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Patient Safety Learning

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  1. Patient Safety Learning
    The proportion of patients with type 2 diabetes who have had recommended health checks has fallen substantially, provisional data from 2021 suggests, as have the numbers hitting key disease control targets.
    In response, primary care experts have called for GP practices to receive targeted investment to focus on the checks, which they had to deprioritise as the vaccination programme was introduced.
    There are now 3.24 million people with a diagnosis of type 2 diabetes in England, the data across all GP practices shows.
    National Diabetes Audit figures for England from January to September 2021 showed that:
    74% of patients had received a HbA1c check and 70% a blood pressure check compared with 93% and 95% respectively in 2019/20. In the first nine months of last year, 61.9% of patients had an HbA1c under 58 mmol/mol, compared with around 66% in previous years. The proportion of patients with blood pressure targets of under 140/80 was 66.5% in the latest figures compared with around 73-74% during 2015 to 2020. Speaking with Pulse, Professor Partha Kar, NHS England national specialty advisor for diabetes said while this was not the final data, a drop off had been expected for a range of reasons outside GPs control.
    ‘What we have seen is that there was a massive drop off in wave one. Then around the middle of 2020 it started to pick up again but then it’s dropping off again so irrespective of data cleaning, I suspect you will see a massive drop off compared to where things have been over the last four or five years.
    ‘We need to be very clear its not because anyone was twiddling their thumbs, it’s because primary care was asked to do something else.
    ‘We can’t go back to primary care again for the vaccines because they are being taken away from the thing that they’re amazing at which is delivering long-term conditions at scale.’
    Read full story
    Source: Pulse, 2 February 2022
  2. Patient Safety Learning
    ‘We’ve broken the social contract between the NHS and its people’. That was the blunt conclusion of one senior NHS figure surveying the aftermath of the government’s U-turn on the mandatory vaccination of staff.
    Most of the NHS’ leadership at national and local level were behind the policy of mandatory vaccination. They believed it was the right thing to do for patients, colleagues and the service.
    But they were also acutely aware of the reluctance of some staff to get the jab and that changing their minds would be tough – and in some cases unsuccessful. They were also prepared to deal with the consequences of the failure to convert the waverers.
    They put their credibility and reputations on the line to give the vaccination push as much chance of success as possible. They found time to have and facilitate difficult conversations, even though those discussions were bound to impact on morale at a time of huge pressure.
    …and then the government pulled the rug from under them.
    Read full story (paywalled)
    Source: HSJ, 2 February 2022
  3. Patient Safety Learning
    An NHS England review into the behaviour of high-profile senior leaders who took over a Midlands trust has concluded that the interim CEO “behaved poorly and inappropriately” while its chair was “complicit with” and failed to address problems.
    NHS England had commissioned an independent probe into allegations about the behaviour of new executives, who had recently been appointed to the board of Walsall Healthcare Trust.
    David Loughton and Professor Steve Field, who hold the same roles at the Royal Wolverhampton Trust, were brought in as interim chief executive and chair respectively in spring 2021.
    Walsall has faced care quality concerns for some years and it was hoped the pair from neighbouring Wolverhampton would bring improvements. 
    Dr McLean wrote in her review: “Leadership changes can, understandably, represent a period of anxiety for those affected but this can be minimised if changes are made in line with appropriate values and processes. 
    “Whilst I conclude that the joint chair and interim CEO were motivated to act in the best interests of patients, I was saddened by much of what I heard.
    ”In the narratives I heard, there was a consistent lack of compassion or respect for people.”
    She concluded: “The interim CEO, while motivated by the safety and care of patients, has behaved poorly and inappropriately … the joint chair has been complicit with and failed to address this behaviour.”
    Read full story (paywalled)
    Source: HSJ, 2 February 2022
  4. Patient Safety Learning
    Electronic systems and clinical decision support software must become “the norm” for all NHS clinicians, under plans being drawn up by NHS England’s new transformation directorate, HSJ has revealed.
    The massive increase in clinicians’ use of technology forms a major part of the draft plans, seen by HSJ, with the new directorate set to launch ambitious targets for the health service.
