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Patient Safety Learning

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  1. Patient Safety Learning
    The NHS waiting list in England has hit a new record high, with almost 7.8 million people waiting for treatment, data shows.
    An estimated 7.75 million people were waiting to start treatment at the end of August, up from 7.68 million in July. It is the highest number since records began in August 2007.
    The waiting list for treatment has been growing for much of the last decade, passing three million in 2014, four million in 2017, five million in 2021 and seven million in 2022.
    As the NHS waiting list grows A&E pressures are “ running red hot”, a major think tank has warned, with new figures showing 123,000 patients waited more than 12 hours in emergency departments last month.
    Some 8,998 people in England are estimated to have been waiting more than 18 months to start routine hospital treatment at the end of August, up from 7,289 at the end of July, according to data.
    A total of 396,643 people in England had been waiting more than 52 weeks to start routine hospital treatment at the end of August, up from 389,952 at the end of July.
    The Government and NHS England have set the ambition of eliminating all waits of more than a year by March 2025.
    Read full story
    Source: The Independent, 12 October 2023
  2. Patient Safety Learning
    The daughter of a man who took his own life after experiencing years of pain linked to botched dental surgery said she had "lost faith in the system".
    Clive Worthington, from Harlow, Essex, travelled to Hungary for dental implants in 2008.
    Several follow-up procedures from the same dentist back in the UK over the next seven years were unsuccessful.
    The government said it was addressing a so-called loophole which meant the 81-year-old missed out on compensation.
    Last week, an inquest concluded Mr Worthington's death in 2022 was a suicide.
    Senior Essex coroner Lincoln Brookes said the "long-term consequences" of Mr Worthington's unsuccessful dental surgery "impacted significantly on his mental health and ability to cope with daily life".
    In 2017, the General Dental Council (GDC) found Dr Eszter Gömbös, who was employed by Perfect Profiles, at fault for the work.
    Mr Worthington was awarded £117,378 in damages and legal costs at Chelmsford County Court in November 2019 - one of the highest pay-outs for dental negligence in the UK.
    But the insurer which covered Dr Gömbös - the Dental Defence Union (DDU) - argued "discretionary indemnity" and refused to pay.
    Read full story
    Source: BBC News, 12 October 2023
    Related hub content
    “I’ve been mocked, scolded and gaslighted”: a harmed patient’s experience of orthodontic treatment A patient harmed by orthodontic treatment shares their story We want to hear from patients with experience of NHS and/or private orthodontists and dentists in any healthcare setting, including community practices and hospitals.
    Did the orthodontist/dentist give you the treatment and support you needed? If you had ongoing problems, how did the orthodontist/dentist and other healthcare professionals respond? Have you tried to make a complaint? Share your experience of orthodontist and dentistry services
  3. Patient Safety Learning
    Valproate-containing medicines will be dispensed in the manufacturer’s original full pack, following changes in regulations coming into effect on Wednesday 11 October 2023. The Medicines and Healthcare products Regulatory Agency (MHRA) has published new guidance for dispensers to support this change.
    Following a government consultation, this change to legislation has been made to ensure that patients always receive specific safety warnings and pictograms, including a patient card and the Patient Information Leaflet, which are contained in the manufacturer’s original full pack. These materials form a key part of the safety messaging and alert patients to the risks to the unborn baby if valproate-containing medicines are used in pregnancy.
    The changes follow a consultation on original pack dispensing and supply of medicines containing sodium valproate led by the Department of Health and Social Care (DHSC), in which there was overwhelming support for the introduction of the new measures, to further support safety of valproate-containing medicines.
    Minister for Public Health, Maria Caulfield, said:
    “This safety information will help patients stay informed about risks of valproate, and I encourage all dispensers of valproate to consult the new guidance carefully.
    “This continues our commitment to listening and learning from the experiences of people impacted by valproate and their families and using what we hear to improve patient safety.”
    Read full story
    Source: MHRA, 11 October 2023
  4. Patient Safety Learning
    Three patients have died after being given a bowel test by a doctor who failed to ensure treatment needed was carried out, a health board has said.
