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Patient Safety Learning

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  1. Patient Safety Learning
    Thrombosis UK has warned that deaths involving blood clots are higher than expected as it called for more transparency over the work hospitals are doing to reduce the risk for patients.
    Before the pandemic hit, hospitals were regularly publishing data on the number of patients who had been risk assessed for blood clots. In March 2020, the NHS in England took the decision to suspend the data collection on venous thromboembolism (also known as VTE) risk assessments to “release capacity in providers and commissioners to manage the Covid-19 pandemic”.
    But the data collection and publication is yet to resume. The charity said the data shows how many VTE cases are missed in hospitals.
    One bereaved man described how his mother died last year after the condition was missed. Tim Edwards, 42, said healthcare workers missed signs of the condition while Jennifer Edwards, 74, was in hospital on the south coast.
    Despite having many symptoms of a pulmonary embolism she was discharged home and died three days later. Mr Edwards said: ““My mother’s symptoms were missed from her admission to hospital right up to her time in the cardiology department.
    “She was discharged and passed away three days after phoning the NHS with shortness of breath. She should not have died. I took it upon myself to enquire about the circumstances surrounding her death and was overwhelmed by the lack of care taken.
    “Sadly, I know this is not an isolated case.”
    Read full story
    Source: Wales Online, 12 May 2023
    Further reading on the hub:
    Pulmonary embolism misdiagnosis – a systemic problem (a blog from Tim Edwards) Independent review of pulmonary embolism fatalities in England & Wales – recent trends, excess deaths, their causes and risk management concerns (Tim Edwards) Jenny, and why we must learn from her misdiagnosis of pulmonary embolism National Voices: Pulmonary embolism misdiagnosis - a blog by Helen Hughes.
  2. Patient Safety Learning
    Thousands of people have been missed off the government's high risk list for Covid-19 despite meeting the criteria.
    Among them have been transplant patients, people with asthma and some with rare lung diseases.
    Many are worried it will affect their ability to access food and medical supplies as they shield from the virus, unable to leave their homes for at least 12 weeks.
    "It's like she's been forgotten," said Bev Pearson, mother of 20-year-old heart transplant patient Lucy Pearson.
    Miss Pearson, from Whitsbury in Fordingbridge, Hampshire, had her transplant 14 years ago and still visits hospital for regular check-ups. She has been shielding in the home she shares with her mother, brother and sister - none of whom have been venturing out in an attempt to protect her.
    Despite registering her daughter on the government list herself, she said she had received no confirmation.
    When she asked her GP she was told it had "nothing to do with the surgery", she added.
    Read full story
    Source: BBC News, 7 April 2020
  3. Patient Safety Learning
    As the death toll from the virus soars above 40,000, slowly the horrendous toll on non-Covid patients is emerging.
    These are patients who are not afflicted by coronavirus, but who have had their treatment or diagnosis for other potentially deadly conditions postponed or cancelled, as hospitals scrambled to make way for an overwhelming burden of COVID-19 patients.
    Sherwin Hall, a 27-year-old from Leeds, had tried 13 times in one month during the lockdown to get a proper diagnosis for the crippling pain in his groin. He was initially told it might be a sexually transmitted disease. Eventually he was given the all clear of any STD after multiple blood tests and begged for an MRI scan. But he claims he was told no scans would be available because of the COVID-19 emergency.
    Finally he got a scan which confirmed a 14 cm tumour near his pelvis. He clams his consultant confirmed the delay in diagnosis and therefore cancer treatment may have serious consequences on his chances of survival.
    He told ITV news "I am very angry at the way I have been treated due to COVID-19 and the delay on my cancer treatment and now I am fighting for my life."
    His lawyer, Mary Smith, who specialises in medical negligence at Novum Law in Bristol, says she is worried there will be a spike in cases involving delayed diagnosis or treatment coming across her desk.
    She wants an urgent overhaul of the management of this crisis, now its peak appears to have passed. 