    Other targets include every integrated care system creating virtual wards which are the equivalent size of a district general hospital — around 500 beds each — and installing electronic patient records at every NHS trust.
    The proposals are led by former US healthcare chief Tim Ferris, NHSE’s new transformation director, who was appointed last year.
    According to the plans, NHSE’s ambition is to increase the “safe and effective use” of computer assisted processes and clinical decision support so it becomes the “expected norm for all clinicians”.
    NHS leaders have welcomed the use of virtual wards to improve home care and reduce hospital occupancy, but clinicians have warned of safety issues within virtual wards, with some prominent doctors calling for a careful implementation of the policy.
    Read full story (paywalled)
    Source: HSJ, 2 February 2022
  5. Patient Safety Learning
    Dr Ted Baker has been formally appointed as the new chair of the Health Services Safety Investigations Body (HSSIB).
    The Secretary of State for Health and Social Care, Rt Hon Steve Barclay MP, made the announcement today (1 December 2022).
    Dr Baker is a retired consultant paediatric cardiologist, and most recently was Chief Inspector of Hospitals at the Care Quality Commission (CQC) between 2017 and 2022.
    Dr Baker says: “I am delighted to be joining such a ground-breaking organisation. I have been impressed by the quality of the work coming from the HSIB and I am excited to be joining the organisation at such an important time in its history."
    Source: HSIB, 1 December 2022
  6. Patient Safety Learning
    The government has written off £8.7bn it spent on protective equipment bought during the pandemic, accounts show.
    The Department for Health and Social Care documents show items costing £673m were unusable, while £750m of equipment was not used before its expiry date.
    The largest write-off - £4.7bn - was because the government paid more for it than it is currently worth, now that global supplies have recovered.
    No 10 said the purchases were justified - with 97% of items suitable for use.
    A further £2.6bn of equipment was judged to be unsuitable for use in the NHS, the 2020/21 accounts show, but the Department of Health and Social Care (DHSC) believes it could still be sold or given to charities.
    At the start of the pandemic, countries around the world were clamouring for personal protective equipment (PPE), sending prices soaring.
    No 10 said "we stand by the decision to purchase the items that we did", saying the approach was "justified" to get PPE to the front line. And the government was now able to "mitigate" similar problems in the future by "massively increasing our onshore-based PPE production".
    Read full story
    Source: BBC News, 1 February 2022
  7. Patient Safety Learning
    It is one of many mysteries about Long Covid: Who is more prone to developing it? Are some people more likely than others to experience physical, neurological or cognitive symptoms that can emerge, or linger for, months after their coronavirus infections have cleared?
    Now, a team of researchers who followed more than 200 patients for two to three months after their Covid diagnoses report that they have identified biological factors that might help predict if a person will develop long Covid.
    The study, published by the journal Cell, found four factors that could be identified early in a person’s coronavirus infection that appeared to correlate with increased risk of having lasting symptoms weeks later:
    The level of coronavirus RNA in the blood early in the infection, an indicator of viral load. The presence of certain autoantibodies — antibodies that mistakenly attack tissues in the body as they do in conditions like lupus and rheumatoid arthritis. The reactivation of Epstein-Barr virus, a virus that infects most people, often when they are young, and then usually becomes dormant. Having Type 2 diabetes, although the researchers and other experts said that in studies involving larger numbers of patients, it might turn out that diabetes is only one of several medical conditions that increase the risk of Long Covid. The researchers said they had found that there was an association between these factors and Long Covid whether the initial infection was serious or mild. They said that the findings might suggest ways to prevent or treat some cases of Long Covid, including the possibility of giving people antiviral medications soon after an infection has been diagnosed.
    “I think this research stresses the importance of doing measurements early in the disease course to figure out how to treat patients, even if we don’t really know how we’re going to use all that information yet,” said Jim Heath, the principal investigator of the study.
    However, the study authors and other experts cautioned that the findings were exploratory and would need to be verified by considerably more research.
    Read full story (paywalled)
    Source: The New York Times, 25 January 2022
  8. Patient Safety Learning
    After a raft of prenatal check-ups were cancelled because of Covid staff shortages, one mother asked how other mums fared. The replies shocked her.