    NHS Greater Glasgow and Clyde (NHSGGC) said three more patients suffered harm.
    The six patients were identified in a clinical review the health board carried out of 2,700 people the consultant carried out a colonoscopy on between 2020 and 2022.
    The consultant, who has not been named, was suspended in November 2022 and has since left the health board.
    NHSGGC deputy medical director Professor Colin McKay said: “We would like to offer our sincere apologies to patients who were not followed up appropriately and our condolences to the families of those patients who have died."
    “Our investigations found that the doctor did not consistently follow up the results of investigations that had been completed or requested and therefore missed the opportunity for patients to be treated, including a number of patients who went on to develop malignancy."
    Read full story
    Source: The Independent, 11 October 2023
  5. Patient Safety Learning
    The community services waiting list has risen sharply to more than 1 million, with children suffering the longest waits, new data has revealed.
    NHS England figures published today show the adult community waiting list increased from 704,000 to 781,000 between October 2022 – the first published data available – and August. The children and young people’s list rose from 207,000 to 221,000. 
    This means the overall community waiting list for England has exceeded 1 million for the first time since figures were first published in October last year.
    Waits for musculoskeletal services dropped to a low of 255,000 in January. But this progress has since reversed – and, in July, the number of people waiting for care climbed to a high point of 319,000.
    The waiting for podiatry and podiatric services, meanwhile, has climbed by 7% since October from 117,000 to 126,000, adding an extra 8,000 people to the waiting list. These services also account for 46 per cent – or 5,635 – of the waiting list over 52 weeks. 
    Waiting lists for smaller adult specialties have also significantly worsened.
    For example, nursing and therapy support for long-term conditions saw large increases in three areas: continence and colostomy, rising by 16%; respiratory and COPD, rising by 27%; and diabetes, rising by 37%.
    Read full story (paywalled)
    Source: HSJ, 12 October 2023
  6. Patient Safety Learning
    Weight management is a sensitive topic. Nevertheless, the measurement is often used as a marker to inform medical decisions or for someone's personal interest. But for many wheelchair users, accessing scales has proved near impossible.
    "The last time I was weighed was about 22 years ago, " Lizzie tells the BBC podcast, Access All. "I think I was about 15."
    As a result, now aged 37, Lizzie has been through three successful pregnancies, all without knowing how her body was adapting or how her baby was growing.
    Based in Devon, she has a degenerative muscle-related impairment and uses a wheelchair. This makes weighing herself on traditional bathroom scales, which require you to stand still and independently on a small platform, a challenge.
    There is equipment out there to help wheelchair users, like Lizzie. Chair scales enable someone to sit on a seat which records their weight and there are similar bed and hoist versions too. There are also wheel-on scales which are very large and involve subtracting the weight of the chair afterwards. But none of these seem widely available.
    Dr Georgie Budd, who is based in Merthyr Tydfil, says this worries her. A wheelchair user herself she appreciates how difficult it can be for people to access scales.
    "There's a lot of things that we use weight for in health - anaesthetics and drug dosing - and just to keep an eye on it as well for someone's general health. During pregnancy for example, if someone was losing weight I, as a GP, would actually be really quite concerned," she says.
    Neither NHS England nor the government have guidance for doctors nor advice on what equipment to use and no figures are kept on how many hospitals have access to such equipment and where they are.
    The National Institute for Health and Care Excellence (NICE) previously considered the issue in 2014 and requested more research be carried out. But so far nothing has been started.
    Read full story
    Source: BBC News, 13 October 2023
  7. Patient Safety Learning
    The mother of a patient at Muckamore Abbey Hospital has described how her son contracted tuberculosis (TB) while at the hospital.
    She said he had been left severely disabled after a series of associated strokes.
    Patient P116 is now 40 years old and has suffered from severe epilepsy since he was a baby.
    His mother told the inquiry into abuse at the hospital that her concerns over her son's health were ignored.
    She said that even after he began developing symptoms - including losing six stone (38kg) of weight - staff seemed "not to care".
    In the end, he was only diagnosed with TB after his mother took him to hospital herself.
