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Patient Safety Learning

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  1. Patient Safety Learning
    A bill has been proposed to enable women who paid for mesh removal surgery to be refunded.
    Subject to the outcome of the Scottish Parliament election, new legislation will be introduced to allow the Scottish Government to meet the travel, medical and other reasonable expenses of those who had mesh removal surgery outwith NHS Scotland.  Currently the law does not allow for such payments to be made from public funds.
    NHS Scotland is also inviting tenders to allow suitably qualified surgeons to perform free mesh removal, where this surgery is clinically appropriate and where patients wish it to take place outside of NHS Scotland. 
    Health Secretary Jeane Freeman said: “The Scottish Government halted the implantation of transvaginal mesh in 2018, and is committed to keeping this halt in place."
    “We absolutely recognise the serious distress which may have led to women using their own funds to pay for private surgery. As the Scottish Government does not currently have the legal power to refund these past costs we propose introducing legislation in the next parliament, subject to the outcome of the election."
    Read full story
    Source: Scottish Government, 24 March 2021
  2. Patient Safety Learning
    Nurses are a crucial part of care across a wide range of sectors, with patients and other professionals often reliant on their expertise. That’s why the Professional Records Standard Body (PRSB) has been asked to develop a new nursing standard by NHSx for use across all the different health and social care settings. 
    The standard aims to improve quality and safety of care in key nurse-led areas, including care planning. It will reflect best practice and standardise documentation across different nursing settings, to free nurses and give them more time to care. For example, it will standardise information that a district nurse in a care home setting can access and share in the same way as a mental health or hospital nurse, with a focus on the person’s overall wellbeing. 
    Read full story
    Source: PRSB, 30 March 2021
  3. Patient Safety Learning
    The European Parliament voted by 95% to support the Stop Cancer at Work campaign’s demands for:
    Legislative action - not just guidance – now, not next year or the year after.  Specifically, the European Commission should include hazardous drugs (hazardous medicinal products or HMPs) in Annex I, and reprotoxins, in the Carcinogens and Mutagens Directive (CMD). This legislative action should be supported by new guidance to ensure that effective prevention measures are put in place and implemented across Europe. The Stop Cancer at Work Campaign believes that the European Commission should now get on with including hazardous drugs, reprotoxins and other improvements to the Carcinogens and Mutagens Directive (CMD) passed by the Parliament without any further delay. Legislation to include hazardous drugs is not only supported by the Parliament but also the majority of the Member States that make up the European Council.
    As a coalition of essential workers, professionals and cancer patients, the Campaign is demanding action from policymakers and political leaders to stop further preventable deaths. The European Commission’s own research shows that at least 40% of cancer cases are avoidable - but we have yet to see meaningful change and very little on preventing workplace cancer in Europe’s Beating Cancer Plan.
    The scale of the problem is vast: it is estimated that 100,000 new deaths each year of work related cancer from occupational exposure to hazardous substances, the biggest killer in the EU.  The European Commission’s own research shows that at least 40% of cancer cases are avoidable.  The protective equipment, safer technology and proper practices are available and not costly but employers are unlikely to universally introduce them unless they are required to do so.
    The Commission has still not published an independent report which was completed last year and supports legislation to include hazardous drugs (HMPs), in the current revision of the CMD.  This would be in combination with, but not replaced by, new non- legislative EU guidance and a regular review of a list of HMPs based on an agreed definition. The independent report is based on a year-long consultation with Member States, experts, professionals, patients, employers and workers in healthcare and justifies and delivers a consensus, impact assessment and blueprint to legislate now and prevent exposure of workers and patients to hazardous drugs which cause cancer and reproductive problems.
    Source: Stop Cancer at Work, 26 March 2021
    European Parliament votes to stop cancer at work and include hazardous drugs and reprotoxins in the Carcinogens and Mutagens Directive (CMD) 25.03.21.docx
  4. Patient Safety Learning
    The system for introducing new medical technologies into the NHS remains complex, crowded, and difficult to manage, according to a new report by the Medical Technology Group (MTG).
    The paper also calls for innovative treatments with medical devices to be given the same support as new pharmaceutical medicines.