    Read full story
    Source: ITV News, 9 June 2020
  4. Patient Safety Learning
    NHS workers have raised concerns about the prospect of all health and social care staff in England being compelled by law to take the Covid vaccine.
    The Downing Street review which is considering making it mandatory for NHS workers to have the jab, as a way of protecting patients, has led to questions about its moral and legal implications.
    A consultant in a busy north-west hospital said they would feel “incredibly uncomfortable” with the idea of forcing NHS staff to have the vaccine. They said they would prefer a concerted high-profile campaign to encourage staff to have the vaccine, with a last-resort option of asking unvaccinated staff to take on different roles, away from the frontline.
    “I would feel very uncomfortable with us forcing anyone to have it – you can’t force an injection into someone,” the consultant said.
    Last week Care UK said it only wanted to hire new staff who had had the vaccine, while another care provider, Barchester, said it wanted all of its staff, including current workers, to have had the jab by 23 April, adding that if they did not they would not be considered for shifts.
    The matron of a care home in Merseyside said there had been a lot of pressure put on her to have the vaccine, which was making her anxious.
    “I don’t want to be bullied into a decision when I have legitimate concerns. I feel being told I am selfish and putting others at risk is insulting," she said.
    However, a CBT therapist in her 30s, who also works in the north-west of England believed all NHS staff should be vaccinated, regardless of their role. She said her hospital trust’s values emphasised “care, compassion and commitment” and individuals who refused the vaccine could potentially harm others.
    “If we’re going to be caring for people, it comes under that value and it’s a core part of what the NHS is about. So if someone is saying they don’t want the vaccine, it puts into question whether you are going against the values of the trust.”
    Read full story
    Source: The Guardian, 3 March 2021
  5. Patient Safety Learning
    A 73-year-old patient has said he was neglected at an NHS hospital and left to cry for help in "excruciating pain" during an ordeal that lasted months.
    Martin Wild was admitted to Salford Royal last year due to a spinal infection and claims he was denied pain relief and left lying in his own urine.
    Consultant Glyn Smurthwaite said Martin was "the most neglected acute patient I have ever seen".
    The trust that runs the hospital has apologised for failings in his care.
    Mr Wild came home from Salford Royal Hospital in January after an eight-month stay because of an infection following a private spinal operation.
    He said he was forced to phone 999 from his hospital bed when first admitted to the acute medical ward in May 2023 after struggling to get staff to give him pain relief and his Parkinson's medication.
    "I was left on my own in excruciating pain, with little pain relief, and I was laying on this bed for over a week before I saw a consultant."
    Mr Wild was discharged despite warning staff he was not well enough and no one could look after him at home, and ended up being readmitted days later via A&E.
    He said his poor care continued during his second stay, and Mr Wild recalled that he was shaking so much in pain that he knocked bottles of urine on to his bed after they had been left on the table with his food.
    Mr Wild was left lying in the urine-soaked sheets for hours before they were changed.
    Read full story
    Source: BBC News, 3 March 2023
  6. 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
  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
    Steve Barclay is back as England's health secretary, just as the NHS prepares for what its chief executive Amanda Pritchard says could be a "very, very challenging winter".
    The government has said "intensive work" is under way in the 15 most under-pressure hospital trusts in England, to speed up ambulance delays, free up beds and reduce waiting times in A&E.
    Emergency departments across the UK are struggling to quickly treat patients.
    Only 57% of people who turned up at major A&E departments in England last month were seen, admitted or discharged within four hours, well below the 95% national target.
    The latest figures from Gloucestershire Royal show it performs slightly worse than average, with 55% dealt with in four hours.
    One medic, speaking anonymously to the BBC, said: "I wouldn't bring a member of my family to this hospital. And winter is going to be worse unless something changes fast."
    Read full story
    Source: BBC News, 28 October 2022
  9. Patient Safety Learning
    The daughter of a man who took his own life after experiencing years of pain linked to botched dental surgery said she had "lost faith in the system".