    Due to the delay in the diagnosis and the way the family's complaint was handled, a serious adverse incident review was carried out and P116's mother received a letter of apology from the then permanent secretary at the Department of Health, Richard Pengelly, and Theresa Villiers, who was Northern Ireland secretary at the time.
    His mother told the inquiry her son's time in Muckamore remained a "major trauma" for the family and she still found it very difficult to talk about.
    She told the inquiry she felt strongly that "independent expert support" should be given to patients abused or neglected in Muckamore, including specialist counselling for the patients and their families.
    Read full story
    Source: BBC News, 12 October 2023
  8. Patient Safety Learning
    The true picture of A&E waiting times in Wales has been seriously under-reported for a decade, the BBC can reveal.
    The Royal College of Emergency Medicine (RCEM) has established thousands of hours are missed from monthly figures.
    Senior A&E doctors have been raising the issue for months.
    The Welsh government said it would ask health boards for assurances they were following the guidance "to ensure the data is absolutely transparent".
    The RCEM said it could not measure "how bad" things were because thousands of patients subject to so-called "breach exemptions" were not included in the overall A&E waiting times.
    The Welsh government initially disputed the RCEM's claim, but after seeing detailed figures - which were obtained through freedom of information (FOI) requests to health boards - it changed its position.
    Wales' health minister has repeatedly claimed A&E waiting times in Wales have "bettered English performance".
    But once the missing data is taken into account, it suggests the performance in Wales is worse.
    Read full story
    Source: BBC News, 16 October 2023
  9. Patient Safety Learning
    Imagine being on your period and "forced to beg for pads and tampons". According to 24-year-old Lara, that's common for her and others on mental health hospital wards in the UK.
    When she posted about her experience online, people from across the country responded with their own similar stories.
    Mental health hospitals have various rules in place for safety reasons, including access to certain items. However, NHS guidance states that period products should be available to anyone who needs them. Lara says this hasn't always been the case for her.
    "I've had a number of hospital admissions to psychiatric units and on one of my first they confiscated my period products," she says.
    Lara's currently on one-to-one observations for her own safety, which means someone has to escort her to the toilet and watch her change a pad or tampon.
    But she says her worst experience was when she's had to wear anti-ligature clothing - again for safety reasons.
    "I was forced to remove my pants and sanitary pad - which meant I just had to bleed into the clothing," she says.
    "I understand the need for safety to come first, but this experience was unhygienic, traumatising and embarrassing for people to see."
    Eleanor is 20 years old and recently spent time in a mental health hospital.
    At her "most unwell", she says she didn't have access to her own clothing and had to wear the same special clothing Lara spoke about.
    "I'd have two or three people watching me changing and even though I know it's for my own safety, it's dehumanising," she says.
    Newsbeat asked a number of unions, organisations and charities to comment on the experiences described but none wanted to provide one.
    But one mental health professional, Kasper, did agree to discuss it.
    Kasper agrees that safety is always a top priority but adequate period provision is often overlooked."I'm sure all trusts have a policy, but don't think it's always applied - and my observation is that it very much depends on what staff are on shift, especially when there can be lots of agency workers," Kasper says."We do keep products on my ward, but there's not much of a range.
    "Patients can't access them and some staff don't know where they are either - so the onus is very much on patients, which can be tricky when they're unwell."
    Read full story
    Source: BBC News, 16 October 2023
  10. Patient Safety Learning
    NHS England has recorded more than 120,000 breaches of its mixed-sex hospital accommodation guidance in the past six years, a 257% increase.
    Guidance added to the NHS constitution in 2012 states that hospital patients will not share sleeping accommodation with members of the opposite sex “except where appropriate”. Exemptions include critical care wards or patients receiving treatment, such as chemotherapy, where they “may derive comfort from the presence of other patients with similar conditions”.
    The guidance also says patients should not share toilet or bathroom facilities with members of the opposite sex and should not “have to walk through an area occupied by patients of the opposite sex to reach toilets or bathrooms”.
    However, data from NHS England analysed by the Observer shows thousands of breaches every month, with patient dignity and safety put at risk. 
