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Patient Safety Learning

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  1. Patient Safety Learning
    The World Health Organization (WHO) has called for “immediate and concerted action” to protect children from contaminated medicines after a spate of child deaths linked to cough syrups last year.
    In 2022, more than 300 children - mainly aged under 5 - in the Gambia, Indonesia and Uzbekistan died of acute kidney injury, in deaths that were associated with contaminated medicines, the WHO said in a statement on Monday.
    The medicines, over-the-counter cough syrups, had high levels of diethylene glycol and ethylene glycol.
    “These contaminants are toxic chemicals used as industrial solvents and antifreeze agents that can be fatal even taken in small amounts, and should never be found in medicines,” the WHO said.
    As well as the countries above, the WHO told Reuters on Monday that the Philippines, Timor Leste, Senegal and Cambodia may be affected because they may have the medicines on sale. It called for action across its 194 member states to prevent more deaths.
    “Since these are not isolated incidents, WHO calls on various key stakeholders engaged in the medical supply chain to take immediate and coordinated action,” WHO said.
    Read full story
    Source: The Guardian, 24 January 2023
  2. Patient Safety Learning
    The Care Quality Commission (CQC) missed multiple opportunities to identify abuse of patients at a privately run hospital and did not act on the concerns of its own members, an independent review has found.
    Bosses at the CQC have been criticised in an independent report by David Noble into why the regulator buried a critical report into Whorlton Hall hospital, in County Durham, in 2015.
    His report published today said the CQC was wrong not to make public concerns from one of its inspection teams in 2015.
    “The decision not to publish was wrong,” his report said, adding: “This was a missed opportunity to record a poorly performing independent mental health institution which CQC as the regulator, with the information available to it, should have identified at that time.”
    Read full story
    Source: The Independent, 22 January 2020
  3. Patient Safety Learning
    Four carers have been found guilty of ill-treating patients at a secure hospital, following a BBC Panorama investigation.
    Nine former staff at Whorlton Hall, near Barnard Castle, County Durham, had faced a total of 27 charges. Five of those on trial have been cleared.
    Jurors heard vulnerable patients were mocked and treated with "contempt".
    Lawyers for the defendants argued their clients had been doing their best in very challenging circumstances.
    The men found guilty have been bailed and will be sentenced at Teesside Crown Court in July.
    Speaking after the verdicts, Christopher Atkinson, of the Crown Prosecution Service, said the four men had a "duty of care for patients who, due to significant mental health issues, were wholly dependent on their support every day of their lives".
    He said it was "clear" there were times when the care provided was "not only devoid of the appropriate respect and kindness required but also crossed the line into criminal offending".
    Read full story
    Source: BBC News, 27 April 2023
  4. Patient Safety Learning
    "We don't know the long-term side effects of Covid vaccines." That's a claim that's still common to see shared online.
    But a year is actually considered relatively "long term" when it comes to vaccine safety.
    This week marks the anniversary of the first delivery of Covid-19 vaccines under the Covax scheme - as well as being more than 14 months since the first dose was given.
    And scientists explain that's enough time for all but the rarest side effects to have emerged.
    Read full story
    Source: BBC News, 25 February 2022
  5. Patient Safety Learning
    Within hours of the catastrophic Fern Hollow bridge collapse in Pittsburgh, USA, the National Transportation Safety Board was on the scene, finding answers to “Why?” and “How can we keep this from ever happening again?” What could be more obvious than the value of having a team of experts on the alert — and empowered with the authority — to provide promising solutions to dangerous situations?
    Transportation industries embraced the recommendations because they know what its corporate mission and obligation to the public is: to get people from place to place as efficiently and safely as possible.
    Sadly, we cannot say the same for health care, says Karen Wolk Feinstein. 
    There is no single federal agency entrusted with a sole mission: to make health care as safe as possible by investigating solutions to major threats. Therefore, there has been comparatively little progress to protect patients from medical mistakes.
    We don’t understand well enough the preconditions and root causes of adverse events, making it difficult to prevent harm before it happens; we haven’t deployed the safety technology and analytics we have available; and we often don’t share existing lessons learned or actionable solutions, says Karen.
    That’s why a coalition of US experts, including leaders from hospitals, insurers, patient safety groups, consumer advocates, foundations, universities, technology companies and employers has formed to promote the establishment of an independent, nonpunitive federal agency dedicated to finding data-driven solutions to the problem of medical error. A National Patient Safety Board, modelled after the National Transportation Safety Board, would identify patient safety events, study the root causes of these events and issue recommendations to prevent future lapses.
