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Patient Safety Learning

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  1. Patient Safety Learning
    RaDonda Vaught, a former nurse in Tennessee who was convicted on felony charges for fatally injecting a patient with an incorrect drug, was sentenced to probation Friday in a case that became a rallying cry for health-care workers fearful that medical mistakes would be criminalised.
    Vaught, who worked at Vanderbilt University Medical Center in Nashville, faced up to eight years in prison for giving 75-year-old Charlene Murphey a fatal dose of the wrong medication in December 2017. Prosecutors said that instead of giving Murphey a dose of the sedative Versed, Vaught injected the patient with the powerful muscle relaxant vecuronium, which left her unable to breathe. Vaught, 38, was convicted in March of criminally negligent homicide and gross neglect of an impaired adult.
    Davidson County Criminal Court Judge Jennifer Smith ruled Friday that Vaught would be granted a judicial diversion, meaning the conviction would be expunged from the records if she completed a three-year probation.
    “Ms. Vaught is well aware of the seriousness of the offense,” Smith said, according to NPR, noting that the Murphey family had suffered a “terrible loss.” “She credibly expressed remorse in this courtroom.”
    The judge added that Vaught, who was shaking and had broken into tears as the order was read, had no previous criminal record and would never be a nurse again.
    Vaught, who took responsibility for her actions immediately, had apologized to the Murphey family in court, saying she’d “be forever haunted by my role in her untimely passing.”
    The judge’s sentencing Vaught to probation instead of prison ends a case that has galvanised healthcare workers who have spoken out against poor working conditions that have only been exacerbated during the coronavirus pandemic.
    Medical errors, including those that result in death, are usually dealt with by state medical boards. Lawsuits against those involved in fatal medical mistakes are almost never prosecuted in criminal court, which made Vaught’s case a matter of national interest in recent months.
    Read full story  (paywalled)
    Source: Washington Post, 14 May 2022
  2. Patient Safety Learning
    Tens of thousands of emergency calls are taking more than two minutes to be answered in England amid a crisis in the ambulance service, The Independent has learned.
    More than 37,000 emergency calls took more than two minutes to answer in April 2022 – 24 times the 1,500 that took that long in April 2021, according to a leaked staff message.
    April’s figures were slightly down compared to March, The Independent understands, when 44,000 calls took more than two minutes to answer.
    The deterioration in 999 calls being answered within the 60-second goal comes as ambulance services across the UK have been placed under huge pressures.
    The latest NHS data showed long delays in response times for ambulance services with stroke or suspected heart attack patients waiting more than 50 minutes on average. Response times are being driven by ambulances being held up outside of A&Es because emergency departments are unable to take patients.
    In March, there were likely to have been more than 4,000 instances of severe harm caused to patients as a result of ambulances being delayed by more than 60 minutes.
    Martin Flaherty, managing director of AACE said: “It is no secret that UK ambulance services and their staff are under intense pressure, which is further evidence of the need to secure more funding for ambulance services as soon as possible, continue to find more ways to protect and care for our staff, prevent the depletion of our workforce and above all, eradicate hospital handover delays.
    “AACE believes that whilst reasons such as overall demand and increasing acuity of patients are certainly contributory factors, the most significant problem causing these pressures remains hospital handover delays. These have increased exponentially and the numbers of hours lost to ambulance services is now unprecedented. For example, in some regions in March, ambulance trusts were losing up to one third of all the ambulance hours they were capable of producing due to hospital handover delays.”
    Read full story
    Source: The Independent, 15 May 2022
  3. Patient Safety Learning
    Junior doctors have been prevented from returning to scandal hit heart surgery unit previously criticised over “toxic” culture, The Independent has learned.
    A coroner defended cardiac surgery at St George’s University Hospital, criticising an NHS-commissioned review into 67 deaths that warned of poor care.
    However, The Independent has learned the unit received a critical report from Health Education England (HEE), the body responsible for healthcare training, just last year.
    The NHS authority was so concerned about culture problems and “inappropriate behaviour” within the unit that it took away the junior doctors working there.
