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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Families involved in a major review into maternity failings at Nottingham University Hospitals Trust (NUH) have criticised the decision of the review team to press ahead with the publication of an interim report, despite serious concerns about its terms of reference and methodology. A “thematic review” into NUH was first announced last year after reports that dozens of babies died or were brain damaged after errors were made at the trust over the last decade. More than 460 families have since contacted the review team. The review has been overseen by NHS England and local commissioners, but, in April, the families called for an independent inquiry and asked for it to be carried out by Donna Ockenden, the senior midwife who chaired the high-profile review of Shropshire maternity services, which reported in March. Last month, NHSE chief operating officer Sir David Sloman wrote to families and said former strategic health authority chair Julie Dent would be brought in to chair the review. However, Ms Dent stepped down from the role weeks later, citing “personal reasons”. A new chair is yet to be appointed. Despite these uncertainties, families have been told by the review team that an interim report will be issued shortly. Gary Andrews, whose daughter Wynter died after being delivered by caesarean section at NUH’s Queens Medical Centre in 2019, said to issue an interim report “seems at odds with the current situation” and risked causing “significant distress” to families. He added: “We need government to get to grips with this review. Put the brakes on, ensure its structure and design and objectives are fully supported by families, before any interim report can be issued.” Read full story (paywalled) Source: HSJ, 19 May 2022
  2. News Article
    The latest batch of hospital patient safety ratings from America's Leapfrog Group shows a general decline among “several” hospital safety measures concurrent with the onset of the COVID-19 pandemic, according to the healthcare safety watchdog. Released Tuesday, the scores are accompanied by a report from Leapfrog that highlights a “significant” decline in the experiences of adult inpatients at acute care hospitals during the pandemic, with many areas “already in dire need” prior to the pandemic deteriorating even further. “The healthcare workforce has faced unprecedented levels of pressure during the pandemic, and as a result, patients' experience with their care appears to have suffered,” Leah Binder, president and CEO of the Leapfrog Group, said in a statement. Leapfrog’s twice-annual reports assess more than 30 patient safety measures and component measures compiled from the Centers for Medicare & Medicaid Services (CMS) and Leapfrog’s hospital surveys between July 2018 and March 2021. The most recent release assigns letter grades to nearly 3,000 US general hospitals and is the second collection of scores to incorporate safety and experience data from the COVID-19 pandemic. Read full story Source: Fierce Healthcare, 10 May 2022
  3. Content Article
    Health policy-making and reform require, first and foremost, a sound understanding of how a health system is performing. To assist countries in this process, the Health Systems Performance Assessment Framework for Universal Health Coverage offers a comprehensive attempt at guiding the collection and analysis of health system data in relation to policy goals and 21st century challenges. This book is grounded in the premise that any whole-of-sector assessment exercise should collect information on and examine the performance of both the functions of the health system as well as its performance goals. Thus, it follows through each of the health system functions (i.e., health system governance, financing, resource generation and service delivery), outlining their purpose, the sub-functions needed to fulfil that purpose, and assessment areas to evaluate how well a function performs. This innovative framework conceptually links health system functions to intermediate and final health system goals. As a result, policy-makers will be better able to determine and analyse possible origins or impact of poor performance on a particular health system outcome.