    Clive Worthington, from Harlow, Essex, travelled to Hungary for dental implants in 2008.
    Several follow-up procedures from the same dentist back in the UK over the next seven years were unsuccessful.
    The government said it was addressing a so-called loophole which meant the 81-year-old missed out on compensation.
    Last week, an inquest concluded Mr Worthington's death in 2022 was a suicide.
    Senior Essex coroner Lincoln Brookes said the "long-term consequences" of Mr Worthington's unsuccessful dental surgery "impacted significantly on his mental health and ability to cope with daily life".
    In 2017, the General Dental Council (GDC) found Dr Eszter Gömbös, who was employed by Perfect Profiles, at fault for the work.
    Mr Worthington was awarded £117,378 in damages and legal costs at Chelmsford County Court in November 2019 - one of the highest pay-outs for dental negligence in the UK.
    But the insurer which covered Dr Gömbös - the Dental Defence Union (DDU) - argued "discretionary indemnity" and refused to pay.
    Read full story
    Source: BBC News, 12 October 2023
    Related hub content
    “I’ve been mocked, scolded and gaslighted”: a harmed patient’s experience of orthodontic treatment A patient harmed by orthodontic treatment shares their story We want to hear from patients with experience of NHS and/or private orthodontists and dentists in any healthcare setting, including community practices and hospitals.
    Did the orthodontist/dentist give you the treatment and support you needed? If you had ongoing problems, how did the orthodontist/dentist and other healthcare professionals respond? Have you tried to make a complaint? Share your experience of orthodontist and dentistry services
  10. Patient Safety Learning
    Hundreds of people believe the helpline failed their relatives. Now they are demanding their voices be heard. 
    Families whose relatives died from COVID-19 in the early period of the pandemic are calling for an inquiry into the NHS 111 service, arguing that many critically ill people were given inadequate advice and told to stay at home.
    The COVID-19 Bereaved Families for Justice group says approximately a fifth of its 1,800 members – more than 350 people – believe the 111 service failed to recognise how seriously ill their relatives were and direct them to appropriate care.
    “We believe that in some cases it is likely these issues directly contributed to loved ones dying, due to causing a delay in receiving treatment, or a total lack of treatment leading to them passing away at home,” said the group’s co-founder Jo Goodman, whose father, Stuart Goodman, died on 2 April aged 72.
    Many families have said they had trouble even getting through to the 111 phone line, the designated first step, alongside 111 online, for people concerned they may have COVID-19.
    The service recorded a huge rise in calls to almost 3m in March, and official NHS figures show that 38.7% were abandoned after callers waited longer than 30 seconds for a response. Some families who did get through have said the call handlers worked through fixed scripts and asked for yes or no answers, which led to their relatives being told they were not in need of medical care.
    “Despite having very severe symptoms including skin discolouration, fainting, total lack of energy, inability to eat and breathlessness, as well as other family members explaining the level of distress they were in, this was not considered sufficient to be admitted to hospital or have an ambulance sent out,” Goodman said.
    Some families also say their relatives’ health risk factors, such as having diabetes, were not taken into account, and that not all the 111 questions were appropriate for black, Asian and minority ethnic people, including a question to check for breathlessness that asked if their lips had turned blue.
    Read full story
    Source: The Guardian, 21 September 2020
  11. Patient Safety Learning
    "It would be much better if I was out there than in here," said Roger.
    The 69-year-old looked wistfully across Newport from the window next to his bed at the Royal Gwent Hospital in Wales.
    He has been here for three weeks after being admitted with an infection and although he is now well enough to leave, and desperate to do so, he can't.
    Roger has cerebral palsy and the impact of his recent illness means he needs extra care to be arranged before he can safely go home.
    Roger is not alone.
    "At least a quarter of patients in our care of the elderly beds are in a similar position," explained Helen Price, a senior nurse at the hospital.
    "It is very much a waiting game for that care to be available," she said.
