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Patient Safety Learning

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  1. Patient Safety Learning
    To raise awareness of an illness estimated to kill 30 million people a year globally – and up to 44,000 people a year in the UK – East of England Ambulance Service NHS Trust (EEAST) is encouraging people to learn to spot the signs of sepsis – and know what to do.
    As part of World Sepsis Day, EEAST staff have been sharing stories about how they have been affected by sepsis in their families.
    Read full story
    Source: East of England Ambulance Service NHS Trust, 13 September 2019
     
  2. Patient Safety Learning
    The National Guardian’s Office (NGO) has published a 'Summary of speaking up learning and actions' in response to the referrals made from the review into the handling of two speaking up cases at Northwest Ambulance Service NHS Trust (NWAS). The review is the product of the NGO’s engagement process, the central feature of which is the actions the trust will take to address the issues highlighted.
    These include explaining the scope of the role of the Freedom to Speak Up Guardians and the issues they can support workers to raise. The trust has also committed to consider their approach to the independence, timeliness and handling of investigations into speaking up matters. They also recognised the need to address perceived attitudes towards female workers.
    “The trust has outlined significant steps it is making to ensure these issues are taken seriously, and the learning is embedded in effective improvement actions,” explained Dr Henrietta Hughes, National Guardian for the NHS.
    Daren Mochrie, NWAS’ Chief Executive, said, “It’s really important for us to give our staff the confidence to be able to share any concerns and observations safely and confidentially. This creates an open and honest reporting culture within the trust. We welcome the findings of the report and are now putting the learning from this into action to even further improve our reporting system.”
    Source: National Guardian's Office, 12 September 2019
  3. Patient Safety Learning
    A mental health trust is preparing to seek a merger or acquisition by another provider in a bid to address its financial challenges, HSJ has learned. 
    In a message to staff, North West Boroughs Healthcare Foundation Trust said growing financial pressures were “likely to put the quality and safety of patients at risk”.
    It said various options were discussed by governors and the trust board at a meeting yesterday, and it was agreed to pursue a “merger or acquisition of the whole organisation with one or more provider trusts”.
    Read full story (paywalled)
    Source: HSJ, 12 September
  4. Patient Safety Learning
    Midwives have called on the government to end the policy of charging some migrants for maternity care, saying it undermines trust and creates a climate of fear among vulnerable pregnant women.
    A report by Maternity Action, backed by the Royal College of Midwives, says some women were seeking maternity care late in pregnancy, missing tests and treatments, or completely avoiding antenatal care for fear of charges and Home Office sanctions.
    “Midwives should not act as gatekeepers to maternity services,” said Gill Walton, chief executive and general secretary of the Royal College of Midwives.
    Read full story (paywalled)
    Source: BMJ, 9 September 2019
  5. Patient Safety Learning
    A new report from the AHSN Network is shining a light on ways we can do more to improve safety for residents of care homes.
    The publication showcases over 30 examples of projects delivered by England’s 15 Patient Safety Collaboratives (PSCs) and the Academic Health Science Networks (AHSNs) which host them. They include case studies in medicines safety, dementia, monitoring and screening, and workforce development.
    AHSN Network Patient Safety Director Dr Cheryl Crocker, said:
    “Many residents have complex healthcare needs, reflecting multiple long-term conditions, significant disability and advanced frailty. All these factors make caring for residents an incredibly difficult job for care homes and their staff.
    “Given this operating landscape, there are some fantastic examples of care, safety and quality improvement in care homes. The aim of this summary is to share good practice supported by the AHSN Network, and we are actively encouraging readers to get in touch with those who have shared their work for this report and discuss how we can have even greater impact on patient safety and improvement in care homes.”
    Read full report
  6. Patient Safety Learning
    Hundreds of thousands of people in England are getting hooked on prescription drugs, health chiefs fear. 
    A Public Health England (PHE) review looked at the use of strong painkillers, antidepressants and sleeping tablets - used by a quarter of adults every year. It found that at the end of March 2018, half of people using these drugs had been on them for at least 12 months. Officials said long-term use on such a scale could not be justified and was a sign of patients becoming dependent.