    Current NHS mechanisms to support the uptake and use of innovative technology are severely limited in scope and are focused on ‘picking winners’ rather than the broad system-wide adoption of new technology, the report states.
    It points to the Accelerated Access Pathway, for instance, which supports fewer than 10 technologies each year; and the lack of a clear mechanism to support the widespread uptake of innovative products across the NHS.
    And the absence of a broad, national commissioning policy means patients sometimes miss out on the benefits of established technology due to a regional variation in access.
    Read full story
    Source: BBH, 24 March 2021
  5. Patient Safety Learning
    A CORONER has slammed a hospital trust after a vulnerable patient caught Covid-19 on a ward where beds were not socially distanced.
    Senior coroner for Brighton and Hove, Veronica Hamilton-Deeley, has sent a rare Regulation 28 report for the prevention of future deaths to the Royal Sussex County Hospital, following the death of 78-year-old Brian Button last October.
    The grandfather-of-three from Pevensey was admitted to hospital after a fall, but contracted coronavirus on the Catherine James ward within the Acute Respiratory Unit.
  6. Patient Safety Learning
    In January, England's only NHS gender clinic for children and young people was rated "inadequate" by the country's health watchdog - the lowest rating, meaning it is performing badly.
    The findings make for sobering reading with inspectors raising "significant concerns" about the way the Gender Identity Development Service (GIDS) works.
    Nearly 5,000 children are waiting - sometimes for up to two years - for an appointment, and the management team has been disbanded following the inspection. 
    Now BBC News has had exclusive sight of an external report written in 2015 which recommended GIDS take drastic action.
    It argued the service was "facing a crisis of capacity" to deal with an ever-increasing demand and strikingly it should "take the courageous and realistic action of capping the numbers of referrals immediately".
    With Care Quality Commission inspectors recently confirming many of the risks highlighted still remain, some have expressed concern about why neither GIDS, nor NHS England, which has ultimate responsibility for the service, have done more to help the children and young people it cares for.
    Read full story
    Source: BBC News, 30 March 2021
  7. Patient Safety Learning
    A witness to an inquiry into deaths at England’s largest mental health trust has been intimidated by “cruel and calculated pressure”, with messages described by the man leading the investigation as “truly shocking”.
    In a statement at the start of hearings into the quality of care at Southern Health Foundation Trust, inquiry chairman Nigel Pascoe QC said one witness had received threatening telephone calls, messages and emails, which he said were “totally unacceptable, damaging and deeply disturbing”.
    Mr Pascoe said the inquiry had been told Beth Ford, whose job title at the trust is service user involvement facilitator, had been intimidated by members of the public.
    Ms Ford, who has autism, was admitted to hospital for her mental health earlier this month as a result of the abuse, but has now returned home.
    It’s the latest incident to hit the controversial inquiry, which has itself faced fierce criticism from the families of five patients who died between 2011 and 2015.
    The families have pulled out of the inquiry and accused the investigation and NHS England of bullying them and going back on promises to properly investigate the deaths of their relatives.
    Maureen Rickman, whose sister Jo Deering died in 2011, told The Independent she didn’t believe any of the main families were involved in intimidating witnesses.
    Read full story
    Source: The Independent, 29 March 2021
  8. Patient Safety Learning
    People aged 16 or over who live with immunosuppressed adults should be prioritised for COVID-19 vaccination alongside priority group 6 (people aged 16 to 65 who have a clinical condition that puts them at higher risk), the UK government’s vaccine advisory committee has said.
    This would include people living in households with an adult who has a weakened immune system, such as those with blood cancer or HIV, or people on immunosuppressive treatment, including chemotherapy, the Joint Committee on Vaccination and Immunisation (JCVI) said. These people are not only more likely to have poorer outcomes after SARS-CoV-2 infection but may not respond as well to the vaccine as others, recent evidence indicates, said the JCVI.
    The committee said it had made the new recommendation after evidence emerged showing that the covid-19 vaccines may reduce transmission, meaning that vaccinating those around immunosuppressed individuals could help reduce their risk of infection.