    This is the third time HEE has intervened since 2018, when the unit was criticised in an independent review for having a “toxic” culture.
    In a statement, Professor Geeta Menon, postgraduate dean for South London at Health Education England, said: “HEE carried out a review of cardiac surgery at St George’s University Hospital in July 2021 and concluded that further improvements were required to create a suitable learning environment for doctors in training.
    "Unfounded’ NHS criticism and investigation caused unnecessary deaths at London heart surgery unit
    “We continue to work closely with the trust to implement our requirements and recommendations and will reassess their progress this summer. HEE is committed to ensuring high quality patient care and the best possible learning environment for postgraduate doctors at St George’s.”
    The Independent understands that a report issued in December, following the HEE visit, identified problems of “inappropriate behaviour”, poor team working from consultants and raised concerns the culture problems previously identified at the unit persisted.
    Read full story
    Source: The Independent, 14 May 2022
  4. Patient Safety Learning
    Families are being ‘left without the support they need’, as overstretched services struggle to handle ‘a significant and growing minority’ of children not developing as expected.
    Figures published by the Office for Health Improvement and Disparities earlier this month show 79.6% of children who received a two-to-two-and-a-half year review with an ages and stages questionnaire during quarter three of 2021-22 met the expected level in all five areas of development measured.
    The five areas assessed by the screening questionnaire are communication skills, gross motor skills, fine motor skills, problem solving, and personal-social. A lower-than-expected score in any of the five areas will likely mean some sort of intervention, which may include further monitoring from health visitors or referral to a specialist service. However, health visitor numbers are declining. ber 2015.
    Alison Morton, Institute of Health Visiting executive director, said: “The latest national child development data highlight a worrying picture with fewer children at or above the expected level of development at two-to-two-and-a-half years. While the majority of children are developing as expected, a significant and growing minority are not.
    “The pandemic and its impacts are not over. In many areas, despite health visitors’ best efforts, they are now struggling to meet growing levels of need and vulnerability and a backlog of children who need support. In our survey, health visitors reported soaring rates of domestic abuse, mental health problems, child behaviour and development problems, poverty, and child safeguarding.
    “In addition, onward referral services like speech and language therapy, and mental health services, also have long waiting lists and families are left without the support that they need.”
    Read full story
    Source: HSJ, 16 May 2022
  5. Patient Safety Learning
    Thousands of patients have been left without vital healthcare after nearly 1 in 10 physiotherapists was prevented from practising after their regulator removed them from its register.
    Exactly 5,311 physiotherapists were deregistered by the Health and Care Professions Council (HCPC) on 1 May because they had not renewed their registration after the HCPC decided not to send out reminder letters.
    Ash James, director of practice and development at the Chartered Society of Physiotherapy (CSP), said its helpline had been swamped with calls from distressed physiotherapists, concerned for their patients and worried about dramatic losses in income.
    “In one of the trusts in Liverpool, 23 physios were sent home in one day, and obviously the implication for patients is huge,” he said.
    “At a time when the workforce is stretched by the Covid backlog, it’s obviously not ideal that we’ve lost 9% of the workforce overnight.”
    Physiotherapists have many roles but play a crucial part in helping people leave hospital after long stays, because lengthy bed rest leads to muscle wastage that leaves patients needing physiotherapy to learn to walk again.
    So far, only about 2,300 physios have been re-registered. With most practitioners seeing at least five patients a day, the number of cancelled NHS and private appointments in the past two weeks could range between 50,000 to 100,000.
    Read full story
    Source: The Guardian, 14 May 2022
  6. Patient Safety Learning
    Jeremy Hunt has been accused of ignoring serious NHS staff shortages for years and driving medics out of the profession while health secretary after he intervened this weekend to warn of a workforce crisis.
    Promoting his new book, 'Zero: Eliminating Unnecessary Deaths in a Post-Pandemic NHS', Hunt said tackling the “chronic failure of workforce planning” was the most important task in relieving pressure on frontline services. Now the chair of the health and social care committee, he said the situation was “very, very serious”, with doctors and nurses “run ragged by the intensity of work”.