    Caitlin (not her real name) worked on an acute mental health ward in a private hospital which switched from 12 women-only beds to 15 mixed beds. “Women on our ward often had a history of sexual or domestic abuse,” she said. “Some had tried to end their life in the wake of this, and a lot of them felt intimidated by the level of aggression shown by some men on the ward.”
    Women and men had separate wings but shared a communal area. “A lot of the women were really fearful of the men,” she added.
    Caitlin said the use of mixed-sex accommodation had a negative impact on some women’s recovery. “Women would stay in their rooms, not even coming out to watch TV,” she says. “Some acutely unwell women would display sexually disinhibited behaviour in the communal areas, which is a symptom of their diagnosis. They were put in a position where their dignity could not be protected.”
    “Women make hundreds of conscious and unconscious decisions to keep ourselves safe from men,” said Karen Ingala-Smith, author of Defending Women’s Spaces. “Women should not have to be on their guard like this when they are in hospital.” 
    Read full story
    Source: The Guardian, 15 October 2023
  11. Patient Safety Learning
    Trusts haven been warned to be careful of “contentious” approaches to staff recognition, such as those that mimic the “clap for carers” initiative organised during the pandemic.
    NHS England has published a Staff Recognition Framework which stresses marking staff achievements is important. However, it also warns staff could also be demoralised by recognition they felt was derisory.
    The framework says: ”During the pandemic, studies suggested the weekly 8pm ‘clap for carers’ movement and use of the word ‘heroes’ were contentious approaches to staff recognition. The NHS is always in the media spotlight. Don’t let this put you off but do consider the broader political and economic context.”
    Recent strikes saw clinicians make the point that organised clapping was no substitute for increase-linked pay increases.
    The document for senior leaders recommends “developing a recognition strategy” which takes a triple track “formal, informal and everyday” approach to celebrating staff achievement.
    It said “evidence shows that pay alone will not influence staff wellbeing, engagement, and retention in the long-term – praise and social approval have also proved to be critical factors”. 
    Read full story (paywalled)
    Source: HSJ, 12 October 2023
  12. Patient Safety Learning
    Most trusts are thought to have missed the deadline to launch a new national incident reporting system that has already been beset with difficulties and delays.
    Seventy per cent of more than 150 patient safety managers polled during a patient safety management network meeting last month said their organisation would not meet the 30 September go-live deadline for the new learning from patient safety events (LFPSE) incident reporting system.
    LFPSE is a key part of NHS England’s safety strategy and replaces the historic national reporting and learning system.
    The new reporting system was originally due to be implemented by March 2023. However, this deadline was pushed back six months, after widespread concerns were raised by patient safety managers, which included software quality, incident reporting form complexity and lack of time for testing.
    Managers have pinned the latest launch delay on RLDatix – the vendor which provides incident software for more than 60% of trusts  – claiming it could not provide the functionality needed and its releases were “not fit for purpose”.
    Read full story (paywalled)
    Source: HSJ, 16 October 2023
  13. Patient Safety Learning
    A mother’s claim that a hospital failed to provide suitable experts for a coroner to determine the cause of her daughter’s death could lead to a second inquest.
    The attorney-general has acknowledged in a letter to the mother of Gaia Young that although the facts of the case did not suggest that NHS officials had been in contempt of court they “may amount to a reason to seek a fresh inquest”.
    The dispute centres on the circumstances of the death of Gaia Young, 25, who died at University College Hospital, London, in 2021 after being admitted for a sudden headache and vomiting, having spent the day cycling.
    At her inquest in February 2022 the coroner gave a narrative ruling, stating that “a missed chance” by doctors when she arrived at the hospital led to her death, concluding that the cause of death was unclear. Her mother, Lady Dorit Young, has argued that doctors misread her daughter’s condition and failed to treat her appropriately as she deteriorated. Young told the inquest that the hospital sent a doctor to the hearing to give evidence who was insufficiently skilled to assist the coroner, and that the hospital had more suitably qualified experts available.