    Hospitals in Wales are fuller than ever, according to the latest statistics. In the final week of January more than 95% of all acute beds in the Welsh NHS were occupied, which is the highest figure ever recorded.
    Paul Underwood, who manages urgent care in Aneurin Bevan University Health Board, said there are well over 350 patients medically fit enough to leave hospital.
    "Roughly a third of patients do not need to be accommodated on those sites and that's extremely difficult," he said.
    Read full story
    Source: BBC News, 16 February 2023
  12. Patient Safety Learning
    Emma Hardy MP has secured a Westminster debate on gynaecological wait times.
    Gynaecology waiting lists across the UK have now reached a combined figure of more than 610,000 – a 69% increase on pre-pandemic levels. New analysis by the Royal College of Obstetricians and Gynaecologists (RCOG) shows that in England, gynaecology waiting lists have grown the most by percentage increase of all elective specialties.
    Emma is co-chair of the All Party Parliamentary Groups (APPGs) for Surgical Mesh and Endometriosis - both come under the heading of ‘gynaecological conditions’ and both are being impacted by increased waiting times.
    Through her involvement with these APPGs, Emma has heard the testimony of so many women whose lives have been impacted by conditions that can be so painful and debilitating that they impact on every aspect of family, social and work life. Emma will ask the minister to launch an investigation into possible gender bias in the prioritisation of gynaecology services and ensure that elective recovery will address the unequal growth of gynaecology waiting lists compared to other specialties.
    Emma said: "It is completely unacceptable that 610,000 women are waiting for gynaecological care across the UK. The reality is that many of these women will be in excruciating pain awaiting treatment, unable to go about their day-to-day lives."
    Read full story
    Source: Hull Daily Mail, 5 July 2022
  13. Patient Safety Learning
    A man was left in a care home for five months without regard for "basic human rights", an investigation has found.
    The Nottinghamshire man, who had dementia, was placed in the home for two weeks as respite for his family. But the county council failed to properly assess whether he could return home, leaving his family with a £15,000 care bill, the Local Government and Social Care Ombudsman said.
    The authority has apologised and said it would make improvements.
    The ombudsman launched an inquiry after complaints from the man's family.
    He was placed in the care home by his wife while she struggled to look after her son, who had been diagnosed with terminal cancer. The investigation found that after the first two weeks, the man's wife said she still could not cope with his return.
    But instead of carrying out a review or assessment to judge what support was needed for him to potentially go home, the council allowed the case to "drift".
    The ombudsman, Michael King, said: "The man had a right to respect for his family life, and to enjoy his existing home peacefully."
    "But the council did not have any regard for the man's human rights during those five months he was away from his family."
    In its report, the watchdog said it found "fault causing injustice".
    Read full story
    Source: BBC News, 4 March 2021
  14. Patient Safety Learning
    Suicidal thoughts are three times as common in those living with a spinal cord injury in the UK, according to new research
    And yet, it’s estimated that only one third of people living with a spinal cord injury (SCI) are getting access to mental health support, and of those, 68% do not feel that support services available are able to meet their needs.
    These alarming statistics are taken from a new report, ‘It’s not just physical’ which was presented to parliament yesterday (17 November).  The report shines a light on the mental health problems faced by people with spinal cord injuries in the UK today.
    It's calling on the NHS, government and other health policy makers to provide better mental health support services for people with spinal cord injuries – and their unpaid carers – as a matter of urgency.  Nik Hartley, Spinal Injuries Association CEO said:
    “We are at risk of failing thousands of people in the UK living with a spinal cord injury. Our new report highlights that psychological damage caused by a SCI is, at best, considered as an afterthought, and at worst, completely ignored by the medical profession. We need urgent action and for services to be sufficiently specialised to support the thousands of people living with this type of injury before it is too late.”
    Read full story
    Source: Spinal Injuries Association, 17 November 2021
  15. Patient Safety Learning
    With the distressing spate of news reports about mums and ­babies who weren’t kept safe in hospital, an initiative in the Midlands to improve patient safety in maternal and acute care settings comes as a relief.