    The JCVI’s chair of COVID-19 immunisations, Wei Shen Lim, said, “The vaccination programme has so far seen high vaccine uptake and very encouraging results on infection rates, hospitalisations, and mortality. Yet we know that the vaccine isn’t as effective in those who are immunosuppressed. Our latest advice will help reduce the risk of infection in those who may not be able to fully benefit from being vaccinated themselves.”
    Read full story
    Source: BMJ, 29 March 2021
  9. Patient Safety Learning
    The Royal College of Midwives (RCM) has launched a new positioning statement to call for a Digital Midwife in every maternity service in the next 12 months.
    The trade union, which represents the majority of practising midwives, has called for every trust to recruit or train Digital Midwives to lead on digital transformation programmes and ensure systems that are introduced are interoperable.
    The RCM has said it’s not just a call for investment but a need to ‘drive forward digital transformation and clinical informatics of maternity care’.
    Hermione Jackson, RCM Digital Advisor,  said: “For too long maternity services have been overlooked, passed over and generally left at the back of the queue when it comes to digital investment. Investing in digital technology and giving staff the training and equipment they need will lead to better care, regardless of where that care is delivered.
    “There is clear evidence that more and better use of digital technology is supported by women, midwives, maternity support workers and other maternity staff. We need the Government and hospital Trusts and Boards to give maternity services the tech they need to do their jobs even better. Improvements have been happening but at a snail’s pace and we need to see this move much more rapidly simply to catch-up with other areas of the NHS.”
    The RCM said it will be publishing new guidance on electronic record keeping for midwives and maternity support workers later in March.
    Read full story
    Source: Health Tech Newspaper, 16 March 2021
  10. Patient Safety Learning
    Tens of thousands of post-operative deaths could be avoided by ensuring patients are given coronavirus vaccines while waiting for elective surgery, a new study suggests.
    People awaiting surgery around the globe should thus be prioritised for COVID-19 jabs ahead of other groups, according to the research, funded by the National Institute for Health Research (NIHR).
    Studying data for 141,582 patients from across 1,667 hospitals in 116 countries – including Australia, Brazil, China, India, UAE, the UK and the US, scientists found that between 0.6 and 1.6% of patients have developed coronavirus in the wake of elective surgery.
    For patients who did contract COVID-19, their risk of death was four to eight times greater than typically seen in the 30 days after surgery.
    Given the higher risks that surgical patients face, scientists calculate that vaccines are more likely to have a life-saving impact upon pre-operative patients – particularly the over-70s and cancer patients – than among the general population.
    The researchers estimated that – in order to save one life in the course of a year – 351 people aged over 70 facing cancer surgery required vaccination. This figure rises to 1,840 among over-70s in general.
    “Pre-operative vaccination could support a safe restart of elective surgery by significantly reducing the risk of Covid-19 complications in patients and preventing tens of thousands of Covid-19-related post-operative deaths,” said co-lead author Aneel Bhangu, from the University of Birmingham.
    Read full story
    Source: The Independent, 25 March 2021
  11. Patient Safety Learning
    Miscarriage may be associated with an increased risk of early death, researchers have said.
    The BMJ published a study suggesting that this risk is particularly acute for those who have experienced repeated miscarriages, especially ones that occurred early on in a woman’s life.
    US-based researchers said that women who had experienced a miscarriage were 19% more likely to die prematurely. They pointed out that a miscarriage “could be an early marker of future health risk in women.”
    The authors of the paper hoped to see if there was any link between miscarriage and a risk of death before the age of 70. Data used was taken from 101,681 women as part of the Nurses’ Health Study in the US. This was made up of female nurses aged between 25 and 42 years.
    The researchers followed the women for 24 years and said that 2,936 premature deaths were recorded, this included 1,346 from cancer and 269 from cardiovascular disease.
    It appeared that death rates from all causes were comparable both for women with and without a history of miscarriage. However, rates were higher for women who had experienced three or more miscarriages as well as for women who had their first miscarriage under the age of 24.
    The study found that the association between miscarriage, or “spontaneous abortion,” and premature death was strongest for deaths from cardiovascular disease.
    Read full story
    Source: The Independent, 25 March 2021
  12. Patient Safety Learning
    Many doctors from black, Asian and minority ethnic backgrounds say key risk assessments have still not taken place, or have not been acted on.