    In the letter, Young said a court had ordered the hospital to “ensure the attendance at the inquest of such medical witness or witnesses to give oral evidence as are best able to assist [the coroner] with the likely cause of the deceased’s cerebral oedema and thus her death”. Lady Young believes that her daughter died from a metabolic encephalopathy — a brain injury — and asked for a neurological specialist to attend the inquest. She said the expert who attended was “not appropriately qualified or experienced” and that the inquest “was uninformed and uninformative: a waste of time and money”.
    Truth For Gaia provides open access to coroner’s inquest papers, transcript, medical records and post-mortem reports.
    Source: The Times, 16 November 2023
  14. Patient Safety Learning
    The government ignored expert warnings to regulate physician associates (PAs) for more than two decades and now patients have come to harm, doctors have said.
    A leading doctors’ union blamed the “dithering of successive governments” for the “extremely dangerous” increase in PAs carrying out doctors’ duties.
    Jeremy Hunt, then health secretary, told a House of Lords committee in 2016 that the government was “committed to introducing legislation for regulatory reform” and it was “a question of finding a parliamentary slot”, citing Brexit debates as a cause of the delay.
    Seven years, two consultations and at least two deaths later, regulation of PAs is still a year away, following a series of delays that the Faculty of Physician Associates itself has called “disappointing”.

    Dr Matt Kneale, co-chair of the Doctors’ Association UK, told The Telegraph the lack of regulation “poses a significant risk to both patient safety and the overall standard of care within the NHS”.
    He said supervising doctors taking on the accountability for PA was not a “tenable long-term solution”.

    “Regulation could and should have been introduced earlier to prevent instances of patient harm. The lack of action for over two decades is concerning and requires urgent action,” he added.
    Read full story (paywalled)
    Source: The Telegraph, 14 October 2023
  15. 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
  16. Patient Safety Learning
    An ambulance trust has apologised after a patient who was declared "dead" later woke up in hospital.
    As first reported by The Northern Echo, the individual was taken by paramedics to Darlington Memorial Hospital on Friday. The newspaper reported they had been declared dead following an incident earlier that day.
    The North East Ambulance Service (NEAS) apologised to the patient's family and said an inquiry had begun.
    The patient has not been identified or their current condition revealed.
    NEAS director of paramedicine Andrew Hodge said: "As soon as we were made aware of this incident, we opened an investigation and contacted the patient's family.
    "We are deeply sorry for the distress that this has caused them.
    "A full review of this incident is being undertaken and we are unable to comment any further at this stage.
    "The colleagues involved are being supported appropriately and we will not be commenting further about any individuals at this point."
    Read full story
    Source: BBC News, 17 October 2023
  17. Patient Safety Learning
    High use of agency staff contributed to the care failings exposed at a mental health trust by undercover reporters, an internal inquiry has found.
    Essex Partnership University Trust was at the centre of a Channel 4 documentary last year which raised concerns over care, including the use of restraints and patient observations.
    The trust initially refused to release the final report after a freedom of information request by HSJ, but has now released a redacted version on appeal. 
    The report identified a number of concerns in relation to patient and staff safety, saying factors that contributed to these concerns included high usage of temporary staff and high patient acuity on the two acute mental health wards recorded.
    The internal inquiry looked into allegations of the inappropriate use of restraints raised in the documentary. This section, which contained redactions, found restraint was taught to be used as a last resort, but suggested high temporary staffing levels and a “lack of confident and adequately skilled staff” contributed to guidance not being followed.
    Another concern was around staff sleeping on duty and the use of mobile phones during patient observations. The internal inquiry found there was an “absence of visible leadership and role modelling” to ensure this did not happen during clinical practice.
    Read full story (paywalled)
    Source: HSJ, 17 October 2023
  18. Patient Safety Learning
    Health advocates in the USA are calling on the Biden administration to declare a public health emergency over a steep rise in congenital syphilis cases. The easily treated infection has quintupled in 10 years and can have harrowing impacts on children.
    Congenital syphilis happens when a baby contracts syphilis from its mother. Up to 40% of babies born to untreated mothers will be stillborn or die. Others can be left with severe birth defects such as bone damage, anaemia, blindness or deafness, and “neurological devastation”.