    The newly announced Midlands Patient Safety Research Collaboration will bring together NHS trusts, ­universities and private business to evaluate how digital tools can help clinical decision making and reduce danger for patients.
    Problems can arise if communication is poor between medics when patients move between departments.
    Professor Alice Turner of Birmingham University said: “The power of new technology available to us means that we can address one of the ongoing areas of risk for patients, which is effective communication and clinical decision making.
    “The new collaboration will be looking at how digital tools can make a real difference to reduce risks and support patient safety in the areas of acute medicine and maternal health.”
    Digital decision-making tools could improve prescribing and personalised management for patients needing emergency care.
    Importantly, these tools should provide a smoother flow of information between healthcare professionals in acute care between hospitals, doctors and the West Midlands Ambulance Service, and hopefully reduce risks of patient harm at key points during acute care.
    Read full story
    Source: The Mirror, 18 December 2022
  16. Patient Safety Learning
    “Little progress” has been made improving patient safety in the NHS over the past 20 years, said the Chief Inspector of Hospitals at the Care Quality Commission (CQC). 
    Professor Ted Baker yesterday revealed he receives between 500 and 600 reports of “never events” a year, incidents that are wholly preventable whatever the circumstances.
    This includes an occasion where surgeons operated on the wrong eye of a patient.
    Speaking at Patient Safety Learning's annual conference, he said that hospital managers routinely hide evidence from the CQC, because they regard the organisation as out to blame them.
    The chief inspector called for a fundamental change in culture whereby NHS bosses drove safety improvements for their own sake, rather than in order to pass an inspection.
    Read full story
    Source: The Telegraph, 2 October 2019
  17. Patient Safety Learning
    Health coach Jasmine Hayer had to give up her life in London and move back in with her parents after catching Covid. Now she is focused on a twin goal - battling back to health while helping others get the right treatment for Long Covid.
    Dr William Man, the head of the Royal Brompton Hospital's chest clinic, started treating her in December, as part of a clinic seeing 100 severe long Covid cases in the UK.
    Jasmine describes it as a "complete game changer".
    However, she worries that other so-called "long haulers" are not getting the help they need because they face "such a battle" to be taken seriously.
    She decided to start a blog to document her symptoms and wants to share her story as widely as possible in the hope of helping others.
    "I've had messages from around the world and I was so happy to hear that one girl has shown her doctor my blog and he is giving her more tests as a result," she says.
    "I know how lonely and scary it is when you are fighting to be believed. You are literally on your own."
    Read full story
    Source: BBC News, 7 April 2021
  18. Patient Safety Learning
    Major change is required if Northern Ireland's emergency departments are to avoid another "exceptionally difficult" winter, a senior consultant has warned.
    Dr Brendan Lavery, who works for the Western Health Trust, said "standing still is not an option". He described the system as currently operating on a "knife edge".
    The Department of Health said it was "a very challenging time" for staff "with COVID-19 restrictions impacting on an already fragile system".
    Speaking to BBC News NI, Dr Lavery likened the situation to "Groundhog Day" with decade-long problems like capacity and staffing exacerbated by the lingering effect of the COVID-19 pandemic on other healthcare services.
    The department responded: "Well before COVID-19, there was clear evidence that our urgent and emergency care services were under increasing pressure. This is an unsustainable position that requires sustained investment and reform, including, of course, long-term investment in staffing. There is no quick or easy solution to these problems."
    Read full story
    Source: BBC News, 12 May 2021
  19. Patient Safety Learning
    NHS staff are at risk of high rates of post-traumatic stress disorder (PTSD) if they don't get the right support as the coronavirus outbreak subsides, health service adviser Prof Neil Greenberg has said.