    But his comments drew sharp criticism from healthcare staff, who said Hunt – the longest-serving health secretary in the 74-year history of the NHS – failed to take sufficient action to boost recruitment while in the top job between 2012 and 2018. Instead, critics said, his tenure saw health workers quit the NHS in droves for jobs abroad or new careers outside medicine. There are now 100,000 vacancies in the NHS, and the waiting list for treatment has soared to 6.4 million.
    “There’s an avalanche of pressure bearing down on the NHS. But for years Jeremy Hunt and other ministers ignored the staffing crisis,” said Sara Gorton, the head of health at Unison, the UK’s largest health union. “The pandemic has amplified the consequences of that failure. Experienced employees are leaving at faster rates than new ones can be recruited.”
    “Hunt has recently been an articulate analyst of current issues, particularly workforce shortages, but these haven’t come out of the blue,” said Dr Colin Hutchinson, the chair of Doctors for the NHS. “At the time he could have made the greatest impact, his response was muted. We have to ask: was the service people were receiving from the NHS better, or worse, at the end of his time in office? At the time when it most mattered, he was found wanting.”
    Read full story
    Source: The Guardian, 15 May 2022
  7. Patient Safety Learning
    It was hailed as a cutting-edge laboratory that would play a key role in response to Covid-19 and future epidemics, carrying out 300,000 tests a day.
    Announcing the project in November 2020, then-health secretary Matt Hancock said the project “confirms the UK as a world leader in diagnostics”.
    But less than 18 months later, the Rosalind Franklin Laboratory – named in honour of the renowned British scientist – has been plagued by failure while costing almost twice as much as its initial £588m budget, The Independent understands.
    Instead of being at the forefront of the fight against Covid, the project opened six months late, facing a string of issues with equipment, staff and construction, with barely 20% of its touted capacity being reached.
    Now, as the government winds down its “lighthouse” testing labs as part of the plan to “live with Covid”, leaving the Leamington Spa facility as the last lab standing, there are questions about the future of the site – and whether it would be able to cope with the nation’s testing needs alone if another deadly wave of Covid were to emerge.
    Read full story
    Source: The Independent, 28 April 2022
  8. Patient Safety Learning
    The United States could see a deficit of 200,000 to 450,000 registered nurses available for direct patient care by 2025, a 10 to 20% gap that places great demand on the nurse graduate pipeline over the next three years.
    The new estimates and analysis come from a McKinsey report published this week. The shortfall range of 200,000 to 450,000 holds if there are no changes in current care delivery models. The consulting firm estimates that for every 1% of nurses who leave direct patient care, the shortage worsens by about 30,000 nurses.
    To make up for the 10 to 20%, the United States would need to more than double the number of new graduates entering and staying in the nursing workforce every year for the next three years straight. For this to occur, the number of nurse educators would also need to increase.
    "Even if there was a huge increase in high school or college students seeking nursing careers, they would likely run into a block: There are not enough spots in nursing schools, and there are not enough educators, clinical rotation spots or mentors for the next generation of nurses," the analysis states. "Progress may depend on creating attractive situations for nurse educators, a role traditionally plagued with shortages."
    Read full story
    Source: Becker's Hospital Review, 12 May 2022
  9. Patient Safety Learning
    Doctors and paramedics have told the BBC that long waits for ambulances across the UK are having a "dangerous impact" on patient safety.
    BBC analysis found a 77% rise in the most serious safety incidents logged by paramedics in England over the past year, compared to before the pandemic.
    In Wales, Scotland and Northern Ireland, the 999 system is also under "tremendous pressure", doctors say.
    NHS England said the safety of patients is its "absolute priority".
    In October, nine-year-old Willow Clark fell off her bike on a country path in Hertfordshire, cracking her helmet and leaving her with a fractured skull and a nine-inch laceration across her leg.