  4. News Article
    Parents whose children have mysteriously fallen ill with hepatitis and received a delayed diagnosis could be entitled to negligence claims, lawyers believe. Officials are no closer to explaining a recent and unusual outbreak in cases of liver inflammation recorded among young children across the UK. To date, a total of 163 children have been diagnosed. Eleven of these have received liver transplants, while 13 are currently in hospital. Globally in recent months, 300 children have been struck down by the illness, which has no clear cause. Because the UK cases have been identified retrospectively, there is potential that doctors and medics may have “missed signs” which would have led to earlier hepatitis diagnoses and treatment, lawyers say. “There are a significant number of these diagnoses which are actually retrospective,” said Jonathan Peacock, a partner at VWV specialising in clinical negligence. “The obvious issue there from a negligence point of view is if you have missed signs, which ought to have led you to a diagnosis of hepatitis earlier, as a result of which it’s gone untreated and the outcome is worse, then potentially you’re negligent. “There’s two stages: was the care diagnosis, treatment, intervention, was that of a reasonable standard? If the answer is no – there was clearly a negligent delay, or a breach of duty of care, then the second question that then arises is has the individual been harmed by that delay?” Read full story Source: The Independent, 10 May 2022
  5. News Article
    A chief executive has described her ‘considerable regret’ that growing difficulty in discharging patients has resulted in nearly half of her trust’s inpatients being clinically ready to leave. Debbie Richards, who leads Cornwall Partnership Foundation Trust, a community and mental health provider, highlighted the issue at the trust’s board meeting last month, amid a “dearth of adult social care provision” across the country. In her update to the board, Ms Richards said delays in finding onward care for patients awaiting discharge meant “almost 50 per cent of our community hospital beds are occupied by patients who have no medical need to be in hospital”. In her report to the board, Ms Richards said: “Despite having over 5,000 care home beds in Cornwall, the majority of these are full, or care home providers are unable to offer beds because of a lack of staffing. “Where there is capacity, this tends to be for lower-level residential beds where unfortunately there is much less demand.” Siobhan Melia, chair of the NHS Community Network and CEO of Sussex Community FT, said the “dearth of adult social care provision” was the biggest limiting factor in discharging delayed patients home, followed by high staff vacancies and sickness absence." She called for a national long-term funding settlement for social care and reform of the sector to address the key challenges. Read full story (paywalled) Source: HSJ, 10 May 2022
  6. News Article
    A baby died after maternity staff repeatedly missed chances to intervene to save his life, an official investigation has found. Giles Cooper-Hall was just 16 hours old when he died after a catalogue of errors in the maternity care of his mother, Ruth Cooper-Hall, at Derriford hospital in Plymouth. A Healthcare Safety Investigation Branch (HSIB) report into the incident has exposed how inexperienced and overstretched staff failed to carry out proper checks, recognise there was an emergency or seek help from senior doctors until it was too late. It comes just weeks after the independent Ockenden report into more than 1,800 cases revealed serious failings in the maternity care provided at Shrewsbury and Telford hospital NHS Trust. It revealed how Ruth Cooper-Hall, then aged 37, was not personally seen by a consultant when she went into labour in October last year, despite recommendations made in the interim Ockenden report published in December 2020. The HSIB report also suggested Giles’ death could have been avoided if staff had known about the care plan for his mother’s labour. Instead, vital messages were not passed on, with the investigation finding this was likely to be because the staff responsible were “distracted” by other tasks. Read full story Source: The Guardian, 10 May 2022
  7. News Article
    Hundreds of severely mentally ill prisoners in urgent need of hospital treatment are being left in prison cells due to bed shortages in secure NHS psychiatric units, an investigation has discovered. Freedom of information (FoI) responses from 22 NHS trusts reveal for the first time that just over half of the 5,403 prisoners in England assessed by prison-based psychiatrists to require hospitalisation were not transferred between 2016 and 2021 – an 81% increase on the number of prisoners denied a transfer in the previous five years. In some areas, the majority of mentally ill prisoners were not admitted, which could be the result of long delays or a trust refusing to take certain patients. Norfolk and Suffolk NHS foundation trust, which was rated inadequate by the Care Quality Commission last month, only admitted 16 of 41 prisoners