lothian may have missed screenings.
    The health board said in January that 369 women considered to have a higher risk of developing the disease may not have received appointments at the right time.
    A major review of the programme in Scotland has made 17 recommendations to strengthen and improve services.
    They include:
    A more "person-centred" approach based on calling individual women - rather than the GP practice where they are registered - to set their next test date. Greater flexibility of appointments to provide better access and uptake, with more contact such as texts or phone calls to keep appointments on patients' radar. An online appointment cancellation and rebooking system to provide greater individual convenience. Evening and weekend appointments and more availability in rural and semi-urban locations. Read full story
    Source: BBC News, 24 May 2022
  11. Patient Safety Learning
    Damage to the body’s organs including the lungs and kidneys is common in people who were admitted to hospital with Covid, with one in eight found to have heart inflammation, researchers have revealed.
    As the pandemic evolved, it became clear that some people who had Covid were being left with ongoing symptoms – a condition that has been called Long Covid.
    Previous studies have revealed that fewer than a third of patients who have ongoing Covid symptoms after being hospitalised with the disease feel fully recovered a year later, while some experts have warned Long Covid could result in a generation affected by disability.
    Now researchers tracking the progress of patients who were treated in hospital for Covid say they have found evidence the disease can take a toll on a range of organs.
    What’s more, they say the severity of ongoing symptoms appears to be linked to the severity of the Covid infection itself.
    “Even fit, healthy individuals can suffer severe Covid-19 illness and to avoid this, members of the public should take up the offer of vaccination,” said Prof Colin Berry, of the University of Glasgow, which led the CISCO-19 (Cardiac imaging in Sars coronavirus disease-19) study.
    “Our study provides objective evidence of abnormalities at one to two months post-Covid and these findings tie in with persisting symptoms at that time and the likelihood of ongoing health needs one year later,” Berry added.
    Read full story
    Source: The Guardian, 23 May 2022
     
  12. Patient Safety Learning
    "I knew I always felt different, but I didn't know I was autistic."
    For Rhiannon Lloyd-Williams, it would take until she was 35 to learn just why she felt different.
    Now research by Swansea University has found it takes on average six years longer to diagnose autism in women and girls than in males.
    A study of 400 participants found that 75% of boys received a diagnosis before the age of 10 - but only 50% of girls.
    It also found the average age of diagnosis in girls was between 10 and 12 - but between four and six for boys.
    Now charities in Wales are calling for greater investment into services to help better understand autism in females and speed up a diagnosis.
    "The parents responding to the study said there was a marked impact on the girls mental health while waiting for a diagnosis," said Steffan Davies, who carried out the research.
    "Girls represented in the study had a lot more pre-existing diagnosis, which suggests they are being misdiagnosed with anxiety disorders, eating disorders, and that tends to defer from the root diagnosis which tends to be autism."
    Autism UK said this gender gap has long been an issue and is the down to the diagnosis criteria and research used, which has been focused around young boys.
    "Many girls end up missing out on education, because the environment they're expected to learn in is just too overwhelming, while accessing healthcare can be difficult. Women are often not believed," said executive director Willow Holloway.
    Read full story
    Source: BBC News, 23 May 2022
  13. Patient Safety Learning
    In England, only a third of adults – and half of children – now have access to an NHS dentist. As those in pain turn to charity-run clinics for help, can anything stop the rot?
    It is over an hour before the emergency dental clinic is due to open, but Jodie Manning is taking no chances. She hasn’t been able to eat for four days – “I can’t physically bite down any more” – and is determined to get an appointment. 
    Aged 19, she has been to hospital with severe toothache “three-and-a-half times” in the previous year. The half is when they sent her home without treatment; on the other occasions, she was kept in overnight after collapsing from pain and dehydration, when even drinking liquids hurt her swollen mouth. Morphine has become her crutch: she fell asleep in college recently after taking the powerful painkiller. Like many of those waiting grimly in line, she has been struck off by her NHS dentist after not attending for two years, even though surgeries were shut to all but emergency cases during Covid.
    The same desperation can be seen across England, particularly in the north and east. Only a third of adults – and less than half of English children – now have access to an NHS dentist, according to the Association of Dental Groups (ADG). At the same time, three million people suffer from oral pain and two million have undertaken a round trip of 40 miles for treatment, the ADG calculated recently, calling dentistry “the forgotten healthcare service”. Tooth extraction is now the most common reason for a child to be admitted to hospital, costing the NHS £50m a year.