    Alison, 38, gave birth to her son in June 2021 at a busy London hospital.
    “We had exemplary care during delivery, and the midwives looking after me during my antenatal care were likewise fantastic,” she recalls.
    “However, I didn’t see a midwife face-to-face between my nine-week intake appointment and my 30th week of pregnancy. Then I saw nobody again until I was 34 weeks pregnant, and the next time I was seen was at 38 weeks, even though you’re supposed to be seen weekly at that stage.”
    At Alison’s two-week postpartum check-up, she had to have her stitches examined in a chair as no other facilities were free.
    “The ward was so full they’d had to close the birth centre; labour and delivery was full, and I met two women labouring in the early stages of their induction in the hallway. The midwives that came to do home visits were rushed and left me in tears every time,” she says.
    When another mother found she was suffering from early pregnancy malaise, she reluctantly decided to go back to the London hospital where she had given birth eight years before.
    Her high-risk twin pregnancy had ended in premature birth at 24 weeks and tragedy – with one baby dying after a three-month battle in intensive care. Throughout her antenatal journey, crucial appointments had been cancelled due to staffing issues, with the result that nobody picked up on early signs of premature labour, until it was too late for intervention.
    Her hopes of receiving better care this time, assuming the trust would be aware of my history, evaporated quickly. By nearly 15 weeks of pregnancy, I had still not been seen by anyone, with text messages supposed to inform me of appointments failing to arrive.
    When she queried why I had been given a date for a scan two weeks after the latest possible date such a screening could give a diagnosis of chromosomal abnormality, a clinic receptionist told me I should go private if I didn’t like my appointments. A complaint triggered an apology from the trust’s chief executive months later for protracted problems in the booking process, as well as an apology from the deputy head of midwifery for the receptionist’s “inappropriate” advice.
    Read full story
    Source: The Guardian, 30 January 2022
     
  9. Patient Safety Learning
    The Care Quality Commission (CQC) will restart inspections from 1 February with a focus on the urgent and emergency care system, the regulator has announced.
    In December, CQC postponed inspections of some services to support the acceleration of the vaccination booster programme. They also prioritised activity to help create more capacity in adult social care.
    However, considering the current situation – including the easing of restrictions across the country – they have reviewed and updated their regulatory approach. From 1 February the CQC will inspect where:
    there is evidence that people are at risk of harm. This applies to all health and social care services, including those where inspections were previously postponed except in cases where we had evidence of risk to life CQC can support increasing capacity across the system, particularly in adult social care a focus on the urgent and emergency care system will help us understand the pressures, where local or national support is needed, and share good practice to drive improvement. Much of their approach is unchanged and remains in line with the update from the Chief Inspectors on 10 December 2021.
    This includes:
    achieving their ambition to complete 1,000 infection prevention and control (IPC) inspections in adult social care rapid response to requests to set up new Designated Settings activity to rate adult social care services that are registered and not yet rated inspections of adult social care providers currently rated as Requires Improvement to identify where improvement has taken place and re-rate where possible. Alongside their risk-based activity, CQC will undertake ongoing monitoring of services. This helps to identify where CQC may need to take further action to ensure people are receiving safe care and offer support to providers. It also remains important that people share concerns or examples of good practice, CQC said.
    Read full story
    Source: CQC, 27 January 2022
  10. Patient Safety Learning
    The number of people who try suicide has risen steadily in the U.S. But despite gains in health coverage, nearly half are not getting mental health treatment.
    Suicide attempts in the United States showed a “substantial and alarming increase” over the last decade, but one number remained the same, a new study has found: Year in and year out, about 40% of people who had recently tried suicide said they were not receiving mental health services.
    The study, published in JAMA Psychiatry, traces a rise in the incidence of suicide attempts, defined as “self-reported attempts to kill one’s self in the last 12 months,” from 2008 to 2019. During that period, the incidence rose to 564 in every 100,000 adults from 481.