    PHE medical director Prof Paul Cosford said he was worried. "These medicines have many vital clinical uses and can make a big difference to people's quality of life." But he added there were too many cases where patients were using them for longer than "clinically" appropriate - where the drugs would have simply stopped working effectively or where the risks could outweigh the benefits.
    Read full story
    Source: BBC News, 10 September 2019
  7. Patient Safety Learning
    The parents of five-year-old Tafida Raqeeb, who is on life support, are going to the High Court to challenge an NHS decision which is preventing them from taking her abroad. 
    Tafida Raqeeb suffered a traumatic brain injury in February as a result of a rare condition, arteriovenous malformation, where a tangle of blood vessels causes blood to bypass the brain tissue. Tafida's mother and father want to seek treatment in Italy. But the Royal London Hospital, which is caring for their daughter, says releasing her is not in her best interests.
    A spokesperson for Barts Health NHS Trust, which runs the hospital, said that its clinicians and independent medical experts had found "further medical treatment would not improve her condition".
    In England and Wales the concept of parental responsibility is set out in law, in the Children Act 1989. This gives parents the responsibility broadly to decide what happens to their child, including the right to consent to medical treatment. But this right is not absolute. If a public body considers that a parent's choices are not in the best interests of their child, and an agreement cannot be reached, it can challenge these choices by going to court. It comes down to a judge to make the final decision, based on the evidence available.
    Read full story
    Source: BBC News, 2 September
  8. Patient Safety Learning
    The Academic Health Science Network (AHSN) has published their plan for a safer future: 'Patient Safety in partnership: Our plan for a safer future 2019-2025' . Their plan supports the NHS Patient Safety Strategy and sets out how England’s 15 AHSNs, and the Patient Safety Collaboratives (PSCs) they host, will work more closely with their local health and care organisations to improve safety both in hospitals and community-based services such as care homes.
    AHSN's "ambition is to support the delivery of the NHS Patient Safety Strategy and therefore our vision is aligned to the national strategy: ‘for the NHS to continuously improve patient safety'.’'
    Patient Safety Learning is delighted to be working with The AHSN and Patient Safety Collaboratives and welcomes their Patient Safety in Partnership plan:
    "We believe that it will make a difference for patient safety and represents a step forward from the good work that AHSNs are already doing. We believe that there is opportunity for even more to be achieved with the resources, scale and capability within the AHSN networks. We absolutely applaud the statement that patient safety is a central priority and guiding principle for all AHSNs, and we recognise the AHSNs’ distinct role as orchestrators across the healthcare system. We think that AHSNs, with PSCs, can reinforce this position by taking a powerful role in bringing, enabling and supporting systems thinking for patient safety across healthcare."
    Patient Safety Learning will be sharing details of the innovation and improvement programmes on the hub.
  9. Patient Safety Learning
    Patient safety is frequently at risk in NHS hospital trusts in England, with 70% of them failing to meet national safety standards, according to an Observer analysis of inspection reports, with staff shortages the biggest problem. 
    Reports by the Care Quality Commission (CQC) reveal that managers at one trust failed to act on staff reports of abuse and violence, while a shortage of critical beds at another trust led to three serious incidents resulting in patient harm. Of 148 acute and general hospital trusts, safety standards at 96 are rated as “requires improvement” by the CQC; six are rated inadequate, the lowest category. The others are rated good, with none outstanding.
    Read full story
    Source: Guardian, 8 September 2019
  11. Patient Safety Learning
    Almost half (47%) of new mothers get less than three minutes or no time to discuss their mental and physical health at the routine six week postnatal check-up, according to a survey by the National Childbirth Trust (NCT).
    The charity is calling on the government to provide funding for a full postnatal check-up so that GPs have sufficient time to talk to a new mother about her health and wellbeing.
    Read full story (paywalled)
    Source: BMJ, 5 September 2019
  12. Patient Safety Learning
    The coroner looking into the death of Scottish teenager Amy Allan has found significant failings in her care by Great Ormond Street Hospital.
    Amy, from Dalry in North Ayrshire, was 14 when she died in September last year following surgery on her spine. Coroner Edwyn Buckett outlined poor planning and support from the hospital. But he said he "was not able to make a firm conclusion" that those omissions "had caused or materially contributed to her death." The coroner is however likely to issue a prevention of future deaths report.