referred in 2021. Essex Partnership University NHS foundation trust only admitted 24 of 57 prisoners referred in 2021. Lancashire and South Cumbria NHS foundation trust only accepted 18 of the 38 prisoners referred in 2021. Peter Dawson, the director of the Prison Reform Trust, said the figures unearthed by the investigation suggested hundreds of very ill people were being denied the treatment they needed. “It is shocking that a growing number of people are not getting the transfer to hospital that clinicians say is essential for their mental health,” he said. “Instead they are languishing in often overcrowded and dilapidated prisons. It is cruel and guarantees people will leave prison in a worse state than when they came in, with every likelihood that the behaviour that originally led to their arrest and conviction will continue.” Read full story Source: The Guardian, 10 May 2022
  8. News Article
    Local clinical leaders are continuing to question pressure from government and NHS England to relax Covid-19 visiting restrictions. Visitors, and people accompanying patients, have been restricted throughout covid, and in recent months there has been substantial local variation. Ministers and NHSE, as well as other politicians and some patient groups, have been pressing for more relaxed restrictions for some time and in recent weeks have stepped up their instructions. National visiting guidance was eased in March, and other infection control guidance, including requiring the isolation of covid contacts, was relaxed last month. Last week, the Daily Telegraph reported health and social care secretary Sajid Javid planned to “name and shame” trusts not implementing the changes, and to call hospital chief executives directly about it. Meanwhile, chief nursing officer Ruth May reiterated the visiting rules last month, saying on Twitter: “We must not underestimate the important contribution that visiting makes to the wellbeing and personalised care of patients and make it happen.” However, an NHSE online meeting for clinical leaders on Friday was told that while “a great number of trusts have returned to previous visiting policies… we know there are trusts which haven’t implemented this fully”. One said: “It is very difficult to safely return to pre-covid visiting as some hospital’s estate can’t safely support visitors in already over-crowded [emergency departments] and increasingly busy [outpatient departments]. “Surely local risk assessment is key and should be supported rather than increasing pressure to simply blanketly return to pre-pandemic arrangements everywhere?” Read full story (paywalled) Source: HSJ, 9 May 2022 You may also be interested in: Visiting restrictions and the impact on patients and their families: a relative's perspective It’s time to rename the ‘visitor’: reflections from a relative
  9. Content Article
    The National Joint Registry records, monitors, analyses and reports on performance outcomes in joint replacement surgery in a continuous drive to improve service quality and enable research analysis, to ultimately improve patient outcomes.
  10. News Article
    UK health officials say they are still no clearer on the cause of a rise in liver inflammation, or hepatitis, in children. A common adenovirus is thought to play a role, but other possibilities are still being investigated. In the UK, 163 cases have now been identified, and 11 children have received liver transplants. Cases have been detected in 20 countries worldwide, with nearly 300 children affected, and one death. "It's important that parents know the likelihood of their child developing hepatitis is extremely low," said Dr Meera Chand, from the UK Health Security Agency (UKHSA). She said parents should still be alert to the signs - particularly jaundice, a yellow tinge in the whites of the eyes - and they should contact a doctor if concerned. Since last week, another 18 children in the UK with hepatitis have been identified - 118 live in England, 22 in Scotland, 13 in Wales and 10 in Northern Ireland. The children's most common symptoms were jaundice and vomiting - and most have been under five years old. Read full story Source: BBC News, 7 May 2022
  11. News Article
    Traumatised Ukrainian refugees who have sought sanctuary in the UK may have to wait two years before they can get specialised therapy to help them heal from the horrors of war, according to experts. Therapists who specialise in treating war trauma say they have seen NHS waiting lists of two years before refugees can access the specialist treatment they need. Services across the UK are patchy with some areas “treatment deserts when it comes to trauma”, according to Emily Palmer-White, a psychotherapist and community manager at the charity Room to Heal, which provides support for people who have fled persecution. “There are often extremely long waiting lists. I have been told two years. You can’t separate the psychological from the practical – it’s more difficult to help people if they’re preoccupied with survival,” said Palmer-White. A spokesperson for the Department of Health and Social Care said officials recognised the trauma Ukrainians were facing and stood shoulder-to-shoulder with them. However, beyond having access to NHS care officials did not cite any specific provision to provide newly arrived refugees with trauma support. Prof Cornelius Catona, of the Royal College of Psychiatrists, said the visa delays of several weeks would likely exacerbate mental illness for those already struggling and that the refugee schemes should have included a mechanism for spotting signs of trauma early. Viktoriia Liamets, a Ukrainian child and family therapist who recently arrived in the UK after fleeing the war, said Ukrainians arriving in Britain had multiple and complex traumas to contend with. Read full story Source: The Guardian, 9 May 2022