    "I could see it was a really bad accident and I was 20 minutes away from home screaming for help," said her mother Sam. "These really nice people who were passing by phoned 999.
    "They explained she had a severe head injury and her leg was badly hurt but we were told it would be a 10-hour wait for an ambulance and we'd have to get her to hospital ourselves."
    When they got to A&E, Willow was immediately transferred to the trauma department. Doctors told her family that she should not have been moved because of her back and neck injuries.
    She later found out that Willow had been classified as an "urgent" category three case, meaning an ambulance should have arrived within 120 minutes.
    Coroners and lawyers have highlighted recent cases including:
    Staffordshire's assistant coroner issued a 'prevention of future deaths' warning after a patient in Stoke died after waiting eight hours for an ambulance. The family of a man who died after waiting nine hours for treatment has issued a legal challenge against the Northern Ireland Ambulance Service over a "chronic shortage" of ambulances. The London Ambulance service is investigating after a man died when paramedics took almost 70 minutes to respond to a suspected heart attack. Dr Katherine Henderson, an A&E consultant and president of the Royal College of Emergency Medicine, told the BBC's Today programme the problem with ambulance waits was "more serious than we've ever seen it".
    Read full story
    Source: BBC News, 12 May 2022
  10. Patient Safety Learning
    A former medical director on the Isle of Man, who lost her job when she questioned decisions made on the island during the COVID-19 pandemic, has won her case for unfair dismissal at an employment tribunal.
    The hearing, which began in January, heard how Dr Rosalind Ranson was victimised and dismissed from her role after making 'protected disclosures' as part of her efforts to persuade the Manx Government to deviate from Public Health England (PHE) advice in the early stages of the pandemic.
    Dr Ranson, who had extensive experience as a GP and as a senior medical leader in the NHS in England, was appointed to her post as the island's most senior doctor in January 2020 with the aim of tackling what she identified as a disillusioned medical workforce, failings in management, and a bullying culture.
    She was soon called on to provide expert medical advice and guidance on how the Isle of Man’s health system should respond to the spread of COVID-19. In March, Dr Ranson channelled concerns from the island's doctors that the advice from PHE was flawed, and that a more robust approach should be taken to stem the spread of SARS-CoV-2. That included closing the island’s borders – a move that was initially ignored.
    Dr Ranson became concerned that her medical advice was not being heeded and that it might not be being passed on to ministers by the then Chief Executive of the Isle of Man’s Department of Health and Social Care (DHSC), Kathryn Magson, who was not medically qualified.
    The tribunal heard that because Dr Ranson had "blown the whistle" when she spoke out, she was sidelined and eventually dismissed unfairly.
    Read full story
    Source: Medscape, 11 May 2022
  11. Patient Safety Learning
    Nurses from across the country are heading to Washington, D.C., and Nashville, Tenn., this week to march for better working conditions and to show support for nurse RaDonda Vaught. 
    Ms. Vaught, 38, 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. Her case has spurred a national outcry from nurses who argue the ruling sets a dangerous precedent for the profession and will discourage nurses from speaking up about errors. 
    Ms. Vaught's sentencing is scheduled for 13 May in Nashville, and she faces up to eight years in prison. Hundreds of nurses are planning to march in Nashville the day of the hearing to show their support for Ms. Vaught and to fight for better protection for nurses against criminal prosecution of errors. 
    "We expect a large number of people to show up … just to show our strength in numbers and hope that the judge takes this into consideration and makes it slightly better by not sentencing her to any prison time," said Erica, a Las Vegas-based hospice nurse who is attending the sentencing.
    Read full story
    Source: Becker's Hospital Review, 13 May 2022
  12. Patient Safety Learning
    The NHS has recorded its largest monthly increase in the waiting list for 10 months, as unprecedented challenges in urgent and emergency care continue to disrupt recovery.
    The elective figures published today for March presented mixed results, but much of the good news – a drop in the number of two-year waiters – had already been announced by NHS England in unvalidated figures for April.