    Great Ormond Street Hospital admitted Amy's care "fell short of the high standards" it should be meeting but said it had made changes to the way it worked.
    Read full story
    Source: BBC News, 5 September 2019
  13. Patient Safety Learning
    A series of hospital failings contributed to the death of a five-year-old girl who died from toxic shock syndrome, an inquest jury has found. Ava Macfarlane died on 15 December 2017 after being treated at Nottingham's Queen's Medical Centre.  
    Prescribing antibiotics earlier could have "given her chances of survival", Nottingham Coroner's Court heard. Returning a narrative conclusion the jury said there had been "missed opportunities" to diagnose sepsis.
    Dr Keith Girling, medical director at Nottingham University Hospitals NHS Trust, apologised for the "significant shortcomings" in its care.
    He said a number of changes had been made following Ava's death and greater awareness of sepsis, in relation to children with complex medical conditions, had been raised.
    Read full story
    Source: BBC News, 4 September
  14. Patient Safety Learning
    In an open letter to MPs, The King's Fund, the Health Foundation and Nuffield Trust have summarised the four major areas where the impact of a no deal Brexit could be felt most sharply in health and care. 
    There is a very real risk that leaving the EU without an agreement could exacerbate the workforce crisis in health and care, drive up demand for already hard-pressed services, hinder the supply of medicines and other vital supplies, and stretch the public finances which pay for healthcare.
    They conclude that a no deal Brexit could cause significant harm to health and social care services and the people who rely on them.
    Read full letter
    Source: The King's Fund, 3 September 2019
  15. Patient Safety Learning
    An NHS Trust, rated inadequate for more than two years, has been awarded an improved grade by inspectors.
    Isle of Wight NHS Trust has made "improvements in most areas" and is no longer unsafe overall, the Care Quality Commission (CQC) said. Although it recommended the trust should remain in special measures, the CQC gave the trust a rating of "requires improvement".
    The trust said it welcomed the change and was committed to improving further.
    Read full story
    Source: BBC News, 4 September 2019
  16. Patient Safety Learning
    The first baby born using entirely digital maternity notes in north Cumbria has been born at West Cumberland Hospital in Whitehaven. The new digital system replaces the traditional paper-based system with notes being held digitally for staff and linking to a phone app so women no longer need to carry their notes to appointments.
    The app which expectant and new mothers can use is called ‘Maternity Notes’. It helps women track their pregnancy journey and contains lots of information about the baby’s development as they move through their pregnancy, and up to six weeks post-birth. The new system is safer too, with women no longer needing to carry paper maternity notes.
    Since going live on 1 April, 100% of women registering a new pregnancy have signed up to the app.
    North Cumbria University Hospitals NHS Trust is one of only 14 Trusts across the country to implement electronic maternity notes.
    Read full story
    Source: Health Tech Digital, 2 September 2019
  18. Patient Safety Learning
    A survey of consultants in anaesthesia and paediatric intensive care working in the UK and Ireland found that most had experienced work related fatigue.
    The survey, published in Anaesthesia, received 3847 responses from consultants working in the UK and the Republic of Ireland. Most (91%) said that they had experienced work related fatigue and 72% said that this had a moderate or significant negative impact on their social and family life.
    Read full story (paywalled)
    Source: BMJ, 3 September 2019
  19. Patient Safety Learning
    Pharmacists are set to offer rapid detection and help for killer conditions like heart disease as part of a major revamp of high street pharmacy services. The high street heart checks are part of an ambitious target the NHS in England has set itself as part of its Long Term Plan to prevent tens of thousands of strokes and heart attacks over the next ten years.
    Plans are underway for both GPs and community pharmacists to lead the fight against common conditions that cause cardiovascular disease (CVD) and stroke, building on successful pilots which have reduced strokes by a quarter.
    From 1 October 2019, as part of their new £13 billion five-year contract, community pharmacists will start to develop and test an early detection service to identify people who may have undiagnosed high-risk conditions like high blood pressure for referral for further testing and treatment. If successful this could be rolled out to all community pharmacies in 2021-22.
    Professor Stephen Powis, NHS national medical director, said: “Heart disease and strokes dramatically cut short lives, and leave thousands of people disabled every year, so rapid detection of killer conditions through High street heart checks will be a game-changer."