  12. News Article
    The public inquiry into safety and wellbeing issues at two Scottish hospitals is due to resume Monday. This latest stage will hear evidence on the importance of ventilation systems in infection prevention and control. The inquiry is being chaired by Lord Brodie QC and is examining issues at the Queen Elizabeth University Hospital (QEUH) in Glasgow, and the Royal Hospital for Children and Young People (RHCYP) and Department of Clinical Neurosciences in Edinburgh. The RHCYP in Edinburgh was due to open in July 2019 but was delayed after last-minute inspections found safety concerns over its ventilation systems. The Scottish government then stepped in to prevent the hospital from opening just one day before it was due to accept patients. The £840m QEUH campus in Glasgow opened in April 2015 and has faced a series of contamination incidents since then, linked to issues with water quality and ventilation systems. An independent review into the hospital's design published its findings in June 2020. The report found a "series of problems" with the design and build of the hospital, but no clear evidence to link those failures to any "avoidable deaths". Jeane Freeman said in June 2020 that the inquiry had been ordered to protect the "safety and well-being of all patients and their families", which the health secretary said should be a "primary consideration" in all NHS construction projects.
  13. News Article
    People in England are struggling to get dental treatment, as dentists close to new NHS patients, a watchdog says. Healthwatch England, the NHS body representing patients, said the problem was made worse by the rising cost of living and needed "urgent attention". It said some people were living in pain, unable to speak or eat properly, because they could not find treatment. And it warned the poorest were suffering most as they were least able to afford to pay for private dentistry. Healthwatch England said the issue was creating a two-tier system - dividing the rich and the poor - and called on the government to take action. "There is now a deepening crisis," said Louise Ansari, of Healthwatch England. "With millions of households bearing the brunt of the escalating living costs, private treatment is simply not an option - and even NHS charges can be a challenge. "This needs urgent attention." Read full story Source: BBC News, 9 May 2022
  14. News Article
    New calculations from Cancer Research UK estimate that, on average, over 65,000 people in England are left waiting longer than 28 days to find out whether they have cancer each month. These estimates are based on the latest data from the Faster Diagnosis Standard (FDS). The FDS is a performance standard introduced by Government in 2021. It’s used to better capture how long people on certain cancer-related referrals wait for a diagnosis. This applies to people referred by their GP urgently with suspected cancer, following breast symptoms, or have been picked up through cancer screening. The current FDS target is set at 75%, meaning three quarters of people being urgently referred should be told they have cancer or given the all-clear within that timeframe. However, this target has yet to be met. In addition, the data has revealed major variation across the country – with only 78 of 143 trusts meeting the 75% target. This means that despite the tireless efforts of NHS staff, chronic capacity issues mean that people continue to be failed by the system. Michelle Mitchell, our chief executive, said: “As a country we should not be willing to accept that over 1 in 4 people on an urgent referral are left waiting over a month to find out whether they have cancer. Nor should we stand for the variation that exists across the country.” The charity is calling on Government to include a more ambitious target within its upcoming 10-year cancer plan, to help ensure around 54,300 more people each month receive a diagnosis or have cancer ruled out within a month. With a robust plan and sustained investment to build a cancer workforce fit for the future, patients will be diagnosed quicker and earlier, which will save more lives. Read full story Source: Cancer Research UK, 9 May 2022
  15. News Article