    The decline of NHS dentistry has deep roots. Years of underfunding and the current government contract, blamed for problems with burnout, recruitment and retention. Dentists are paid a flat fee for services regardless of how long a treatment takes (they get the same amount if they extract one tooth or five, for example). Covid exacerbated existing challenges, with the airborne disease posing a health risk for dentists peering into strangers’ mouths all day.
    As the British Dental Association put it in its most recent briefing: “NHS dentistry is facing an existential threat and patients face a growing crisis in access, with the service hanging by a thread.”
    Read full story
    Source: The Guardian, 24 May 2022
  14. Patient Safety Learning
    The government is to investigate claims an ambulance service covered up details of the deaths of patients following mistakes by paramedics.
    It follows the Sunday Times report that North East Ambulance Service (NEAS) withheld information from coroners.
    Labour's shadow health secretary Wes Streeting described the alleged cover-up as "a national disgrace".
    Health minister Maria Caulfield said she was "horrified" and there would be a further investigation.
    The newspaper reported that concerns were raised about more than 90 cases and whistleblowers believed NEAS had prevented full disclosure to relatives of people who died in 2018 and 2019.
    Speaking in the House of Commons, Mr Streeting asked why the regulator - the Care Quality Commission (CQC) - had failed to take action.
    Ms Caulfield said that while both the NEAS and the CQC had both reviewed the allegations, further investigation was required.
    The minister said non-disclosure agreements have "no place in the NHS", adding: "Reputation management is never more important than patient safety."
    Read full story
    Source: BBC News, 23 May 2022
  15. Patient Safety Learning
    Health officials are calling for urgent intervention from the government to meet the steep surge in demand for occupational therapy in the wake of the Covid-19 pandemic.
    According to healthcare professionals from both the NHS and the private care system, demand for occupational-therapy-led rehabilitation services in Britain has increased by a staggering 82 per cent over the past six months alone.
    Swelling pressure on already “overloaded” rehabilitation services has stirred up stark warnings from members of the Royal College of Occupational Therapists (RCOT), who say the level of demand for the service they provide “isn’t sustainable” as there isn’t a large enough workforce to meet the need.
    A revealing survey carried out by the college has raised grave questions about the prospect of providing timely rehabilitation for people recovering from short and long-term illnesses who need urgent support to enable them to carry out their daily activities.
    The survey of of 550 occupational therapists working in the UK found that 84 per cent are now supporting people whose needs have become more complex because of delays in treatment brought about by the pandemic.
    As a result of this, coupled with a wider increase in the number of people requiring help, 71 per cent of the RCOT’s respondents felt there were not enough occupational therapists to meet the demand.
    Read full story (paywalled)
    Source: The Independent, 22 May 2022
  16. Patient Safety Learning
    THE NHS has announced plans to scrap prescriptions for 35 conditions in a bid to save the money it spends on drugs available over-the-counter (OTC). The body said it will no longer issue treatments for a range of minor conditions, such as diarrhoea, oral thrush and ailments associated with pain.
    The health body will no longer prescribe drugs for 35 conditions listed below, which patients will have to purchase from their local pharmacy or supermarket going forward. The plan to dial back on prescriptions was devised with the aim of allocating funds to treatments for more serious conditions, according to the health body. Many of the conditions are able to resolve on their own, but prescriptions may still be issued if an exemption applies.
    Acute sore throat Conjunctivitis Coughs, colds, and nasal congestion Cradle cap Dandruff Diarrhoea Dry eyes / sore tired eyes Earwax Excessive sweating Haemorrhoids Head live Indigestion and heartburn Infant colic Infrequent cold sores of the lip Infrequent constipation Infrequent migraine Insect bites and stings Mild acne Mild burns and scalds Mild cystitis Mild dry skin Mild irritant dermatitis Mild to moderate hay fever Minor conditions associated with pain, discomfort and fever (e.g. aches and pain, headache, period pain, back pain) Mouth ulcers Nappy rash Oral thrush Prevention of tooth decay Ringworm/athlete’s foot Sunburn Sun protection Teething / mild toothache Threadworms Travel sickness Warts and verrucae Read full story
    Source: Express, 20 May 2022
  17. Patient Safety Learning
    Three intensive care units for children are not meeting standards for co-located services, a national report has found.