    More than 80% of the NTSB’s recommendations are acted upon. Imagine if this occurred in health care: How many lives could be saved? How much needless suffering could be prevented?
    Read full story
    Source: Pittsurgh Post-Gazette, 10 February 2022
  6. Patient Safety Learning
    At 9.16am Florence Wilkinson gave birth to a healthy baby boy by planned caesarean section. The team of NHS doctors and midwives worked like a well-oiled machine, performing what to them was a standard operation, while also showing real kindness. After a short stint in a close observation bay, Florence was moved onto the postnatal ward. Still anaesthetised, Florence was completely reliant on her partner Ben to help her recover from the birth and feed her son in his first hours of life.
    Yet just a few hours later, the scene was very different. Due to Covid protocol, Ben was not able to stay overnight. 
    At 8pm, midwives bustled around briskly ejecting fathers and birth partners from the ward – and what followed was one of the hardest, most frightening nights of Florence's life. She was alone with a newborn, yet during the course of that night she only saw a midwife once. She was still recovering from my operation and unable to pick up her baby. An exhausted healthcare assistant told Florence she didn’t have time to help and the newborn didn’t feed for seven hours. There simply weren’t enough staff to look after the mothers, but no partner to advocate for them either.
    A review of the maternity policies listed on the websites of 90 hospital trusts in England reveals that 54% still restrict partners from staying overnight after birth. While a few trusts have always limited access at night, many admit to bringing in restrictions during the pandemic which they continue to implement to this day. 
    “It is deeply concerning to hear that some Trusts are continuing to implement restrictions on visiting, such as limited postnatal visiting overnight, under the premise of Covid, particularly at this stage in the pandemic,” says Francesca Treadaway, director of engagement at the charity Birthrights. “There is overwhelming evidence, built up since March 2020, of the impact Covid restrictions in maternity had on women giving birth. It must be remembered that blanket policies are rarely lawful and any policies implemented should explicitly consider people’s individual circumstances.”
    Read full story (paywalled)
    Source: The Telegraph, 13 October 2022
     
  7. Patient Safety Learning
    Two years ago, it seemed that thousands of British women afflicted with crippling pain, ruined sex lives, shattered relationships and wrecked careers would finally get justice and practical redress.
    A government-commissioned report, following a campaign backed by Good Health, recognised that the plastic mesh tape surgeons had used to treat their incontinence and prolapse had caused some women catastrophic harm.
    How many women’s lives have been ruined by this mesh is unknown, but Baroness Cumberlege, who led the official review, estimated it to be ‘tens of thousands’.
    The use of the mesh for stress urinary incontinence was paused in July 2018 as recommended by the inquiry’s preliminary report — then the concluding report, in July 2020, said that this pause should continue until strict requirements on safety and recompense are met.
    These include the establishment of specialist centres to remove mesh from afflicted women, and financial compensation from government and mesh manufacturers for women affected, as well as the setting up of a database of victims to ascertain the numbers involved and their injuries.
    The final report also urged that the watchdog, the Medicines and Healthcare products Regulatory Agency (MHRA), which had approved the use of mesh tape in the 1990s, should be reformed to improve its vigilance on such problems.
    Matt Hancock, then Health Secretary, apologised for the women’s pain. ‘We are going to look carefully at the recommendations,’ he told reporters in July 2020. ‘We need to take action.’
    But words can be cheap: a Good Health investigation has found none of the recommendations has been implemented properly and the use of mesh in women is continuing.
    Read full story
    Source: MailOnline, 6 June 2022
  8. Patient Safety Learning
    Hospitals are sending frail, vulnerable patients home before they are better and without vital medical care, leaving them unable to fend for themselves.
    Over the past fortnight, The Mail on Sunday has received an alarming number of letters from readers who have told of their anger, frustration and sheer desperation at being denied support they were promised. Many have been left bed-bound and unable to wash, dress or use the bathroom for weeks on end.
    The daughter of an 87-year-old stroke survivor had to put a hospital bed in her living room and provide 24/7 care for her mother after the local health team failed to provide adequate support. Within a year, the woman was dead, having been treated with little more than paracetamol.
    In another case, a 70-year-old woman had to take her immobile 84-year-old husband to the hospital in a taxi every day for several weeks to have vital injections, because carers refused to come to their home.