    The researchers drew on data from 484,732 responses to the federal government’s annual National Survey on Drug Use and Health, which includes people who lack insurance and have little contact with the health care system. They found the largest increase in suicide attempts among women; young adults between 18 and 25; unmarried people; people with less education; and people who regularly use substances like alcohol or cannabis. Only one group, adults 50 to 64 years old, saw a significant decrease in suicide attempts during that time.
    Among the major findings was that there was no significant change in the use of mental health services by people who had tried suicide, despite the passage of the Affordable Care Act in 2010 and receding stigma around mental health care.
    Over the 11-year period, a steady rate of about 40%t of people who tried suicide in the previous year said they were not receiving mental health care, said Greg Rhee, an assistant professor of psychiatry at the Yale School of Medicine and one of the authors of the study.
    The Affordable Care Act, which took effect fully in 2014, required all health plans to cover mental health and substance abuse services, and also sharply reduced the number of uninsured people in the U.S. However, many respondents to the survey in the new report said the cost of mental health care was prohibitive; others said they were uncertain where to go for treatment or had no transportation.
    “It is a huge public health problem,” Dr. Rhee said. “We know that mental health care in the U.S. is really fragmented and complicated, and we also know not everybody has equal access to mental health care. So, it’s somewhat not surprising.”
    Read full story (paywalled)
    Source: New York Times,19 January 2022
  11. Patient Safety Learning
    The question of whether to impose a policy requiring mandatory vaccination for NHS staff has raised countless ethical and practical considerations, but with many healthcare workers still unvaccinated and the Government set for a U-turn over mandatory Covid jabs for NHS staff in England, has enough thought been given to the perspective of patients?
    Various legal experts and health groups have argued that while doctors and nurses can reject the offer of vaccination, patients should also have the right to refuse treatment from a healthcare worker who is not jabbed, instead requesting that their care is placed in the hands of someone who is protected.
    With the February deadline pushed back, could patients start to grow weary of staff who have not been vaccinated? Will they feel as though the chance for refuseniks to get jabbed has come and gone, and that it is therefore justified that they are stripped of their right to deliver treatment?
    “Patients have a right to safe care, so it’s reasonable for patients to expect any health or social care professional caring for them to have had a Covid-19 vaccine,” says Rachel Power, chief executive of the Patients Association.
    Most patients may not be overly concerned about the vaccination status of those caring for them, but in a world in which we’re expected to live alongside the threat posed by Covid, there are undoubtedly certain groups who will be more invested in these matters.
    “A person who is ‘vulnerable’ by way of disability or chronic illness (eg immunocompromised) may well have an argument under the Equality Act that the NHS failing to provide vaccinated staff to them constitutes disability-based discrimination,” says one barrister who specialises in mental health capacity law.
    After all, these individuals are most at risk from COVID-19 – and will be for years to come. Clinically vulnerable people who do find themselves in hospital for whatever reason will know that a Sars-CoV-2 infection could further exacerbate their condition, or endanger their lives.
    Read full story
    Source: The Independent, 30 January 2022
  12. Patient Safety Learning
    MPs will be asked this week to end the “shocking” practice of making cystic fibrosis patients in England pay prescription charges for the drugs that they need to stay alive. The condition is the nation’s most common inherited, life-threatening disease and affects more than 7,000 people.
    Prescription charges, first introduced in 1952, were abolished in 1965; then, when they were reintroduced in 1968, exemptions were made for those suffering from long-lasting ailments such as cancers, diabetes and epilepsy. But children with cystic fibrosis were not expected to live to adulthood and so the condition was not exempted.
    As a result of new medicines and the creation of special physiotherapy regimes, cystic fibrosis patients now live well into their 40s.
    “Medicine and society have moved on, so should the exemption list to reflect modern-day experience,” said Paul Maynard, the Conservative MP for Blackpool North and Cleveleys, who will call for an end to prescription charges for the disease at a special Commons debate on the illness this week. “As someone who has a long-term medical condition – epilepsy – it has always amazed me that adults with cystic fibrosis have to pay for their prescriptions whilst I do not.”
    Read full story
    Source: The Guardian, 30 January 2022
  13. Patient Safety Learning
    Lawyers’ fees for clinical negligence claims against the NHS could be capped under proposals being considered by ministers.