    About 40% of UK doctors in the UK are from BAME backgrounds, yet 95% of the medics who have died from coronavirus were from minority backgrounds.
    The NHS said last June that its trusts should offer risk assessments to staff, but hundreds told a poll for BBC News that they were still awaiting assessments or action.
    Of 2,000 doctors who responded, 328 said their risks hadn't been assessed at all, while 519 said they had had a risk assessment but no action had been taken. Another 658 said some action had been taken, with just 383 reporting their risks had been considered in detail and action put into place to mitigate them.
    One of those who responded was Dr Temi Olonisakin, a junior doctor in London who has Type 1 diabetes. She had her risk assessment early on in the pandemic.
    "It was as comprehensive as a side A4 paper can be," she says. "I think for a lot of people it felt more like a tick-box exercise, and one that could be used to say: 'We've done what we need to do to make people feel safe' - but I'm not sure in reality that's how people felt."
    Read full story
    Source: BBC News, 26 March 2021
  13. Patient Safety Learning
    The NHS is to spend almost £100m to make maternity units across the NHS safer for mothers and babies in a major victory for families and The Independent – which has been campaigning for better training for midwives and doctors.
    NHS England announced the investment on Thursday in response to the care scandal at the Shrewsbury and Telford Hospital Trust.
    As well as boosting the numbers of midwives and doctors on wards, NHS England said the money would include an extra £26.5m for safety training for midwives and doctors across England.
    The £96m represents one of the biggest investments in maternity services for decades. A total of £46m will be to used to recruit 1,000 extra midwives along with £10m for the equivalent of 80 extra doctors. As well as training cash will also be used to create new roles to oversee trusts safety and help recruit staff from overseas.
    The investment is a direct response to the poor care at the Shrewsbury and Telford Hospital Trust where The Independent revealed in 2019 that dozens of babies and mothers had died or been left brain damaged as a result of persistent poor care over decades. An inquiry is examining more than 1,860 cases, making it the largest maternity scandal in NHS history.
    Read full story
    Source: The Independent, 25 March 2021
  14. Patient Safety Learning
    More than 40,600 people have been likely infected with coronavirus while being treated in hospital in England for another reason, raising concerns about the NHS’s inability to protect them.
    In one in five hospitals at least a fifth of all patients found to have the virus caught it while an inpatient. North Devon district hospital in Barnstaple had the highest rate of such cases among acute trusts in England at 31%.
    NHS England figures also reveal stark regional differences in patients’ risk of catching the virus that causes COVID-19 during their stay. Just under a fifth (19%) of those in hospital in the north-west became infected while an inpatient, almost double the 11% rate in London hospitals.
    Hull University teaching hospitals trust and Lancashire teaching hospitals trust had the joint second highest rate of patients – 28% – who became infected while under their care. The former has had 626 such cases while the latter has had 486. However, the big differences in hospitals’ size and the number of patients they admit mean that the rate of hospital-acquired infection is a more accurate reflection of the success of their efforts to stop transmission of the potentially lethal virus.
    Doctors and hospitals claim that many of the infections were caused by the NHS’s lack of beds and limitations posed by some hospitals being old, cramped and poorly ventilated, as well as health service bosses’ decision that hospitals should keep providing normal care while the second wave of Covid was unfolding, despite the potential danger to those receiving non-Covid care.
    “These heartbreaking figures show how patients and NHS staff have been abysmally let down by the failure to suppress the virus ahead of and during the second wave,” said Layla Moran MP, the chair of the all-party parliamentary group on coronavirus.
    Read full story
    Source: The Guardian, 26 March 2021
  15. Patient Safety Learning
    Following the statement from Nadine Dorries MP, Minister for Patient Safety, providing an update on the Paterson Inquiry, Matt James, Chief Executive of the Private Healthcare Information Network, said: 
     
    “Although we were expecting the Government’s full response by now, it’s reassuring to know that this is still firmly on the agenda. The updates provided today are all welcome, but perhaps most telling is what remains to be addressed – most notably whole-practice information and better information for patients (recommendations one and three).