    And the disabled wife of one 74-year-old man, who fell off a roof and broke his pelvis and ribs, told of the heartbreak at not being able to look after her husband due to her own poor health.
    Campaigners say a Government scheme designed address the ‘problem’ of bed-blockers – the somewhat derogatory term used to describe patients, most of them elderly, who are occupying a hospital bed that they don’t strictly need – is to blame.
    The protocol, called Discharge To Assess, launched eight years ago, aims to get patients home as quickly as possible amid reports that some elderly patients ended up stuck in wards for months on end – usually because the NHS hasn’t been able to organise the next stage of their care, so it’s not safe discharge them.
    Read full story
    Source: Mail Online, 2 September 2023
  9. Patient Safety Learning
    The number of women dying during pregnancy or soon after childbirth has reached its highest level in almost 20 years, according to new data. Experts have described the figures as “very worrying”.
    Between 2020 and 2022, 293 women in the UK died during pregnancy or within 42 days of the end of their pregnancy. With 21 deaths classified as coincidental, 272 in 2,028,543 pregnancies resulted in a maternal death rate of 13.41 per 100,000.
    This is a steep rise from the 8.79 deaths per 100,000 pregnancies in 2017 to 2019, the most recent three-year period with complete data. The death rate has increased to levels not seen since 2003 to 2005.
    The data comes from MBRRACE-UK, which conducts surveillance and investigates the causes of maternal deaths, stillbirths and infant deaths as part of the national Maternal, Newborn and Infant Clinical Outcome Review Programme (MNI-CORP).
    Urgent action is needed to bolster the quality of maternal healthcare, ensure it is accessible to all, and repair the damage inflicted by the pandemic on women’s healthcare services more generally.
    Clea Harmer, the chief executive of bereavement charity Sands, said improving maternity safety also needs to be at the top of the UK’s agenda.
    The government said it was committed to ensuring all women received safe and compassionate care from maternity services, regardless of their ethnicity, location or economic status.
    Anneliese Dodds, the shadow women and equalities secretary, said Labour would seek to reverse the “deeply concerning” maternal mortality figures by training thousands more midwives and health visitors and incentivising continuity of care for women during pregnancy.
    Read full story
    Source: The Guardian, 11 January 2024
  10. Patient Safety Learning
    On a Thursday in mid-August, the doors of a hospital's emergency department two hours west of Toronto were shut.
    A note posted on the front said the ER was closed for the day. It would reopen the following morning at 08:00, but close again for the evening. Patients who needed urgent care were asked to go to nearby hospitals - a 15- to 35-minute drive away.
    It was the ninth time since April that the Huron Public Healthcare Alliance - a network of four hospitals serving around 150,000 people in western Ontario - had to temporarily close or cut back hours at one of its emergency departments.
    Canada is one of the richest countries in the world. Its universal publicly funded healthcare system has been touted by progressive politicians in the US, the country's southern neighbour, who see it as a needed alternative to an American system where millions remain uninsured. 
    But in recent months, Canada's system has been described by workers and hospital executives as being in a state of "crisis". That includes struggling emergency rooms.
    Toronto ER physician Dr Raghu Venugopal said he has seen stretchers lining the hallways, occupied by patients suffering from ailments like a broken hip or abdominal pains.
    On some days, those patients may wait anywhere from two to four days to be admitted to hospital, all while a team of two nurses tends to a total of 50 to 60 patients on the unit.
    Other patients are being examined in the waiting room because the lack of staff has forced parts of the ER to close, meaning there is limited space for doctors to see them privately.
    "We are in a standard-less void where anything goes, and it is shocking," Dr Venugopal said.
    Read full story
    Source: BBC News, 2 September 2022
     
  11. Patient Safety Learning
    Tinkering around the edges, the King's Fund said. A few short-term fixes, according to the Health Foundation. And a plan that will have minimal impact, the Royal College of GPs added.
    These were just a handful of the reactions from those involved with the NHS. And they were not even from organisations usually at the front of the queue when it comes to criticising government policies.
    So why has Therese Coffey's first announcement as Health Secretary for England received such a negative response?
    The fact is the problems the health and care system are facing are deep-rooted. Much is made of the impact of the pandemic but the health service was already struggling before Covid hit. The pandemic has simply exacerbated the situation.
    At the heart of it all is a lack of staff.