    Meanwhile, the system recorded its largest monthly rise in the overall list for 10 months, with the number of patients growing by 174,847 to hit a new record 6.36 million. This is the biggest month-on-month increase since the number jumped between April and May 2021 when it rose by 181,708 to hit 5.3 million.
    The overall list has risen every month since May 2021, but the rises in the last four months have all been under 80,000.
    The NHS warned in February it expects the waiting list to continue rising until March 2024, with patients now seeking care after various covid lockdowns.
    Meanwhile, the number of patients waiting 12 hours from a decision to admit in accident and emergency departments reached a new high in data published today, covering April. 
    Ambulance response times also improved slightly last month from March’s all-time low. Average category one performance – for immediately life-threatening conditions, such as cardiac or respiratory arrest - was 9:02 minutes against a seven-minute target, but still an improvement on last month’s 9:35 minutes. 
    Read full story (paywalled)
    Source: HSJ, 12 May 2022
  13. Patient Safety Learning
    More than 107,000 Americans died of drug overdoses last year, setting another tragic record in the nation’s escalating overdose epidemic, the Centers for Disease Control and Prevention (CDC) estimated Wednesday.
    The provisional 2021 total translates to roughly one U.S. overdose death every 5 minutes. It marked a 15% increase from the previous record, set the year before. The CDC reviews death certificates and then makes an estimate to account for delayed and incomplete reporting.
    Dr. Nora Volkow, director of the National Institute on Drug Abuse, called the latest numbers “truly staggering.”
    The White House issued a statement calling the accelerating pace of overdose deaths “unacceptable” and promoting its recently announced national drug control strategy. It calls for measures like connecting more people to treatment, disrupting drug trafficking and expanding access to the overdose-reversing medication naloxone.
    Experts say the COVID-19 pandemic has exacerbated the problem as lockdowns and other restrictions isolated those with drug addictions and made treatment harder to get.
    Read full story
    Source: AP News, 11 May 2022
  14. Patient Safety Learning
    The scope of the UK public inquiry into the handling of the Covid pandemic has widened to include a focus on children.
    When the draft terms were published in March, there was criticism that they failed to even mention the impact on children and young people. But after a public consultation, the final terms have been published and now incorporate the effect on the health, wellbeing and education of children.
    The final terms of reference were decided following a four-week public consultation on the draft terms.
    As well as expanding the terms to include the impact on the health, wellbeing and education of children and young people, the inquiry will also look at the wider mental health impact across the population.
    The focus on inequalities will also be strengthened, the inquiry said, so that the unequal impact on different sections of society will be considered at all stages.
    Alongside these issues, the UK-wide inquiry will also look at the following issues which were included originally:
    the UK's preparedness for the pandemic the use of lockdowns and other "non-pharmaceutical" interventions, such as social distancing and the use of face coverings the management of the pandemic in hospitals and care homes the procurement and provision of equipment like personal protective equipment and ventilators support for businesses and jobs, including the furlough scheme, as well as benefits and sick pay. Read full story
    Source: BBC News, 12 May 2022
  15. Patient Safety Learning
    The Government is considering setting a tougher cancer diagnostic target as part of its declared ‘war on cancer’, HSJ  has been told.
    Sajid Javid announced a “war on cancer” and launched a call for evidence on what could be done to improve services in February.
    HSJ understands one of the measures being considered is increasing the existing target for cancer diagnosis, set in the 2019 NHS long-term plan.
    The current target committed the service to diagnosing 75% of cancers at stages one and two by 2028.
    At present, performance is around 54% and late stage diagnosis is a key factor behind the UK’s poor performance on cancer mortality, compared with other wealthy nations.
    Cancer Research UK has asked for government, as part of the latest consultation, to set a target of at most 20% diagnosed at stage three and four – effectively, 80% or more at stages one and two – by 2032.
    The Royal College of Radiologists pointed out in February that there was a shortfall of nearly 2,000 consultant radiologists and 20% fewer consultant oncologists to meet the existing gaps.