    Read full story
    Source: NHS England, 2 September 2019
  20. Patient Safety Learning
    A five-year-old girl who died due to sepsis complications could have been saved if clinical guidelines had been followed, an inquest heard.
    Ava Macfarlane died of toxic shock caused by a bacterial infection on 15 December 2017. She had presented with symptoms when she first went to hospital two days earlier but they were not picked up. Nottingham Coroner's Court heard she was given Calpol and ibuprofen before doctors allowed her to go home.
    Dr Shearn admitted Ava had been showing at least two "red flags" of sepsis and if he had followed guidelines from the National Institute for Health Care and Excellence and the Sepsis Trust, then the infection would have been picked up earlier. When asked by Assistant Coroner Laurinda Bower whether the "failure to follow the Sepsis 6 Pathway contributed to her death", he replied "it probably did".
    Read full story
    Source: BBC News, 2 September 2019
  21. Patient Safety Learning
    An orthopaedic surgeon falsified records and lied to a patient after he performed the wrong operation on her. 
    Alan Norrish admitted performing the wrong type of partial knee replacement on his patient in January 2018 at the Nuffield Hospital in Cambridge. Having realised his mistake the former Addenbrooke's consultant tried to cover it up by falsifying records and doing "revision" surgery six days later.
    Mr Norrish has been suspended for a year following a medical tribunal. He told the hearing of the Medical Practitioners Tribunal Service (MPTS) he was "shocked" and "upset" when he realised his mistake. It was found he had lied in a letter to a hospital matron about the reason for the second operation, which was carried out on 25 January 2018.
    Read full story
    Source: BBC News, 30 August 2019
  22. Patient Safety Learning
    Hospital patients’ safety is being put at risk by fires, floods and crumbling, overcrowded buildings caused by a £4 billion government squeeze on capital funding, NHS bosses are warning.
    Hospitals say they do not have the funding to replace outdated scanners, fix leaking roofs and boilers, or remove ligature points that suicidal patients may attempt to use to try to end their lives.
    Four out of five (82%) chief executives and chief finance officers at NHS trusts in England fear the lack of capital funding poses a medium or high risk to patient safety.
    Read full story
    Source: Guardian, 30 August 2019
  23. Patient Safety Learning
    The NHS and the national medical regulator could face legal action over the shortage of intravenous feed supplies for hundreds of UK patients, HSJ has learned. 
    The law firm acting for more than a dozen patients affected by the shortage of feed supplies has confirmed to HSJ it has been instructed to take action against NHS England, the Department of Health and Social Care, the Medicines and Healthcare products Regulatory Agency and the company responsible for producing the feed, Calea. 
    Since June, hundreds of patients who rely on IV feed known as total parenteral nutrition have gone without deliveries of their bespoke feed. More than 40 people have been admitted to hospital as a result.
    Read full story (paywalled)
    Source: HSJ, 29 August 2019
  24. Patient Safety Learning
    A small number of babies at a Belfast hospital have been found to have pseudomonas on their skin. The infants involved were being treated in the neonatal unit of the Royal Jubilee Maternity Service. Although the bacteria was found on their skin, it does not mean the babies were infected. Staff have put in place infection prevention measures and carried out a deep clean of the unit.
    A spokesperson for the Belfast Health Trust said while the issue was unfortunate it wanted to reassure patients, their families and the public that the situation was being managed appropriately.
    Read full story
    Source: BBC News, 29 August 2019
  25. Patient Safety Learning
    An NHS children’s mental health unit has been closed down by the Care Quality Commission after being rated “inadequate” last week.
    A child and adolescent mental health ward run by Tees, Esk and Wear Valley’s Foundation Trust has been closed after the CQC took enforcement action to protect the safety of patients.
    In a statement today, a CQC spokesman said: ”[We have] taken urgent enforcement action at Tees, Esk and Wear Valley’s Foundation Trust which will lead to the closure of the child and adolescent mental health service units at West Lane Hospital. The Holly unit at West Park Hospital and Baysdale Unit at Roseberry Park are unaffected. The action follows continued concerns identified at earlier inspections in June and August, and the recent inspection on 20 and 21 August 2019."
    Read full story (paywalled)
    Source: HSJ, 23 August 2019
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