     
    “While it’s disappointing not to see more specifics, it is crucial that the recommendations are implemented properly and with the right consideration, resisting the temptation to create new systems from scratch and instead build on the excellent progress made by organisations such as NHS Digital, GIRFT, NCIP and PHIN.
     
    “We will continue to work with our partners across the NHS and private sector to make positive changes which improve transparency, accountability and information for patients. We will continue to liaise with the Department of Health and Social Care when invited to do so.”
     
    Press release
    Source: PHIN, 23 March 2021
  16. Patient Safety Learning
    A pilot project that puts patient involvement at the heart of clinical trials and medicine development has been launched by the Medicines and Healthcare products Regulatory Agency (MHRA).
    From the 23 March, when new applications for selected medicines (new active substances and new indications) are received, the applicant company will be asked for evidence on the patient involvement activities they undertook when developing their product. For clinical trials, whilst additional information won’t be requested at this early exploratory stage of the pilot, the MHRA will be documenting in medical assessment reports if there is evidence of patient involvement in clinical trial applications in order to better understand the current scope of activities.
    In considering how patient involvement is integrated into the approvals process, the MHRA hopes to learn from any patient-related activities that take place during development, and use this knowledge to improve the quality of clinical drug development and health outcomes in the future.
    During the pilot, the information provided by the applicants will be voluntary and will not alter the outcome of their application. However, in future, the agency hopes that a successful pilot will lead to patient involvement playing a greater role in the final assessment process, when clinical trials are approved, or medicines are licensed.
    Dr June Raine, MHRA Chief Executive, comments:
    "Patients are at the heart of everything we do. Gathering this information will help us gain a better understanding of the current landscape and give us important insight into the valuable work being done across our innovative life sciences sector.
    I’m excited for the opportunity to learn more so that we can work together to shape the future of effective patient involvement and better outcomes for all."
    Read press release
    Source: MHRA, 23 March 2021
  17. Patient Safety Learning
    The CQC will consider equality and human rights policy issues that have arisen from the COVID-19 pandemic under an agreement with the Equality and Human Rights Commission (EHRC).
    In a statement published on the new memorandum of understanding (MoU), the CQC and the EHRC confirmed they will work together on five ‘key areas of focus’.
    These also include looking at how leadership can reduce inequalities in patients’ access to – and outcomes from care – in local areas, and ‘collaborating for better leadership on equality for staff working in the NHS and social care’, the regulator said.
    In a separate blog on the agreement, Ted Baker, CQC’s chief inspector for hospitals, said: ‘We will continue to work together to respond to the equality and human rights issues that have arisen from the COVID-19 pandemic. This includes the EHRC contributing to our work on use of DNACPR and CQC supporting the dissemination of key findings relating to health and social care from EHRC key reports and briefings.’
    The memorandum, which applies to all providers regulated by the CQC, also outlines how both organisations will share information on human rights issues.
    Read full story
    Source: Management in Practice, 15 March 2021
  18. Patient Safety Learning
    Doctors and nurses were absent from crucial meetings about oxygen supplies to hospital wards in the run up to the coronavirus crisis, a safety watchdog has warned.
    At one hospital trust, which was forced to declare a major incident during the second wave of the crisis, doctors had not attended the hospital’s medical gas committee (MGC) since 2014.
    The Healthcare Safety Investigation Branch (HSIB) said it had discovered a similar lack of input at other NHS trusts and also warned that none of the urgent alerts and guidance from NHS England ahead of the Covid surge had been discussed at the committee.
    HSIB has launched an investigation into the failure of oxygen piping systems during the Covid surge after a number of hospitals were forced to declare major incidents and divert patients to other hospitals.
    Read full story
    Source: The Independent, 24 March 2021
  19. Patient Safety Learning
    Middle-aged women experience the most severe, long-lasting symptoms after being treated in hospital for COVID-19, two UK studies suggest.
    Five months on, 70% of patients studied were still affected by everything from anxiety to breathlessness, fatigue, muscle pain and "brain fog".
    But the researchers say there is no obvious link with how ill people originally became.
    How women's bodies fight off illness could explain their poorer recovery.