    One of England’s most challenged integrated care systems (ICS) is set to miss by more than 800 patients the government’s target of eliminating two-year elective waits by July. Devon ICS currently estimates 860 patients will have waited longer than two years for planned care by July 2022, when all patients waiting longer than two years should have been treated – according to the NHS’s elective recovery plan. It is the first reported example of an ICS forecasting to miss the high-profile target which government has agreed with NHS England. The ICS, which is among the health systems with the lowest rating from NHSE, is a national outlier against the target, with around 1,500 patients currently waiting two years or more for care. The backlog has occurred despite the ICS previously being one of 12 systems given extra money for planned care through the elective accelerator programme and retaining the use of its Nightingale Hospital. Read full story (paywalled) Source: 6 May 2022
  16. News Article
    A course helping some of the most vulnerable people in the country by teaching them to be comedians is proving so successful that it is being socially prescribed by NHS trusts and private practices across the country. “I’ve taught comedy for 10 years, and students often told me how much stronger, more resilient and happier they were after exploring their personal histories through standup comedy,” said Angie Belcher, founder of Comedy on Referral and comedian-in-residence at Bristol University. “That inspired me to prove that the models, exercises and games used in a standup comedy course can help people to recover from emotional problems such as mental illness, postnatal depression, PTSD and anxiety disorders,” she said. After completing a highly successful six-week NHS course for trauma survivors in Bristol, Comedy on Referral has now won NHS funding to help men at risk of suicide in London. Belcher is also in discussions with a private practice to extend the course to young people with autism and ADHD. “My course for trauma victims encourages them to process their trauma in a different way, so they can change who the victim is and choose the narrative. They can actually go right down into ‘This is what I was thinking and then this thing happened to me’,” said Belcher. “This enables survivors to consciously use comedy to change their perspective of their experiences, but it also puts them in a physically powerful position because being on stage is very powerful,” she said. “You can speak directly to an audience about important things, which means you have the opportunity to change their lives..." Read full story Source: The Guardian, 9 May 2022
  17. Content Article
    The subtext of this monthly review of European healthcare issues from Roger Steer is to identify whether Europe can offer lessons to the UK on health and social care issues or indeed how Europe can learn its own lessons and put flesh on the bones of its previous promises of a Social Europe.
  18. Content Article
    GB News interviews Kath Sansom, founder of Sling the Mesh, and Alec Shelbrooke, MP, on the thousands of lives that have been ruined by mesh implants.
  19. Content Article
    Endurance athletes have been left using wheelchairs or barely able to walk. But the government acts like Covid is beaten, writes Rose George in this Guardian article.
  20. News Article
    A big rise in GP referrals being deferred because no appointment slots are available, in the wake of the covid pandemic, has sparked concerns that patients are going undiagnosed and missing out on the correct treatment. Outpatient referrals are typically classed as having an “appointment slot issue” when no booking slot is available within a timeframe specified by the provider, under the NHS e-referral system. The latest NHS Digital figures, analysed by HSJ, show the number of ASIs was 52% higher in March 2022 than February 2020 — up from 245,582 to 374,209. The statistics suggests appointment slot issue accounted for 77% of all bookings in March 2022, 26% of all referrals and 19% of bookings and referrals combined. In February 2020, this was 32%, 17% and 11% respectively. The Royal College of GPs told HSJ there was a risk of patients “simply disappearing” off lists if the issue was not properly managed, while charity Patient Safety Learning said the issue was a “growing problem” which NHS England must “urgently investigate”. Patient Safety Learning chief executive Helen Hughes 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. “Patients who cannot access outpatient services may deteriorate further while they wait for care, and it is not clear that in these cases there is the appropriate support available for them. There is also the potential for patients to be misdiagnosed and receive inappropriate treatment without specialist involvement, and the potential of a postcode lottery of care emerging for some conditions.” Read full story (paywalled) Source: HSJ, 6 May 2022 Read Patient Safety Learning's blog: Rejected outpatient referrals are putting patients at risk and increasing workload pressure on GPs
  21. News Article