    Launching a consultation, the government said “tackling increasing and disproportionate legal fees” for cases worth less than £25,000 would protect NHS funding.
    The Department of Health said claimants’ legal costs for “lower value claims” were “currently more than four times higher on average” than the NHS’s legal costs in defending the claims. It cited a case in which lawyers claimed £72,000 in legal costs when the patient was awarded £3,000.
    Patient Safety Minister Maria Caulfield said: “I’m committed to making the NHS the safest healthcare system in the world. When harm does occur, it’s essential the NHS learns from what went wrong, and people who have been negligently harmed are entitled to claim compensation.
    “Unfortunately, we are seeing some law firms profiting at the NHS’ expense through legal costs that far outweigh the actual compensation awarded to patients. This diverts resources from the NHS frontline as staff work hard to tackle the COVID-19 backlogs.
    “Our proposals will cap legal costs for lower value claims to ensure they are fair and proportionate, and ensure patients’ claims are resolved as swiftly as possible without reducing the compensation they deserve.”
    A spokesman for Thompson’s Solicitors, which acts for patients in such claims, told iNews: “Costs already have to be reasonable, proportionate and necessary in order to be recoverable. The answer is for the NHS to admit fault quicker and not cause cases to drag on for years."
    Read full story
    Source: iNews, 31 January 2022
  14. Patient Safety Learning
    Downing Street appears likely to drop its policy of dismissing frontline NHS and care staff in England who refuse Covid vaccinations, a minister has strongly indicated, after nursing and care organisations called for this to happen.
    A decision would be made “in the course of the next few days”, according to Simon Clarke, the chief secretary to the Treasury. He said the lower severity of the Omicron variant of Covid did “open a space” for the policy to be reversed.
    The apparent imminent U-turn came as the Royal College of Nursing argued that both the change in severity from Omicron and the number of NHS vacancies meant the mandatory vaccination policy should be dropped.
    The National Care Association said it would also welcome a change of policy, while warning that many unvaccinated care staff had already lost their jobs in the run-up to the 1 April deadline.
    Asked about reports of a change to the policy, Clarke told Sky News that ministers had hoped to find “the right balance between having the maximum impact for measures that support public safety in the face of the virus, but also have the minimum impact in terms of our wider freedoms as a society”.
    Read full story
    Source: The Guardian, 31 January 2022
  15. Patient Safety Learning
    A mum says her life has been destroyed following a hernia repaired with a mesh implant – with pain so severe she considered ending her life.
    Roseanna Clarkin, 38, has suffered excruciating pain since medics used mesh products to repair the issue.
    Now she wants the use of mesh in hernia operations to be suspended, as it has for vaginal mesh following years of suffering by thousands of women.
    Revealing her own hell, Roseanna told how she was in so much pain last month she asked for ­guidance about how to legally end her own life.
    She added: "When I was going to the doctor's after my op, I wasn't believed. They told me it was all in my head and even told my husband Brendan 'Don't get roped into this'".
    Roseanna said: "I suspect the mesh has moved. But even the other week one of the GPs at my practice was suggesting it was in my head."
    Roseanna launched a petition calling for the suspension of mesh in hernia ops. It is going through the public ­petitions committee at Holyrood.
    To date, more than 70 patients or their families have written to the committee about their experiences with hernia mesh implants.
    Labour's health spokeswoman, Jackie Baillie, who campaigned for vaginal mesh ops to be suspended, called for an urgent review of the uses of mesh for other procedures.
    She said: "It has taken years for the serious problems caused for women who had transvaginal mesh used in their surgical treatment to be resolved but it appears to be affecting other conditions too."
    She warned: "We can't repeat the mistakes of the past."
    Read full story
    Source: Daily Record, 31 January 2022
  16. Patient Safety Learning
    A mum says her life has been destroyed following a hernia repaired with a mesh implant – with pain so severe she considered ending her life.
    Roseanna Clarkin, 38, has suffered excruciating pain since medics used mesh products to repair the issue.
    Now she wants the use of mesh in hernia operations to be suspended, as it has for vaginal mesh following years of suffering by thousands of women.