    The larger study - led by the University of Leicester - which is yet to be peer-reviewed, followed up more than 1,000 patients who had been admitted to hospital with Covid-19 in the UK last year. It found that up to 70% had not fully recovered, an average of five months after leaving hospital, with women most affected.
    A separate smaller pre-print study, led by University of Glasgow, found women under 50 were seven times more likely to be more breathless, and twice as likely to report worse fatigue than men of the same age who had had the illness, seven months after hospital treatment.
    Read full story
    Source: BBC News, 25 March 2021
  20. Patient Safety Learning
    A flagship government programme to improve care for people with learning disabilities has had an ‘unclear’ and ‘limited’ impact after six years, an NHS England report has found.
    A report into the national learning disability mortality review programme (LeDer) has criticised it for failing to impact improvement of services both nationally and locally.
    The national LeDer programme was launched in 2015 after high profile failures by Southern Health Foundation Trust to investigate the deaths of patients with learning disabilities. Since its launch, the programme has consistently struggled to carry out the number of reviews required, with the backlog growing to 3,800 last year.
    The news follows a year of increasing concern over the disproportionate death rate for those with learning disabilities during the pandemic.
    Read full story (paywalled)
    Source: HSJ, 24 March 2021
  21. Patient Safety Learning
    People living with an eating disorder and their families should be offered greater support, according to a aScottish government review of services.
    The clinicians and psychologists who led the review said that seven of Scotland's health boards had been an 86% increase in referrals for eating disorders over the last year. Figures also showed a 220% jump in paediatric admissions at two regional adolescent in-patient units.
    Their report made 15 recommendations including self-help packages, peer support networks and emotional and practical support for families and carers as well.
    Christine Reid's daughter Madeline Wallace died from anorexia in January 2018.
    The 18-year-old from Peterborough had been studying medicine at Edinburgh University when she became gravely unwell. An inquest into her death found that she "rapidly lost weight" during her first weeks as a student.
    "It was very strange," Ms Reid says. "It was almost like watching someone disintegrating from the inside out. It is a horrible illness."
    "She got this illness and she really didn't want to have it but she couldn't see a way to recover from it," Ms Reid says.
    "She just didn't feel like she got the help she needed."
    An independent review in to Maddy's death made 14 recommendations for changes to eating disorder care at a national and regional level including advice for GPs on anorexia complications.
    "It feels like if lots of different decisions had gone different ways it could have been avoided and that is hard to take," her mother says.
    Read full story
    Source: BBC News, 24 March 2021
  22. Patient Safety Learning
    A previously secret report into children’s services at a scandal-hit NHS hospital has revealed concerns over the safety of services including care of seriously ill babies were raised with managers back in 2015.
    A report by the Royal College of Paediatrics and Child Health (RCPCH) raised serious concerns over children’s services at East Kent Hospitals University Trust in 2015 including senior consultants refusing to work beyond 5pm and a shortage of nurses and junior doctors.
    It also found the neonatal intensive care unit was being staffed by general paediatric doctors instead of specialist neonatal consultants.
    The confidential report was given to The Independent and posted on the trust’s website this week after being mentioned in the terms of reference for an independent inquiry examining dozens of baby deaths at the trust.
    It had never been published by the trust, which three years later had its children’s services rated inadequate. A second major report by the Royal College of Obstetricians and Gynaecologists in 2016 highlighted concerns that were not acted on and later featured in the avoidable death of baby Harry Richford, in 2017 which sparked the scandal into dozens more deaths and brain injuries.
    Bill Kirkup, who is leading the inquiry into East Kent’s maternity services, previously recommended Royal College reviews be registered with the CQC and shared openly by NHS trusts.
    In its report, the RCPCH said there was “resistance from some consultants to work extended hours” across the trust’s different services with signs of clinicians worked in silos at the different hospitals run by the trust.
    It warned that paediatric consultants were “spread too thinly across the service” and consultants were providing specialist clinics based on their interests rather than local need.
    There was “insufficient middle grade doctors to cover both sites” and there were “too few skilled nurses on the wards.”