    Read full story (paywalled)
    Source: HSJ, 13 May 2022
     
  16. Patient Safety Learning
    A trade union has written to every politician representing the Scottish Borders to highlight "dangerous staffing levels" in local hospitals.
    Unison claims serious breaches of safety guidelines are occurring daily due to a lack of nurses, auxiliaries and porters. The letter says staff are unable to take proper rest breaks or log serious incidents in the reporting system.
    NHS Borders said patient and staff safety was its number one priority.
    Unison said working conditions in the area were regularly in breach of regulations.
    Greig Kelbie, the union's regional officer in the Borders, said: "We are getting regular messages from our members to tell us about the pressure they are under - and that they can't cope.
    "The care system was under pressure before Covid, but the pandemic has exasperated the situation, particularly at NHS Borders.
    "The NHS has been stretched to its limits and it is now at the stage where it is dangerous for patients and staff - we're often told about serious breaches of health and safety, particularly at Borders General Hospital where there are issues with flooring and staff falling.
    "We work collaboratively with NHS Borders to do what we can, but we also wanted to make politicians aware of how bad things have become.
    "We need our politicians to step up and implement change - we want them to make sure the Health and Care Act is brought to the fore and that it protects our members."
    Read full story
    Source: BBC News, 13 May 2022
  17. Patient Safety Learning
    Children’s lives are being put at risk, charities warn, as waiting times for eating disorder services soar to record highs.
    The number of children waiting more than four months following an urgent referral for an eating disorder was more than seven times higher at the end of 2021-22 compared to the same period in the previous year.
    Data showed that at the end of quarter four of 2021-22, 94 children were waiting more than 12 weeks following an urgent referral, the highest on record, compared to just 13 at the end of 2020-21.
    The latest NHS data on waiting times for community eating disorder services for children also showed more than 1,900 children were waiting for treatment at the end of March. Of these, 24 were waiting to start urgent treatment - up from 130 last year.
    Sophie Corlett, director of external affairs at Mind, said: “Our government is shamefully failing children and young people with eating disorders at the time when they need help most. Eating disorders have one of the highest mortality rates of any mental health problem. Children in need of urgent NHS treatment for eating disorders should always be seen within one week yet some children are still waiting for treatment after twelve weeks. This is irresponsible and disgraceful.”
    Read full story
    Source: The Independent, 12 May 2022
  18. Patient Safety Learning
    One in four older Americans covered by Medicare had some type of temporary or lasting harm during hospital stays before the COVID-19 pandemic, government investigators said in an oversight report published Thursday. 
    The report from the U.S. Department of Health and Human Services Office of Inspector General said 12% of patients had “adverse events” that mainly led to longer hospital stays but also permanent harm, death or required life-saving intervention. Another 13% had temporary issues that could have caused further complications had hospital staff not acted.
    Investigators reviewed the medical records of 770 Medicare patients discharged from 629 hospitals in 2018 to formulate a national rate on how often patients were harmed, whether preventable or not. An earlier Inspector General review found 27% of patients experienced some type of harm – an investigation that led to new patient safety efforts and incentives. 
    The incremental improvement follows intense focus on patient safety since at least 1999 when the then-Institute of Medicine published To Err is Human, a landmark report that estimated up to 98,000 deaths per year could be due to medical errors. Initiatives have since sought to improve patient safety by limiting medical errors, reducing medication mix-ups and holding hospitals with a poor record of patient safety accountable through Medicare's program to dock the pay of the worst performers on a list of safety measures. 
    While Inspector General investigators noted improvements in certain safety measures, officials said the 25% harm rate is concerning and deserves renewed attention from hospitals and two federal agencies that oversee patient safety: the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality.
    "We still have a significant way to go in terms of improving patient safety," said Amy Ashcraft, a deputy regional inspector general. 
    Read full story
    Source: USA Today News, 12 May 2022
  19. Patient Safety Learning
    A recent report based on research and case studies of good practice in combatting digital health inequalities demonstrates the importance in working with patients who are digitally excluded.