    Royal Stoke University Hospital, Royal Brompton Hospital in London and Freeman Hospital in Newcastle, which all have “level three” paediatric intensive care beds for the most seriously ill patients, do not offer specialised paediatric surgery, according to a report from NHS England’s Getting it Right First Time (GIRFT) programme.
    The report, released in April, said specialised paediatric surgery “should be co-located on the same site” as a paediatric intensive care unit with level three beds and be “immediately available” to meet quality standards set by the Paediatric Intensive Care Society.
    The report also found the units do not offer services such as trauma, neurosurgery and bone marrow transplantation, which it says is a reflection of the variability and “the poor alignment” of specialised paediatric services at PICUs.
    Read full story (paywalled)
    Source: HSJ, 23 May 2022
  18. Patient Safety Learning
    More than 400,000 children and young people a month are being treated for mental health problems – the highest number on record – prompting warnings of an unprecedented crisis in the wellbeing of under-18s.
    Experts say Covid-19 has seriously exacerbated problems such as anxiety, depression and self-harm among school-age children and that the “relentless and unsustainable” ongoing rise in their need for help could overwhelm already stretched NHS services.
    The latest NHS figures show “open referrals” – troubled children and young people in England undergoing treatment or waiting to start care – reached 420,314 in February, the highest number since records began in 2016.
    The total has risen by 147,853 since February 2020, a 54% increase, and by 80,096 over the last year alone, a jump of 24%. January’s tally of 411,132 cases was the first time the figure had topped 400,000.
    Mental health charities welcomed the fact that an all-time high number of young people are receiving psychological support. But they fear the figures are the tip of the iceberg of the true number of people who need care, and that many more under-18s in distress are being denied help by arbitrary eligibility criteria.
    Read full story
    Source: The Guardian, 22 May 2022
  19. Patient Safety Learning
    Black and Asian women are being harmed by racial discrimination in maternity care, according to an inquiry.
    The year-long investigation into "racial injustice" was conducted by the charity Birthrights.
    Women reported feeling unsafe, being denied pain relief, facing racial stereotyping about their pain tolerance, and microaggressions.
    The government has set up a taskforce to tackle racial disparities in maternity care.
    Hiral Varsani says she was traumatised by her treatment during the birth of her first child.
    The 31-year-old from north London developed sepsis - a potentially life-threatening reaction to an infection - after her labour was induced, which she says was only spotted after a long delay.
    "I was shivering, my whole body was aching, my heart was beating really fast and I felt terrible. But everyone kept saying everything was normal," she says. "It was almost 24 hours later before a doctor took my bloods for the first time and realised I was seriously ill."
    She believes her race played a role in her care: "I experienced microaggressions and was stereotyped because of the colour of my skin.
    "I was repeatedly ignored, they just thought I was a weak little Indian girl, who was unable to take pain."
    While death in pregnancy or childbirth is very rare in the UK, there are stark racial disparities in maternal mortality rates. Black women are more than four times more likely to die in pregnancy or childbirth than white women in the UK, while women from Asian backgrounds face almost twice the risk.
    Read full story
    Source: BBC News, 23 May 2022
  20. Patient Safety Learning
    The United States Surgeon General Dr. Vivek Murthy issued a new Surgeon General’s Advisory highlighting the urgent need to address the health worker burnout crisis across the country. Health workers, including physicians, nurses, community and public health workers, nurse aides, among others, have long faced systemic challenges in the health care system even before the COVID-19 pandemic, leading to crisis levels of burnout. The pandemic further exacerbated burnout for health workers, with many risking and sacrificing their own lives in the service of others while responding to a public health crisis. Promoting the mental health and well-being of our nation’s frontline health workers is a priority for the Biden-Harris Administration and a core objective of President Biden’s national mental health strategy, within his Unity Agenda.  
    The Surgeon General’s Advisory Addressing Health Worker Burnout lays out recommendations that the whole-of-society can take to address the factors underpinning burnout, improve health worker well-being, and strengthen the nation’s public health infrastructure.   