    For now there's a national focus on health and care workers. Public billboards praise them, millions turn out on the street for a weekly round of applause and volunteers have been rushing to help in any way they can. But the height of the crisis is when many staff will be in coping mode. It's when things slow down - and the clapping stops - that, psychologists believe, the real risk of difficulties will arise.
    People may need months or even years of "active monitoring" of their mental health after things return to some semblance of normality, according to Prof Greenberg, a world-leading expert in trauma at King's College London.
    The NHS in England is providing crisis support to its staff. But it hasn't produced a formal long-term plan to offer extra psychological services in the aftermath of the pandemic.
    It's what happens after the trauma that is "most predictive of what people will be like in terms of their mental health", according to Prof Greenberg. How well people are supported and how much stress they're put under as they try to recover can make or break whether someone manages well or develops far more serious difficulties including PTSD.
    "If we muck it up then that's going to make the trauma they've already had much more difficult to deal with," he says.
    Read full story
    Source: BBC News, 15 May 2020
  20. Patient Safety Learning
    People with disabilities must be helped more by health providers to access information, a report has found.
    Over 300 people in North Yorkshire were asked about communication from GPs, hospitals, and healthcare providers in a survey by watchdog Healthwatch.
    The report said there is "some good practice" but many patients are not being contacted in their preferred format. This leads to missed appointments which "costs time and money".
    Since 2016, the Accessible Information Standard means health and care organisations must legally provide a "consistent approach to identifying, recording, flagging, sharing, and meeting the information and communication support needs of patients, service users, carers and parents with a disability, impairment, or sensory loss," Healthwatch said.
    But the report said some people receive printed letters which they are unable to read meaning they have to ask for private and confidential information to be relayed.
    Scarborough respondent Ian said it was "amazing" that in the 21st Century many are still facing such issues.
    "The [GP booking] system doesn't anticipate that not everyone can use the phone," he said.
    "The problem is a lot of organisations haven't moved with the times".
    Read full storyp
    Source: BBC News, 21 June 2022
  21. Patient Safety Learning
    More needs to be done to bring maternity units at a city's two main hospitals up to scratch, inspectors have said.
    In 2020 the Care Quality Commission (CQC) found serious concerns at Nottingham University Hospitals NHS Trust and labelled the units "inadequate".
    A new report concluded the trust still has "some areas to address".
    In October a coroner said the death of Wynter Andrews minutes after she was born was "a clear and obvious case of neglect".
    Nottinghamshire assistant coroner Laurinda Bower also revealed a 2018 whistle-blowing letter from midwives to trust bosses outlining concerns over staffing levels as "the cause of a potential disaster".
    In the same month "in response to concerns raised... and coronial inquests", the CQC carried out an unannounced inspection at the hospital and found some staff had not completed training and "did not always understand how to keep women and babies safe", and issued a warning notice over its concerns.
    Its latest report, based on an inspection in April, found improvements in the way women at risk of deterioration were identified and found documentation and monitoring had improved.
    However the CQC found a disconnect between online and paper record-keeping and said there were multiple systems in place that led to duplication and errors at times.
    Read full story
    Source: BBC News, 28 May 2021
  22. Patient Safety Learning
    Patients spent up to 25 hours on trolleys in corridors waiting for treatment and in some cases were left lying on "urine-soaked sheets" and in another on a "blood-stained pillow for several hours" at the Royal Infirmary of Edinburgh.
    Healthcare Improvement Scotland (HIS) inspectors also raised concerns over fire safety in the overcrowded A&E after two visits to the hospital - the first of which was carried out between February 20 to 22 and a further unannounced follow-up in March.
    The watchdog found "multiple systemic failures" in a report published on Thursday but NHS Lothian said a major improvement drive was already underway.
    The health board added that the hospital was had just endured its busiest winter on record ahead of the inspections.
    At the time of the inspection, the emergency department was on some days operating at over three times its capacity.
    The report described this as unsafe and a "fire safety risk" with the evacuation plan in place at the time not reflecting the "significant" impact of overcrowding. 