    “There is not a single baby that should be born in the US with syphilis,” David Harvey, the executive director of the National Coalition of STD Directors, told the Guardian. “We will be judged very severely as a country and a society for allowing this to happen to babies, when it is so easy to diagnose, treat and prevent this disease.”
    Rates of the disease have reached a nearly 30-year high just as supplies of the preferred medication, called Bicillin L-A, are in short supply. Syphilis can be cured with between one and three shots of the medication.
    Pfizer is the only manufacturer of the medication, a form of the first antibiotic ever synthesized, penicillin. The company said it does not expect shortages to be resolved before 2024, and blamed low supply partly on the increase in syphilis cases.
    Read full story
    Source: The Guardian, 17 October 2023
  19. Patient Safety Learning
    ChatGPT , the artificial intelligence tool, may be better than a doctor at following recognised treatment standards for depression, and without the gender or social class biases sometimes seen in the physician-patient relationship, a study suggests.
    The findings were published in Family Medicine and Community Health. The researchers said further work was needed to examine the risks and ethical issues arising from AI’s use.
    Globally, an estimated 5% of adults have depression, according to the World Health Organization. Many turn first to their GP for help. Recommended treatment should largely be guided by evidence-based clinical guidelines in line with the severity of the depression.
    ChatGPT has the potential to offer fast, objective, data-based insights that can supplement traditional diagnostic methods as well as providing confidentiality and anonymity, according to researchers from Israel and the UK.
    Read full story
    Source: The Guardian, 16 October 2023
  20. Patient Safety Learning
    Britain’s top family doctor is calling for a “black alert” system to be introduced in general practice so that doctors can warn when surgeries are dangerously over capacity.
    It comes as a report reveals that almost half of GPs can no longer guarantee safe care for millions of patients, as a shortage of medics means they are unable to cope with soaring demand.
    Prof Kamila Hawthorne, the chair of the Royal College of General Practitioners (RCGP), which represents 54,000 family doctors across the UK, wants a patient safety alert system introduced that is modelled on the operational pressures escalation levels (Opel) warnings – known as “black alerts” – already used by hospitals.
    It would enable practices and GPs to flag unsafe levels of workload, triggering support from their local health system. GP surgeries would be able to temporarily suspend non-priority activities – including some regular health checkups, certain routine but mandatory staff training and non-urgent paperwork – during periods of excessive workload. This would allow surgeries to reprioritise routine and non-urgent activity and ensure patient safety is prioritised.
    Hawthorne said: “General practice is a safety-critical industry yet GPs have none of the mechanisms that other safety-critical professions, such as the air traffic industry, have in place to protect them.
    “Our number one priority is the safety of our patients, but GPs are doing more and more to try to meet the rising demand for our services. When you’re fatigued, you’re more likely to make mistakes and our survey shows that many GPs are no longer able to guarantee that the care they are providing to their patients is as safe as it could be.”
    Read full story
    Source: The Guardian, 17 October 2023
  21. Patient Safety Learning
    Stroke patients should be offered extra rehabilitation on the NHS, say updated guidelines for England and Wales.
    The National Institute for Health and Care Excellence (NICE) had previously recommended 45 minutes a day.
    But it believes some patients may need more intensive therapy for recovery and is suggesting three hours a day, five days a week.
    Experts welcome the advice, but question how feasible it will be for a stretched health service to deliver.
    NICE accepts it may be "challenging", but it says patients and families deserve the best care possible. That includes help regaining speech, movement and other functions caused by the damage that happens to the brain during a stroke.
    NHS England has said increasing the availability of high quality rehabilitation is a priority. More people than ever are surviving a stroke thanks to improvements in NHS care, it added.
    Read full story
    Source: BBC News,18 October 2023
  22. Patient Safety Learning
    At least two trusts are set to fall short on a high-profile pledge to eradicate ‘dormitory’ style wards in mental health facilities, with delays caused by cost pressures and shortage of materials and labour.
    In 2020, ministers said more than 1,200 beds in mental health dormitories across more than 50 sites would be replaced with single, en-suite accommodation by March 2025. Around £400m was allocated to achieve this.