    “At the height of the COVID-19 pandemic, and time and time again since, we’ve turned to our health workers to keep us safe, to comfort us, and to help us heal,” said Secretary of Health and Human Services Xavier Becerra. “We owe all health workers – from doctors to hospital custodial staff – an enormous debt. And as we can clearly see and hear throughout this Surgeon General’s Advisory, they’re telling us what our gratitude needs to look like: real support and systemic change that allows them to continue serving to the best of their abilities. I’m grateful to Surgeon General Murthy for amplifying their voices today. As the Secretary of Health and Human Services, I am working across the department and the U.S. government at-large to use available authorities and resources to provide direct help to alleviate this crisis.”
    “The nation’s health depends on the well-being of our health workforce. Confronting the long-standing drivers of burnout among our health workers must be a top national priority,” said Surgeon General Vivek Murthy. “COVID-19 has been a uniquely traumatic experience for the health workforce and for their families, pushing them past their breaking point. Now, we owe them a debt of gratitude and action. And if we fail to act, we will place our nation’s health at risk. This Surgeon General’s Advisory outlines how we can all help heal those who have sacrificed so much to help us heal.”   
    Read full story
    Source: HHS, 23 May 2022
  21. Patient Safety Learning
    Hundreds of thousands of patients referred to specialists by their GPs are being rejected by hospitals and left to deteriorate because there are no appointments available.
    NHS waiting lists are already buckling under record-high backlogs and now delays are being compounded as local doctors struggle to even get their patients to outpatient services.
    Patients’ referrals are rejected by hospital trusts if there are no appointment slots available, meaning they get bounced back to the GP who is unable to help with their complex needs, leaving them without the care they desperately need.
    Clare Rayner, 54, from Manchester, has been left distraught by delays which have hampered the treatment she needs for complex spinal problems. She is still waiting to find out if an upcoming appointment with a neurologist is going ahead after a request for an urgent review from her GP was ignored five times.
    Outpatient referrals are typically classed as having an “appointment slot issue” (ASI) when no booking slot is available within a specific time frame, under the NHS e-Referral system.
    According to experts, the situation varies between specialities, but is reportedly particularly bad in areas such as mental health and neurology.
    Ms Rayner, a former medical teacher who had to retire because of ill health, said: “I’ve been sent all around the country for neurosurgery over the last few years so have been directly affected by being bounced back to my GP."
    “A unit in London rejected me because they said I lived too far away, which was ridiculous as they take people from all over the UK, and a local consultant just never replied to my GP’s email.
    Ms Rayner said she has endured “massive delays” to her care which had left her intensely frustrated. “It’s left me with significant deterioration with my spinal problems and that’s been very distressing,” she said.
    Helen Hughes, chief executive of charity and campaign group Patient Safety Learning, said: “NHS England needs to urgently investigate, quantify the scale of the problem and take action if we are to prevent these capacity problems resulting in avoidable harm for patients.”
    A target for providers to reduce ASIs to a rate of 4% or less of their total outpatient activity was set by NHS England in 2019. Guidance in subsequent years has seen a move towards the requirement for providers to implement “innovative pathways” to support prevention of ill health.
    Read full story
    Source: iNews, 22 May 2022
    Related blogs on the hub:
    Rejected outpatient referrals are putting patients at risk and increasing workload pressure on GPs A child left waiting for ‘urgent’ surgery, a blog by Clare Rayner  
  22. Patient Safety Learning
    More than one in five patients at some hospitals are leaving accident and emergency departments before completing treatment, and in some cases before being seen for assessment at all, with the rate across England trebling since before the pandemic.
    Experts told the Observer that the increase was probably driven by a combination of long A&E waiting times and by difficulties accessing NHS facilities such as GPs, community health services and NHS 111.
    The figures apply to patients who left A&E before an initial assessment; after an assessment but before treatment started; or before treatment was completed. They include patients who left to find treatment elsewhere.
    David Maguire, a senior analyst with the King’s Fund health thinktank, linked the rise to patients having difficulty accessing other parts of the NHS and going to A&E instead.
    “We’re probably talking about things that won’t require an admission, but it’s important that you get seen by someone,” he said. “So for example, somebody’s got a chest pain, somebody’s got some sort of adverse indication that you would want to seek attention for. It’s a perfectly rational thing to do. But it’s a struggle to access at other points [in the NHS], so you default towards A&E.”