    The report, Putting patients first: championing good practice in combatting digital health inequalities, is the second report by the Patient Coalition for AI, Data and Digital Tech in Health. 
    This report focuses on digital health inequalities and the impact that digital exclusion is having on health in the UK. It highlights different reasons for disparities in a person’s ability to access and use digital health technology and provides insights into the severity of the UK’s digital inequalities.
    The Coalition report concludes recommending that the Government and NHS should:
    Engage with those digitally excluded Ensure patients have a choice Ensure the language is appropriate for all audiences Learn from good practice. Read full story
    Source: The Patients Association, 9 May 2022
  20. Patient Safety Learning
    Hundreds of organisations, including drug companies, private healthcare providers and universities, have breached patient data sharing agreements but not had their access to patient data withdrawn, a report reveals.
    “High risk” breaches were revealed to have occurred at healthcare groups, pharmaceutical giants and educational institutions including Virgin Care, GlaxoSmithKline (GSK) and Imperial College London, during audits by NHS Digital, according to an investigation by the BMJ.
    This means these organisations were handling information outside the remit agreed in data contracts and may be failing to protect confidentiality, the journal said.
    In one instance, local NHS commissioners allowed sensitive, identifiable patient data to be released to Virgin Care without permission from NHS Digital. When auditors tried to get access to Virgin Care to check their compliance, they were denied access for several weeks and the company refused to delete the patient data, the BMJ reported.
    Records about mental health, including children and young people, those with learning disabilities, diagnostic imaging and other confidential patient data was being processed outside the scope of objectives agreed with NHS Digital, at an address that had not been agreed, and without a data sharing contract.
    A spokesperson for Virgin Care said it had “robust data protection in place”.
    “It is outrageous that private companies and university research teams are failing to comply,” said Kingsley Manning, the former chair of NHS Digital. “How is it that these organisations can be so lax with data?”
    Read full story
    Source: The Guardian, 11 May 2022
  21. Patient Safety Learning
    A new high of 6.4 million people in England were waiting for routine NHS treatment in March 2022, as 12 hours waits in A&E hit an all time high last month and ambulance services continued to struggle.
    This is up from 6.2 million in February and is the highest number since records began in August 2007.
    A new record of 24,138 people had to wait more than 12 hours in A&E after a decision to admit them had been made in April.
    The figure is up from 22,506 in March, and is the highest for any calendar month in records going back to August 2010.
    However the number of patients being seen within four hours in April improved compared to March, with 72.3% of patients seen in this time compared to 71.6%.
    Professor Stephen Powis, national medical director for NHS England, said: “Today’s figures show our hardworking teams across the NHS are making good progress in tackling the backlogs that have built up with record numbers of diagnostic tests and cancer checks taking place in March, as part of the most ambitious catch up plan in NHS history.
    “We always knew the waiting list would initially continue to grow as more people come forward for care who may have held off during the pandemic, but today’s data show the number of people waiting more than two years has fallen for the second month in a row, and the number waiting more than 18 months has gone down for the first time."
    Read full story
    Source: The Independent, 12 May 2022
  22. Patient Safety Learning
    Three Senegalese midwives involved in the death of a woman in labour have been found guilty of not assisting someone in danger.
    They received six-month suspended sentences, after Astou Sokhna died while reportedly begging for a Caesarean. Her unborn child also died.
    Three other midwives who were also on trial were not found guilty
    The case caused a national outcry with President Macky Sall ordering an investigation.
    Mrs Sokhna was in her 30s when she passed away at a hospital in the northern town of Louga. During her reported 20-hour labour ordeal, her pleas to doctors to carry out a Caesarean were ignored because it had not been planned in advance, local media reported.
    The hospital even threatened to send her away if she kept insisting on the procedure, according to the press reports.
    Her husband, Modou Mboup, who was in court, told the AFP news agency that bringing the case to light was necessary.
    "We highlighted something that all Senegalese deplore about their hospitals," 
    "If we stand idly by, there could be other Astou Sokhnas. We have to stand up so that something like this doesn't happen again."