    However, information gathered by HSJ via freedom of information requests suggests there will be at least 37 dormitory beds still in use beyond that date.
    In 2018, the Care Quality Commission said: “In the 21st century, patients, many of whom have not agreed to admission, should not be expected to share sleeping accommodation with strangers, some of whom may be agitated”. Patients have told HSJ they felt “distressed”, “unsafe” and “intimidated” on dormitory style wards.
    Leaders of trusts impacted by delays told HSJ of rising cost pressures, shortages of construction materials and availability of labour.
    Read full story (paywalled)
    Source: HSJ, 17 October 2023
  23. Patient Safety Learning
    Over the counter genetic tests in the UK that assess the risk of cancer or heart problems fail to identify 89% of those in danger of getting killer diseases, a new study has found.
    Polygenic risk scores are so unreliable that they also wrongly tell one in 20 people who receive them they will develop a major illness, even though they do not go on to do so.
    That is the conclusion of an in-depth review of the performance of polygenic risk scores, which underpin tests on which consumers spend hundreds of pounds.
    The findings come amid a boom in the number of companies offering polygenic risk score tests which purport to tell customers how likely they are to get a particular disease.
    Academics at University College London (UCL) who undertook the research are warning that such tests are so flawed they should be regulated “to protect the public from unrealistic expectations” that they will correctly identify their risk of a particular disease.
    The authors concluded: “Polygenic risk scores performed poorly in population screening, individual risk prediction and population risk stratification.
    “Strong claims about the effect of polygenic risk scores on healthcare seem to be disproportionate to their performance.”
    Read full story
    Source: The Guardian, 17 October 2023
  24. Patient Safety Learning
    A locum responsible pharmacist has been issued a warning after a patient died when he dispensed the wrong strength of oxycodone during a staffing crunch, the regulator has revealed.
    Paresh Gordhanbhai Patel supplied 120mg rather than the prescribed 20mg of oxycodone hydrochloride to an “elderly” patient while working two locum shifts as responsible pharmacist at Crompton Pharmacy at Whitley House Surgery in Chelmsford.
    After taking one tablet, the patient died from an “accidental” oxycodone “overdose”, the General Pharmaceutical Council’s (GPhC) fitness-to-practise (FtP) committee heard at a hearing held on 11-13 September.
    Mr Patel admitted that he was “stressed and overtired” when he failed to notice a “discrepancy” between the prescribed strength of oxycodone and what he ordered and dispensed,
    The regulator heard that Mr Patel was “over-conscientious” and felt compelled “at a human level” to help out at the under-staffed pharmacy, despite the fact that it was “not safe to do so”, it added.
    Mr Patel admitted that his errors “amounted to misconduct” and conceded to the committee that his fitness to practise was “impaired” because he “breached one of the fundamental principles of the pharmacy profession.”
    The regulator heard that Mr Patel had “immediately” admitted his mistake to the pharmacy and did so again at the coroner’s inquest, where he also publicly apologised to the patient’s family.
    Read full story
    Source: Chemist and Druggist, 12 October 2023
  25. Patient Safety Learning
    Thousands of complaints made against nurses and midwives were rejected by the watchdog without investigation last year as it battles a huge backlog amid concerns rogue staff are being left unchecked.
    The Nursing and Midwifery Council has rejected hundreds more cases a year since 2018, including 339 where nurses faced a criminal charge, 18 for alleged sexual offences and 599 over allegations of violence in 2022-23, according to data shared exclusively with The Independent.
    The new figures come after The Independent revealed shocking allegations that nurses and midwives accused of serious sexual, physical and racial abuse are being allowed to keep working because whistleblowers are being ignored and that the NMC was failing to tackle internal reports of alleged racism.
    And now, a new internal document, obtained by The Independent, reveals more staff have come forward to raise concerns since our expose.
    Former Victims’ Commissioner Dame Vera Baird KC said the backlog of complaints was “worryingly high” and called for urgent action to tackle it.
    Read full story
    Source: The Independent, 19 October 2023
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