    Addressing this is not easy and cannot be done overnight. It takes five years to train a doctor, three a nurse, which is why there is a big push on international recruitment at the moment.
    To free up GP appointments, pharmacists are being asked to take on some of their workload, while funding rules are being relaxed to allow GPs to use more of their money to recruit senior nurses.
    But there is nothing in the plan about where these new senior nurses are going to come from, which is why the Royal College of GPs has been so dismissive.
    It is a similar story for hospitals services, where accident-and-emergency waits, ambulance response times and the backlog in routine treatments such as knee and hip replacements have all worsened in recent years.
    Coffey is also introducing a £500m fund to get thousands of medically fit patients out of hospital as soon as possible. Local areas will decide how to spend the money and it could allow hospitals to pay for extra help at home for patients who need it.
    But it amounts to little more than a sticking plaster and is an approach already used to relieve the pressure during the pandemic. The real issue is the care sector is short of staff, with even more vacancies than in the NHS.
    Read full story
    Source: BBC News, 22 September 2022
     
  12. Patient Safety Learning
    A primary school teaching assistant died from a stroke after hospital staff told her family that the life-saving treatment she needed was not available at weekends.
    Jasbir Pahal, 44, who had four children and was known as Jas, died in November last year after suffering a stroke. Her family was told she could only be treated with aspirin because a procedure to remove the blood clot was only available from 8am to 3pm, Monday to Friday.
    It has now emerged that the life-saving treatment, called mechanical thrombectomy, was available at an NHS hospital trust just a 40-minute drive away from the Calderdale Royal hospital in Halifax where she was being treated, but there were no arrangements for such transfers.
    Jasbir’s husband, Satinder Pahal, 49, said: “We have paid the ultimate price for this deficient service. Despite our pleas to save Jas’s life, all they could do was to give her an aspirin.
    “My wife was a vegetarian, never drank alcohol or smoked. She was fit and healthy and she wasn’t given the chance to survive. Jas was the centre of our worlds and her loss will impact us for ever.” The family are calling for urgent action to prevent future deaths."
    The Observer reported last month of warnings by the Stroke Association charity and clinicians about the regional variations in access to mechanical thrombectomy. It has been described as a “miracle” treatment, with some patients who were at risk of death or permanent disability walking out of hospital the day after the procedure.
    Read full story
    Source: The Guardian, 15 October 2023
  13. Patient Safety Learning
    Channel 4 News says they have seen a Public Health England document indicating that not all healthcare and other essential workers with symptoms will be tested because there simply isn’t the capacity to do so – with testing prioritised in order of clinical need.
    Public Health England say they won’t comment on the contents of a leaked document and it is still subject to ongoing discussions.
    View full story
    Source: Channel 4 News, 15 March 2020
  14. Patient Safety Learning
    In March, while the UK delayed, Ireland acted. For many this may prove to have been the difference between life and death.
    The choices our governments have made in the last month have profoundly shaped what risks we, as citizens, are exposed to during the course of this pandemic. Those choices have, to a large extent, determined how many of us will die.
    At the time of writing, 365 people have died in Ireland of COVID-19 and 11,329 have died in the UK. Adjusted for population, there have been 7.4 deaths in Ireland for every 100,000 people. In the UK, there have been 17 deaths per 100,000. In other words, people are dying of coronavirus in the UK at more than twice the rate they are dying in Ireland.
    In her article, Elaine Doyle explores why this might be.
    Read full story
    Source: The Guardian, 14 April 2020
  15. Patient Safety Learning
    The number of people dying needlessly in A&E soars on a Monday as hospitals are stretched to the limit and failing to discharge patients at the weekend, new data shows.
    Figures uncovered by The Independent show an average of 126 patients died every Monday between 2020-2023 – 25% higher than any other day. On a Saturday, the average number of deaths drops as low as 90.
    Waiting times are also shown to spike massively at the start of the week, with an average of 9,300 patients spending more than 12 hours waiting on a Monday – up to 2,000 more than any other day.
    Medical experts said the rise in A&E waits can be attributed to people staying away from hospitals during weekends and patients not being discharged from medical care, causing a bottleneck in an already buckling system.
    The stark statistics also directly contradict repeated government efforts to make the NHS a seven-day service. Multiple coroners have warned the government and health leaders about delays to patients’ treatment and diagnosis due to variations in staffing and access to specialists – particularly over the weekend.