    He added that staff shortages and social care capacity were also contributing factors.
    “I think it’s a lot of the NHS not functioning properly. Pre-pandemic, there was a certain amount of flex in the system – even with the problems that we were seeing around performance – that meant you could come to A&E with some of these issues. That flex in the system has gone – the capacity has been absorbed by other issues.”
    Read full story
    Source: The Observer, 21 May 2022
  23. Patient Safety Learning
    Quinn Evie Beadle died in 2018. Her parents later found out that the “kind, caring” 17-year-old had been failed by a paramedic at the scene of her death — and that the ambulance service altered documents to try to stop them finding out the truth.
    The teenager, who dreamt of becoming a medic but suffered poor mental health, was found after she hanged herself near her home in Shildon, Co Durham, on the evening of 9 December 2018. The paramedic who attended the scene made basic mistakes, and made no effort to clear her airway or continue with basic life support — despite the fact her heart was still active.
    But instead of attempting to learn lessons, bosses at the North East Ambulance Trust (NEAS) set out to prevent the family learning what happened.
    They changed a key witness statement given to the coroner at her first inquest, removing references to mistakes the paramedic had made and inserting the claim that any life support offered would “not have had a positive outcome”. They also withheld from the coroner a key piece of evidence — a reading from a heart monitor — which demonstrated Quinn’s heart activity.
    It is thought Quinn’s death could be one of more than 90 cases in the past three years in which the NEAS failed to provide families with the whole truth about how their relatives died.
    Senior managers repeatedly withheld key evidence from coroners about deaths linked to service failures, an internal report shows. In some cases, bosses doctored or suppressed evidence to cover up failures by staff.
    An independent report into a small number of the cases, including Quinn’s, raised by whistleblowers found that, as in her case, statements were changed or suppressed and pieces of key evidence not disclosed.
    Read full story (paywalled)
    Source: The Sunday Times, 22 May 2022
  24. Patient Safety Learning
    A health worker has been arrested on suspicion of administering poison with intent to endanger life after a child died at Birmingham Children's Hospital.
    The 27-year-old woman was arrested on Thursday and has been suspended from her role at the hospital.
    The child was being treated in the Paediatric Intensive Care Unit, a spokesperson for the hospital said.
    Police said the woman had been released while investigations continued and forensic tests were being examined.
    A spokesperson for Birmingham Women's and Children's NHS Foundation Trust said it was "supporting the infant's family at this distressing time and ask that privacy is respected during this process".
    "Following the death of an infant at our Paediatric Intensive Care Unit at Birmingham Children's Hospital, we have asked West Midlands Police to examine what has happened, in line with our own safeguarding policy," it added.
    "The staff member involved has been suspended by the Trust following the national process on the sudden unexpected death of a child."
    Read full story
    Source: BBC News, 23 May 2022
  25. Patient Safety Learning
    Hospital admissions for people with eating disorders in England have risen 84% in the last five years, official NHS figures reveal.
    There were 11,049 more admissions for illnesses such as bulimia and anorexia in 2020-21 than in 2015-16, with 24,268 admissions in total. Experts described the increase as “alarming”.
    The number of children and young people admitted to hospital with eating disorders grew from 3,541 to 6,713, with a 35% increase in the last year alone as the Covid pandemic hit, according to the analysis by the Royal College of Psychiatrists.
    A particularly stark rise in admissions – 128% – was seen in boys and young men, from 280 hospital admissions in 2015-16 to 637 in 2020-2021.
    The college has published guidelines to help health professionals identify people whose eating disorders have become life-threatening and get them the right care. It said the signs that somebody was dangerously ill could be missed at GP surgeries and in A&E due to a lack of guidance and training.
    Dr Dasha Nicholls, who chaired the development of the medical emergencies in eating disorders guidelines, said: “Eating disorders such as anorexia, bulimia and binge eating don’t discriminate, and can affect people of any age and gender.
    “They are mental health disorders, not a ‘lifestyle choice’, and we shouldn’t underestimate how serious they are. Even though anorexia nervosa is often referred to as the deadliest mental health condition, most deaths are preventable with early treatment and support. Full recovery is possible if spotted and treated early.”
    Read full story
    Source: The Guardian, 19 May 2022

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