    Read full story
    Source: BBC News, 11 May 2022
  23. Patient Safety Learning
    A nurse who filmed up the gowns of unconscious women patients and recorded staff using the toilet at a large teaching hospital has been jailed for 12 years by a judge who said he had "brought shame on an honourable profession".
    Paul Grayson, 51, was also told by the judge he must serve an extended licence period of 4 years when he is eventually released.
    The judge described how four patients were targeted as they recovered from surgery at Sheffield's Royal Hallamshire Hospital – one of whom has never been identified from the footage.
    Sentencing Grayson on Tuesday, Judge Jeremy Richardson QC said: "You have betrayed every ounce of trust reposed in you.
    Earlier this week, the court heard one victim, who was secretly filmed in the shower by Grayson over a number of years, face him directly in court as she told him his "sick and disgusting perversions" and "evil actions" were crimes that "have torn me into pieces".
    The court heard that one victim was unconscious after an eye operation when Grayson filmed her up her gown, and could be seen moving her underwear.
    The woman told police she had "put her trust in staff at the hospital to keep her safe".
    The victim said that she has since been due to have an operation at another hospital but she "can't bring myself to go".
    Read full story
    Source: Medscape UK, 11 May 2022
  24. Patient Safety Learning
    A trust chief who blew the whistle on her predecessor’s ‘aggressive’ behaviour and lack of interest in patient safety says it was the hardest thing she has had to do in her career.
    Janelle Holmes, who is now chief executive of Wirral University Teaching Hospital Foundation Trust, was among four Wirral University Teaching Hospital Foundation Trust senior executives who wrote to regulators in 2017 about the behaviour of the trust’s then CEO David Allison.
    They said he would react with “dismay and aggression” to concerns being raised about service quality, and staff were afraid to speak up as a result. The intervention led to Mr Allison’s departure and a subsequent independent investigation found “deep systemic cultural issues”. Mr Allison always denied his behaviour was inappropriate.
    In an interview with HSJ, Ms Holmes talked of the difficulties in taking those actions, and the subsequent efforts to overhaul the trust’s culture.
    She said: “From a personal integrity perspective, it was the right thing to do…and I [also] felt I had a personal responsibility to make it right afterwards.
    “But yes, it was the most difficult thing I’ve ever had to do.”
    She said: “I remember watching Sir David Dalton (the ex-Salford CEO) probably more than 10 years ago… say ‘we are harming patients’.. it was like ’you can’t say that’.
    “But actually [there was a] complete sea change and [it became] an organisation where [speaking out] was the right thing to do. That’s the only way you can ensure you’re delivering good quality high standard services. If you’re acknowledging mistakes happen, you’re learning from them, you’re correcting things… I think that then starts to shape how our clinicians and staff feel.
    Read full story (paywalled)
    Source: HSJ, 12 May 2022
  25. Patient Safety Learning
    Heart surgery patients in London have died “unnecessarily” and faced increased risk of death as botched NHS investigations into dozens of deaths reduced a hospital’s ability to treat people, a coroner has warned.
    “Unnecessary” patient deaths have occurred as a result of heart surgery at St George’s University Hospital Trust being restricted and emergencies diverted to other “over stretched” hospitals, following investigations by national NHS bodies.
    The warning that deaths have occurred and may occur in the future, comes following the conclusion of a series of inquest hearings in March, during which it was found the NHS’ wrongly blamed a team of cardiac surgeons for the deaths of dozens of patients.
    Coroner Fiona Wilcox, in a report published on Wednesday, has now said the “inadequate” NHS led investigations, which criticised the care of 67 patients, led to people being put increased risk of death.
    The NHS’ investigations into the deaths of 67 patients ruled there were “shortcomings” in care. It led to complex operations being diverted elsewhere and doctors being referred to the General Medical Council. Two doctors have sinced been exonerated following GMC hearings.
    According to the coroner’s findings, capacity within cardiac surgery at the unit is down by 60% and staff are becoming “deskilled.”
    Read full story
    Source: The Independent, 11 May 2022

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