    Adrian Boyle, president of the Royal College of Emergency Medicine, said the NHS England data clearly signposted an “increased risk” at the start of the week. Another expert said the sharp rise in deaths on Mondays showed an A&E “running constantly in the red zone”.
    Read full story
    Source: The Independent, 8 April 2024
  16. Patient Safety Learning
    Emma Moore felt cornered. At a community health clinic in Portland, Oregon, USA, the 29-year-old nurse practitioner said she felt overwhelmed and undertrained. Coronavirus patients flooded the clinic for two years, and Moore struggled to keep up.
    Then the stakes became clear. On 25 March, about 2,400 miles away in a Tennessee courtroom, former nurse RaDonda Vaught was convicted of two felonies and facing eight years in prison for a fatal medication mistake.
    Like many nurses, Moore wondered if that could be her. She'd made medication errors before, although none so grievous. But what about the next one? In the pressure cooker of pandemic-era health care, another mistake felt inevitable.
    Four days after Vaught's verdict, Moore quit. She said Vaught's verdict contributed to her decision.
    "It's not worth the possibility or the likelihood that this will happen," Moore said, "if I'm in a situation where I'm set up to fail."
    In the wake of Vaught's trial ― an extremely rare case of a health care worker being criminally prosecuted for a medical error ― nurses and nursing organizations have condemned the verdict through tens of thousands of social media posts, shares, comments, and videos. They warn that the fallout will ripple through their profession, demoralizing and depleting the ranks of nurses already stretched thin by the pandemic. Ultimately, they say, it will worsen health care for all.
    Read full story
    Source: Kaiser Health News, 5 April 2022
  17. Patient Safety Learning
    Last year, Diana Berrent—the founder of Survivor Corps, a US Long COVID support group—asked the group’s members if they’d ever had thoughts of suicide since developing Long Covid. About 18% of people who responded said they had, a number much higher than the 4% of the general US adult population that has experienced recent suicidal thoughts.
    A few weeks ago, Berrent posed the same question to current members of her group. This time, of the nearly 200 people who responded, 45% said they’d contemplated suicide.
    While her poll was small and informal, the results point to a serious problem. “People are suffering in a way that I don’t think the general public understands,” Berrent says. “Not only are people mourning the life that they thought they were going to have, they are in excruciating pain with no answers.”
    Long Covid, a chronic condition that affects millions of Americans who’ve had COVID-19, often looks nothing like acute COVID-19. Sufferers report more than 200 symptoms affecting nearly every part of the body, including the neurologic, cardiovascular, respiratory, and gastrointestinal systems. The condition ranges in severity, but many so-called “long-haulers” are unable to work, go to school, or leave their homes with any sort of consistency.
    Long COVID can also be incredibly painful, and research has linked chronic physical pain to an increased risk of suicide. Nick Güthe has been trying to spread that message since his wife, Heidi Ferrer, died by suicide in 2021 after living with Long Covid symptoms for about a year. Among her most disruptive symptoms, Güthe says, were foot pain that prevented her from walking comfortably, tremors, and vibrating sensations in her chest that kept her from sleeping.
    “My wife didn’t kill herself because she was depressed,” Güthe says. “She killed herself because she was in excruciating physical pain.”
    Read full story
    Source: Time. 13 June 2022
  18. Patient Safety Learning
    The United States remains one of the most dangerous wealthy nations for a woman to give birth.
    Maternal mortality rose by 40% at the height of the pandemic, according to new data released by the US Centers for Disease Control and Prevention.
    In 2021, 33 women died out of every 100,000 live births in the US, up from 23.8 in 2020. That rate was more than double for black women, who were nearly three times more likely to die than white women, according to the CDC.
    Compared to other countries, the maternal mortality rate was twice as high in the US than in the UK, Germany and France; and three times higher than in Spain, Italy, Japan and several other countries, according to the most recent global comparison data kept by the World Bank.
    "Clearly the US is an outlier," said Joan Costa-i-Font, a professor of health economics at the London School of Economics. "Covid has made [maternal mortality] worse, but it was already a major issue in the US."
    Read full story
    Source: BBC News, 18 March 2023
  19. Patient Safety Learning
    The UK's vaccine advisory body has decided not to recommend vaccines for healthy 12-15-year-olds, but it will offer vaccines to thousands more children with underlying health problems.
    Ministers will now seek more advice on extending the rollout based on factors such as school disruption.