    Read full story
    Source: The Independent, 24 March 2021
  23. Patient Safety Learning
    Deborah Stanford is one of many women who have received a Boston Scientific implant and suffered complications. She has joined Shine Lawyers’ class action, which was filed today in the Australian Federal Court, to hold the manufacturers to account for the continuous pain she has endured since the Obtryx sling was implanted on 12 September 2012.
    Ms Stanford’s bladder was sitting in the birth canal and the sling was placed, on medical advice, to reposition her bladder.
    “It has been 9 years of suffering."
    “If I knew how hard this was going to be, I never would have gone through it,” said Ms. Stanford.
    Boston Scientific is the third pelvic mesh manufacturer to face a class action over their range of prolapse mesh and incontinence sling implants. Shine Lawyers has filed all three actions against Johnson & Johnson, Ethicon and American Medical Systems (AMS).
    Read full story
    Source: Shine Lawyers, 22 March 2021
  24. Patient Safety Learning
    A pregnant nurse who died with COVID-19 felt "pressurised" to return to work despite being "very worried" for her health, an inquest heard.
    Mary Agyeiwaa Agyapong, 28, died after giving birth at Luton and Dunstable Hospital, where she also worked. Her widower Ernest Boateng told the inquest that "due to high demand at the hospital she had to continue working".
    A senior colleague said she had no knowledge of Ms Agyapong being pressured to return or remain at work.
    The inquest in Bedfordshire heard Ms Agyapong was signed off on 12 March 2020, initially for back problems, and died on 12 April. She was admitted to hospital with breathing problems on 5 April and discharged the same day.
    Giving evidence, Mr Boateng said: "Mary continued to work during this time [the start of the coronavirus outbreak], but she was very concerned about the situation involving Covid-19, so much so that when she came home from work she would take her clothes off at the front door and take a shower immediately."
    "She was very worried about bringing Covid into the home."
    Mr Boateng told the inquest his wife had worked "on some COVID-19 wards". 
    "I wanted her to stay at home," said Mr Boateng. "But due to high demand at the hospital, she had to continue working. She tried to reassure me that everything would be OK but I could understand she was anxious and panicking deep down."
    Read full story
    Source: BBC News, 23 March 2021
  25. Patient Safety Learning
    The House of Lords Public Services Select Committee is conducting an inquiry into whether reforming public services can address the growing child vulnerability crisis. 
    Based on Solace's work with children and young people, they have submitted a response calling for better understanding and coordination from public services that intervene and support survivors of domestic abuse.  
    Key recommendations:
    Training on all forms of domestic abuse as defined in the Domestic Abuse Bill should be mandatory for social work qualifications, and periodically updated through continuing professional development.  Domestic abuse is the most common factor identified in assessments of children in need of children’s social care services but training is variable and can lead to social workers putting children at risk because they do not understand perpetrator behaviour.   Safeguarding training for schools should also include mandatory training on domestic abuse and safeguarding designates should be informed of children’s social care safeguarding cases. Safeguarding training, which is statutory, does not have to include training on domestic abuse yet teachers can (and often do) play a crucial role in identifying the signs of abuse and intervening. Operation Encompass is an improvement on communication between the police and schools, but most domestic abuse is not reported to the police.   NHS trusts should ensure staff in maternity units receive regular training on routine enquiry and support for domestic abuse survivors. Domestic violence is the leading cause of foetal death. Maternity services are required to make routine enquiries but we know from our service users that mandatory routine enquiry is still not being done correctly.  Commissioners of domestic abuse services should budget for specialist support for children and young people in those services. We supported 1,392 children in our services in 2019/20. Of the nearly 200 children in our refuges in December 2020, around 30% had children’s services involvement. Upon leaving refuge, many of those mothers had increased their parenting capacity and increased their understanding of the impact of domestic abuse on parenting as a result of parenting workshops they had accessed in the refuge.   Agencies should base their ways of working, communication and data-sharing for children assessed as in need and early help on how they approach children with protection plans. When children are on a child protection plan the coordination between responsible agencies tends to be much better than when children are assessed as being in need, though practice varies. The Government should make clear that sharing information in order to safeguard children is always legitimate within the General Data Protection Regulations (GDPR).   Read Solace's full response

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