    Read full story
    Source: The Herald, 18 May 2023
  23. Patient Safety Learning
    New monitors that can detect the deadly blood condition sepsis are being fitted at a Scottish children's hospital. The equipment will be installed at the Royal Hospital for Children in Glasgow.
    Charlotte Cooper, who lost her nine-month-old daughter Heidi to sepsis last year, said she had "no doubt" the monitors would help save babies' lives. She told BBC Scotland: "You don't have time to come to terms with the fact that someone you love is dying from sepsis because it happens so quickly."
    Ms Cooper now wants to see the monitors installed in every paediatric ward in Scotland. "We need to do whatever we can to stop preventable deaths from sepsis in Scotland," she said.
    The monitors record and track changes in heart rate, temperature and blood pressure, and can pick up early sepsis symptoms. The machines, which have been installed in a critical care area, use the  Paediatric Early Warning Scores to monitor the children for any signs of deterioration in their condition.
    Sepsis Research said early warning of the changes would mean sepsis being diagnosed and treated faster.
    The monitors were accepted on behalf of the hospital by senior staff nurse Sharon Pate, who said: "In a very busy paediatric word it is vital all our patients are monitored regularly and closely for signs of deterioration. The addition of these new monitors will greatly improve our ability to monitor patients and provide vital care."
    Read full story
    Source: BBC News, 4 February 2020
  24. Patient Safety Learning
    Thomas Hebbron is one of the forgotten victims of the pandemic.
    He was diagnosed with leukaemia in February 2019 - a year before Covid hit the UK.
    The eight-year-old, from Leeds, has been treated with chemotherapy which has continued throughout the pandemic, but his health has suffered in other ways - and his mother believes the unrelenting focus on the virus is to blame.
    Pre-pandemic he was seen in person by doctors every two weeks. But that changed to monthly video calls, and liver and urinary problems went undetected.
    His treatment also affected his fine motor skills and has weakened his legs, but he has not seen an occupational therapist since before the pandemic.
    "I want to take this pain away from him," says his mother, Gemma. "I don't want to sit and watch him in this pain, but I can't do anything. I just feel completely helpless."
    Thomas's story is not unique. An analysis by the Nuffield Trust and Health Foundation has for the first time laid bare how access to core health services in England has been squeezed, threatening to leave behind a generation of young people.
    The review has looked at both physical and mental health services and come to the same conclusion - support has been badly disrupted and the plight of children overlooked.
    The Nuffield Trust and Health Foundation have been joined by the Royal College of Paediatrics and Child Health (RCPCH) in calling for a dedicated plan for children to help them recover from the pandemic.
    Dr Camilla Kingdon, RCPCH president, said the figures "do not take into account the many other 'hidden' waiting lists of children waiting for community therapies and diagnostic assessments, especially for autism".
    She added that children are "struggling" and, despite services being stretched, no-one should be deterred from speaking to a health professional.
    Read full story
    Source: BBC News, 18 February 2022
  25. Patient Safety Learning
    In September 2021 Caitlin Glasgow, then 10-years-old, was diagnosed with Covid. She never fully recovered.
    "The rest of Caitlin's classmates all returned to school after isolating for 10 days, but she was still in bed after six weeks," recalls her mother Lorna.
    Lorna believes her daughter has Long Covid. She is one of 175,000 people in Scotland who say they are still affected by the illness.
    Lorna, who lives in Penicuik in Midlothian, said her local GP was helpful and concerned for Caitlin, but it has been difficult to understand why she hasn't recovered like her friends.
    "She still gets pains in her legs, that's probably the worst thing along with the fatigue. There's breathlessness, chest and tummy pain, brain fog and she gets quite light-headed at times."
    A report published by a Scottish government committee said tackling the stigma around long Covid needs "urgent" action.
    The Covid-19 recovery committee has outlined a raft of measures to improve awareness of the condition among healthcare professionals.
    Read full story
    Source: BBC News, 26 April 2023
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