    Revealing her own hell, Roseanna told how she was in so much pain she asked for ­guidance about how to legally end her own life.
    She said: "It sent me to a very dark place. I contacted Euthanasia UK. I asked how I could legally do this is Scotland."
    Roseanna tearfully admitted: "I said to my husband, 'I have had enough of fighting'."
    She added: "When I was going to the doctor's after my op, I wasn't believed.
    Read full story
    Source: Daily Record, 31 January 2022
  17. Patient Safety Learning
    The self-isolation period for positive cases is being cut and the limit on visitors lifted from next week. 
    Residents who test positive will have to self-isolate for up to 10 days, with a minimum isolation period of five full days followed by two sequential negative lateral flow tests – as is already the case for the rest of the population.
    Isolation periods for those having care after an emergency hospital visit will also be reduced to a maximum of 10 days, while a requirement for residents to test or self-isolate after normal visits out will be removed.
    Care homes will have to follow outbreak management rules for 14 rather than 28 days, and by 16 February care workers will need to use lateral flow tests before work rather than taking a weekly PCR test.
    The limit on visitors to care homes will be lifted. Visitors should still obtain a negative lateral flow test result earlier in the day of their visit, and guidance on the use by visitors of PPE such as face masks remains unchanged.
    Read full story
    Source: The Guardian, 27 January 2022
  18. Patient Safety Learning
    At least 1,000 staff at the country’s largest NHS trust are still unvaccinated with a week to go until the deadline, it can be revealed.
    Senior leaders at University Hospitals Birmingham Foundation Trust (UHB), which has a total workforce of over 20,000 people, told a board meeting that 9% of staff, including substantive and active bank workers, had an ‘unknown’ or ‘unvaccinated’ status as of yesterday.
    Like many trusts, UHB is still working through hundreds of records manually, and seeking to contact staff, to establish which are truly ‘unvaccinated’ rather than ‘unknown’, the trust’s chief people officer, Cathi Shovlin, said.
    But she confirmed to the board today that of approximately 1,799 substantive-only staff listed as unknown or unvaccinated, “at least” 1,171 of those in scope are definitely not vaccinated.
    She said the mandatory vaccine programme was “having a significant impact on staff, who range in emotions from disbelief that this will go ahead through to fear of the vaccine, their job, their career, through to anger about the mandate itself”, Ms Shovlin told executives.
    Low uptake has been found particularly among healthcare support workers, porters, housekeeping and cleaners, she said. Diagnostic services, outpatients and surgery, particularly operating departments, were among clinical areas with lower vaccination rates.
    And there has also been reduced uptake in females, particularly women aged 20 to 35, and among Asian, Black British and Black Caribbean staff.
    Read full story (paywalled)
    Source: HSJ, 27 January 2022
  19. Patient Safety Learning
    The inquiry into sex offences carried out in a hospital mortuary will consider whether the trust board ‘received sufficient assurance’ about the issues raised by the assaults, documents shared with HSJ show.
    The draft terms of reference for the independent inquiry have been shared with the families of women and girls abused by maintenance supervisor David Fuller for comment.
    The inquiry will take place in two phases. The first phase – which will concentrate on Mr Fuller’s actions in Maidstone and Tunbridge Wells Trust – will look at his initial employment and access to the mortuary and other areas, and whether processes were appropriate.
    It will also in this phase “consider whether the trust’s board received sufficient assurance on the issues raised by the case”.
    But it will also seek to identify any evidence of “other inappropriate or unlawful activities” by Mr Fuller elsewhere on trust premises. It will review any evidence of concerns around his behaviour, and how the trust and the private contractors who later employed him addressed them.
    In a letter to the families, inquiry chair Sir Jonathan Michael says it is intended that the evidence sessions will be held in private “primarily to protect and safeguard the dignity and anonymity of those people that Fuller abused” but also to encourage people to be “candid”. It is unclear whether families or their legal representatives will be able to attend these private sessions – other than when they are giving evidence – and to raise questions.