    There is general agreement that this was a really tricky call to make. Bur The Joint Committee on Vaccination and Immunisation (JCVI) has focused squarely on the health benefits of vaccination to children themselves - not on the impact to their schooling or other people.
    Children's risk from Covid isn't zero but the chances of them becoming seriously ill from Covid are incredibly small. Deaths among healthy children are extremely rare - most have life-limiting health conditions.
    That means there needs to be a clear and obvious advantage to giving them a jab. However, a very rare side-effect of the Pfizer and Moderna vaccines has made that calculation a lot more complicated.
    Paul Hunter, professor of medicine at University of East Anglia, says there's been intense pressure on the JCVI and he can understand why they are being cautious.
    "I don't know what the answer is - I'm very close to the fence on this. There's not enough data to be absolutely certain."
    Read full story
    Source: BBC News, 4 September 2021
  20. Patient Safety Learning
    “Better upfront planning, training and testing” were needed in a tech launch which was tied to patient harm and service disruption, an NHS England review has found. 
    Royal Surrey and Ashford and St Peter’s Hospitals foundation trusts went live with Oracle Cerner’s electronic patient record in May 2022 – under a programme called Surrey Safe Care – but the implementation has since been linked to incidents of patient harm, including one death, and significant disruption to trust services.
    Now, a lessons learned review, carried out by NHSE’s frontline digitisation team and obtained by HSJ via a Freedom of Information request, has identified 24 areas of improvement.
    The key lessons cited by the review are “better upfront planning, roles and responsibilities, training and testing”. 
    It recommended that, in future implementations, trust boards should be supported by others experienced with implementing EPRs within the NHS to “aid board level decisions and ‘what questions to ask when’”, while clearer responsibilities should also be agreed upon for programme leads and EPR suppliers.
    The review also found the content of training must be evaluated thoroughly, while the EPR supplier should provide “upfront and continuous training”. It added the “full end-to-end testing [by] representatives from all end user groups” should be completed before go-live.
    It also said EPR readiness needs to incorporate “data readiness, such as data quality, and mapping how data has originally been captured [which] may impact reporting and organisational readiness”.
    Read full story (paywalled)
    Source: HSJ, 15 January 2024
    Related reading on the hub:
    NHS England warns electronic patient record could pose ‘serious risks to patient safety’: what can we learn?
  21. Patient Safety Learning
    More than half of England has limited or no access to a ‘gold standard’ eating disorder programme proven to halve the need for intensive treatment, a year after NHS England funded 18 pilot projects in the wake of five women’s anorexia deaths, HSJ analysis reveals.
    Last November NHSE announced it would scale up the first episode rapid intervention in eating disorders (FREED) service – a successful scheme shown to help people aged 16-25 in London – in 19 initial areas before promoting it country-wide.
    The brainchild of King’s College London’s Professor Ulrike Schmidt, FREED sees teenagers and young adults living with a condition for less than three years being contacted within 48 hours of seeking help – with treatment beginning as soon as two weeks later.
    Now it has emerged that just 16 of England’s mental health trusts, out of more than 54, have fully adopted the FREED service, which experts say has halved the need for intensive treatment from 12.5% to 6.5% in early pilots – saving the NHS around £4,400 per patient.
    Read full story (paywalled)
    Source: HSJ, 6 December 2021
  22. Patient Safety Learning
    The widow of a top Scottish government official, who died after contracting Covid, believes the full details of his illness were concealed to protect the reputation of a troubled hospital.
    Andrew Slorance, Scottish government's head of response and communication unit, in charge of its handling of the Covid pandemic, went into Glasgow's Queen Elizabeth University Hospital for cancer treatment a year ago.
    His wife Louise believes he caught Covid there as well as another life-threatening infection. 
    Andrew went in to the £850m flagship Queen Elizabeth University Hospital (QUEH) at the end of October 2020 for a stem cell transplant and chemotherapy as part of treatment for Mantle Cell Lymphoma (MCL). 
    He died nearly six weeks into his stay, with the cause of his death listed as Covid pneumonia. But after requesting a copy of his medical notes, Mrs Slorance discovered her husband had also been treated for an infection caused by a fungus called aspergillus, which had not been discussed with either of them during his hospital stay.
    The infection is common in the environment but can be extremely dangerous for people with weak immune systems.
    Mrs Slorance questions whether it may have played a part in her husband's death, and if so, why she was not told?
    She told the BBC: "I think somebody and probably a number of people have made an active decision not to inform his family of that infection, either during his admission or post-death."