    A coroner has expressed ‘serious concern’ after a trust-wide safety review – prompted by the death of a young mother – was delayed by up to nine months due to ‘staff holidays’. An inquest heard that 25-year-old Natasha Adams, who died by suicide in August 2021, had had her level of care downgraded by Birmingham and Solihull Mental Health Foundation Trust a month earlier, in July, something her family suggested had a “dramatic impact”. She was moved from a “care programme approach” (known as CPA, which involves enhanced care for people with complex needs and/or safety concerns) to “care support” (a non-clinical programme for people with lower-level concerns and complexities). An earlier investigation into her death by the trust, finalised in December, said the trust should audit other cases to check whether the trust’s 2019 “care management and CPA/care support policy” was being complied with. Now Birmingham and Solihull coroner James Bennett has criticised a delay in carrying out the trust-wide audit – writing in a prevention of future deaths report that, as of last month, four months after the report investigating Ms Adams’ care was completed, “no action has been taken”. Read full story (paywalled) Source: HSJ, 5 May 2022
  22. News Article
    Five healthcare staff have been charged with criminal offences as part of a major investigation into the ill-treatment of hospital patients. Concerns had been raised over the welfare of some patients on the stroke unit at Blackpool Victoria Hospital. Three nurses and two healthcare assistants will appear at court for offences including unlawful sedation of patients and theft, police said. The charges relate to a period between August 2014 and November 2018. Those charged are Catherine Hudson, 52, of Coriander Close, Blackpool; Charlotte Wilmot, 47, of Bowland Crescent, Blackpool; Matthew Pover, 39, of Bearwood Road in Smethwick; Victoria Holehouse, 31, of Riverside Drive, Hambleton, and Marek Grabianowski, 45, of Montpelier Avenue, Bispham. They face charges including ill-treatment or wilful neglect, encouraging a nurse to sedate a patient, theft, supplying drugs and perverting the course of justice. Read full story Source: BBC News, 6 May 2022
  23. News Article
    Eight in 10 respondents in the largest survey of menopausal women in the UK said their workplace had no basic support in place and 41% said menopause symptoms were treated as a joke by colleagues. The landmark study found menopausal women were being ignored in the workplace and by healthcare providers, with a third saying it took many GP appointments before they were diagnosed with menopause or perimenopause. This rose to 45% for black and minoritised women. The findings were revealed in a report by the Fawcett Society, based on a survey of more than 4,000 women commissioned by Channel 4 for a documentary by Davina McCall. “Menopausal women are experiencing unnecessary misery and it’s a national scandal,” said Jemima Olchawski, the chief executive of the Fawcett Society. “For too long, menopause has been shrouded in stigma. We need to break the culture of silence and ensure menopausal women are treated with the dignity and support they deserve instead of being expected to just get on with it.” Official guidance states hormone replacement therapy (HRT) should be offered to women struggling with menopause symptoms, but there have been acute shortages of some HRT products and demand is expected to rise. The survey found 39% of women said their GP or nurse offered HRT as soon as they knew they were experiencing menopause, but only 14% of menopausal women said they were currently taking HRT. Read full story Source: The Guardian, 5 May 2022
  24. Content Article
    Workplaces are failing menopausal women and change is urgently needed. A report from the Fawcett Society 'Menopause and the Workplace'' delves into women’s experiences at work and is the largest representative survey of menopausal women conducted in the UK.
  25. News Article
    NHS bosses in England are urging hospitals to offer staff more overtime and tempt retired employees back, to help tackle waiting lists. A letter sent by NHS England said tackling the backlog that had grown during the pandemic would require a "number of high impact actions". And many hospitals were already taking innovative approaches to the issue. More than six million people are on waiting lists for treatment such as knee and hip surgery. According to the General Medical Council, 21,000 doctors are due to retire in September. And part of the plan would be to tempt some of those back by offering part-time opportunities to: train students run virtual consultations help with follow-up check-ups. Other measures recommended by NHS England are: removing caps on consultant hours - in some places senior doctors are limited to 40 hours a week - to offer extra shifts where safe offering more bank shifts - overtime opportunities for trust rather than agency staff increasing the use of NHS reservists - members of the public who have signed up to work for the NHS for at least 30 days a year - to help run wards, feed patients and provide support for the Covid-vaccination programme exploring taking simple procedures, such as cataract surgery, out of operating theatres and into other parts of the hospital. Read full story Source: BBC News, 5 May 2022
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