    Read full story (paywalled)
    Source: HSJ, 28 January 2022
  20. Patient Safety Learning
    The leadership of a prominent cancer trust acted in a ‘defensive and dismissive’ manner when serious concerns were raised about bullying behaviours and multiple failings in the handling of a major research contract, an external review has found.
    As previously revealed by HSJ, NHS England commissioned the review into events at The Christie Foundation Trust after whistleblowers raised numerous concerns over a research project with pharmaceutical giant Roche, and about the way they were treated as a result of speaking out.
    The NHSE review, which was led by Angela Schofield, chair of Harrogate and District FT, was published earlier today within trust board papers. It described the trust’s research division as “ineffective” and said it had “allowed inappropriate behaviours to continue without challenge”.
    The review added: “It may… be thought to be surprising that NHSE/I found it necessary to commission an external rapid review to look into concerns which had been raised by colleagues within the research and innovation division."
    “The root cause of this seems to be an apparent failure by those people in leadership positions who were aware of the concerns that had been raised, in the circumstances covered by the review, to listen to and take notice of a number of people who have some serious issues about the way they are treated and wish to contribute to an improvement in the culture."
    It also summarised the experiences of 20 current and former staff members who said they suffered “detriment as a result of raising concerns”, although it did not make a clear judgement on whether their claims were justified.
    They said: “An experience of bullying, harassment and racial prejudice was described along with lack of respect at work… Patronising behaviour, humiliation and verbal aggression by managers and clinicians in public and private spaces contributed to the perception that working environments were emotionally unsafe.”
    Read full story (paywalled)
    Source: HSJ, 27 January 2022
  21. Patient Safety Learning
    The Healthcare Safety Investigation Branch (HSIB) has launched an investigation into community mental health care following the death of a 56-year-old woman.
    HSIB has begun examining how patients in crisis with severe mental health needs are assessed by NHS services.
    The investigation came after warnings from multiple coroners over the poor assessment of suicide risk in people in mental health crisis in the last year and followed the death of Frances Wellburn, who took her own life in August 2020 while under the care of Tees, Esk and Wear Valleys Foundation NHS Trust (TEWV).
    Wellburn had long-term mental health problems but suffered a crisis and was admitted to hospital in September 2019.
    Following discharge, she was not referred to a specialist NHS service for people experiencing psychosis because clinicians incorrectly believed she was too old for the service, according to a TEWV investigation report seen by The Independent.
    Despite being assessed as a “medium risk”, Wellburn was not contacted by mental health teams for three months. In June 2020, she was admitted to an inpatient unit for three weeks, but her health deteriorated, and she later took her own life.
    Separately, coroner warnings in three prevention of future deaths reports published last year found mental health staff failing to risk assess people who later took their own lives.
    HSIB’s investigation will look into how patients’ risk is assessed when receiving care in the community and how services interact with families and other health services. It will also examine how mental health services consider menopause when assessing women’s mental health and referrals to early intervention psychosis services.
    Read full story
    Source: The Independent, 27 January 2022
  22. Patient Safety Learning
    Over 30 trusts are now mandating FFP3 masks are used beyond settings stipulated in national rules, amid calls for system leaders to clarify the national position on the key staff and patient safety issue.
    Fresh Air NHS, a group of frontline staff who campaign for better protection against Covid-19, said it now knows of 32 trusts which have already introduced enhanced infection prevention control policies that mandate FFP3 use beyond national guidance.
    News that a growing number of trusts are mandating more stringent PPE use comes amid fresh confusion around the national guidance after small but potentially significant alterations were made last week. A new line has been added to guidance which says:: “FFP3 respirator or equivalent must be worn by staff when caring for patients with a suspected or confirmed infection spread by the airborne route.”
    David Tomlinson, consultant cardiologist and also a member of Fresh Air NHS, said NHS trusts were “in fear of going beyond the guidance and allowing non-ICU staff to wear FFP3 respirators”.
    “The guidance doesn’t mandate respirators for staff in highest risk of transmission areas, for example, medical wards housing symptomatic patients at a time in their disease when they are releasing greatest amounts of infectious aerosols,” Dr Tomlinson said. “Real world data has consistently shown far greater rates of SARS2 infection comparing non-ICU healthcare workers to those on ICU.”