    Mrs Slorance believes that officials wanted to protect the hospital, which is already the subject of a public inquiry, and its reputation, "no matter what the cost".
    Mrs Slorance says a full investigation should take place into incidences of aspergillus at the hospital campus.
    In response, NHS Greater Glasgow and Clyde said: "We are sorry that the family are unhappy with aspects of Mr Slorance's treatment, details of which were discussed with the family at the time.
    "While we cannot comment on individual patients, we do not recognise the claims being made. We are confident that the appropriate care was provided. There has been a clinical review of this case and we would like to reassure the family that we have been open and honest and there has been no attempt to conceal any information from them."
    Read full story
    Source: BBC News, 18 November 2021
  23. Patient Safety Learning
    A woman is taking legal action against an NHS trust over the “diabolical” and discriminatory treatment of her profoundly deaf husband, who died of cancer in May last year.
    Susan Kelly, who is also deaf, is angry that her husband, Ronnie, was at no point during two hospital admissions and an outpatient appointment provided with a British Sign Language (BSL) interpreter. Instead, her hearing daughter, Annie Hadfield, was asked to translate his terminal diagnosis, when he was told to “get his affairs in order” and given between two weeks and two months to live, while his wife was left outside the room. He died just over two weeks later at home.
    Medical staff at Sheffield Teaching Hospitals NHS trust also placed a “do not resuscitate” (DNR) order on Kelly, who had Alzheimer’s disease, during his first hospital admission in late April without either his consent or consulting his wife or daughter. His family found out only after their barrister obtained his hospital notes.
    Susan Kelly told the Observer through an interpreter: “I didn’t know what DNR meant. I had no idea. I was really shocked. They’d never asked me anything about it. That wasn’t right, it was wrong. Ronnie wouldn’t have known what it meant.”
    Annie Hadfield added: “I thought it was actually quite diabolical.”
    The trust is undertaking a review to understand what happened. David Hughes, medical director, said: “We do acknowledge that we have more to do to support patients and relatives who have hearing impairments and it is an area of work we are actively looking at to make improvements.”
    Read full story
    Source: The Guardian, 7 March 2021
  24. Patient Safety Learning
    “There’s a gap today that no locum filled, so I am carrying both bleeps and doing the work of two people.” That recent tweet, by a children’s doctor, is one of many examples posted on social media by medics illustrating how NHS staff shortages affect them, patients, the smooth running of important services – and, sometimes, the safety of those who are receiving care.
    It is a concern shared by every organisation that represents frontline staff, by regulators such as the Care Quality Commission (CQC), and by NHS England, the body that oversees the service. 
    In January the CQC reported that an inspection it had undertaken of Colchester hospital in Essex found patients were missing out on meals because there were too few staff on duty to feed them. Some patients were wearing dirty dressings, and others did not have their call bells answered promptly, for the same reason.
    In a letter to the trust that runs the hospital, it said: “All wards’ actual staffing levels and skill mix meant staff were often overstretched. All staff we spoke with expressed concern about the impact on patient care and personal wellbeing.
    “Some staff we spoke to were tearful, reported feeling exhausted and concerned that they were unable to care for patients well enough to keep them safe.”
    Read full story
    Source: The Guardian, 26 March 2023
  25. Patient Safety Learning
    William Wragg, the Tory chair of the Public Administration and Constitutional Affairs Committee (PACAC), has belatedly intervened in the growing crisis over the failure of the Prime Minister to appoint a new Parliamentary Ombudsman to replace Rob Behrens who quits the Parliamentary and Health Service Ombudsman on 31 March 2024.
    In a letter published on the committee’s website, Mr Wragg asks Sir Alex Allan, the senior non executive director on the Parliamentary and Heath Services Ombudsman board, what measures will be taken to keep the office going and what is going to happen to people who, via their MP, want to lodge a complaint to the Ombudsman. He also raises whether reports can be published and complaints investigated. 
    The letter discloses that recruitment for a new Ombudsman began last October and a panel chose the winning candidate at the beginning of January. Since then the Cabinet Office and Rishi Sunak, who has to approve the appointment, have not responded. The silence from Whitehall and Downing Street means no motion can be put to Parliament appointing a new Ombudsman, who then appears before the PACAC for a pre appointment hearing. PACAC has only a couple of weeks to set up the hearing.
    Read full story
    Source: Westminster Confidential, 12 March 2024
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