    Alison Leary, chair of healthcare and workforce modelling at London Southbank University, said: “Trusts choosing to implement evidence based safety interventions is a positive move towards workforce safety.”
    Read full story
    Source: HSJ, 27 January 2022
  23. Patient Safety Learning
    NHS officials who accepted £70,000 in bribes to promote prescription drugs visited GP surgeries to “switch” patients’ medication, a court has heard.
    Paul Jerram and Dr David Turner have been accused of arriving at surgeries claiming to be on official business and changing a patient’s medication – a practice known as “switching”.
    James Hines QC prosecuting, told a trial at Southampton Crown Court that the two men had used their positions with the medicine management team of Isle of Wight Clinical Commissioning Group (CCG) and that if the doctors at the surgeries had known it was “not an official visit, they would have not allowed them to [make the changes]”.
    “They were effectively using their position with the NHS to farm out the services of the medicine management team and they received money to do so,” the court was told.
    Mr Hines QC said: “The prosecution case is that it is completely improper for an NHS professional secretly to promote a particular drug within the NHS to his fellow NHS healthcare professionals when he is in effect in the position of a paid influencer for the pharma company that manufactures that drug.
    “That is what was happening on the Isle of Wight for some years.
    “If it is your job within the NHS to review medication and drugs, and make recommendations or suggestions for alternative medicines to fellow NHS healthcare professionals, you are acting improperly if you secretly accept money from pharma companies, either directly or indirectly, to promote a particular medicine.
    Read full story
    Source: The Telegraph, 27 January 2022
  24. Patient Safety Learning
    A string of failings may have contributed to the death of a “deeply vulnerable” law student who killed herself while being treated in a psychiatric hospital in Bristol, an inquest jury has said.
    Zoë Wilson, 22, had informed staff she was hearing voices in her head telling her to kill herself and 30 minutes before she died was seen by a nurse through an observation hatch looking frightened and behaving oddly but nobody went into her room to check her.
    Speaking after the jury’s conclusions, Wilson’s family said that Avon and Wiltshire mental health partnership NHS trust (AWP) should face criminal charges over the case. AWP said it accepted it had fallen short in its care of Wilson.
    Zoë on the 17 June 2019 she told staff she was hearing voices telling her to kill herself and handed over an item that she could have used to harm herself with. She was not moved to an acute ward and other items that she could have used were not removed.
    At 1am on 19 June she was observed standing beside her bathroom door looking frightened but staff did not go to her. Thirty minutes later she was checked again and had harmed herself. Emergency services were called but she was pronounced dead.
    Giving evidence to Avon coroner’s court, the nurse who saw Wilson at 1am said he had only worked in the unit a handful of times and had not met Wilson before that night.
    The jury concluded that steps taken to keep her safe that night had been inadequate and also criticised communication and information sharing.
    In a statement, her family, said: “Zoë was a wonderful, bright, and deeply vulnerable young woman. She was on a low-risk ward even when she told staff that voices in her head were telling her to kill herself.”
    They called for AWP to face a criminal prosecution by the Care Quality Commission (CQC). “We will continue to fight for justice in her name,” they said. “She will never be forgotten.”
    Read full story
    Source: The Guardian, 27 January 2022
  25. Patient Safety Learning
    Geneticists have warned the public against buying polygenic risk score analyses, which some private fertility clinics claim can help parents using in vitro fertilisation in selecting embryos that carry the least risk of future disease.
    It appears that at least one child has been born after such a procedure, but the use of polygenic risk score analysis in this respect is severely limited. No evidence shows that these tests can predict the likelihood of an unborn child being liable to a specific disease in the future, representatives from the European Society of Human Genetics wrote in the European Journal of Human Genetics.
    Polygenic risk score analysis is mainly offered by fertility clinics in the US, although the practice is also being promoted in the UK.
    Patients need to be properly informed on the limitations of its use and a societal debate, focused on what should be considered acceptable with regard to the selection of individual traits, should take place before any further implementation of the technique in this population.
    Read full story (paywalled)
    Source: BMJ, 26 January 2022

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