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Patient Safety Learning

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  1. Patient Safety Learning
    Patients who abuse NHS staff will be banned from receiving non-emergency care as new figures show more than one in four NHS staff have experienced harassment, bullying or abuse from patients, relatives or members of the public.
    The annual survey of more than 560,000 NHS workers found one in seven staff (15%) had experienced physical violence in the last 12 months while 40,000 staff (7.2%) had faced some form of discrimination during 2019 – an increase from 5.8% in 2015.
    A total of 13% of staff reported being bullied, harassed or abused by their own manager in the past 12 months and almost a fifth (19%) said they had experienced abuse from colleagues.
    The health secretary Matt Hancock has written to staff condemning the abuse and warning assaults on NHS workers will not be tolerated. Under new plans NHS England said that from April NHS hospitals will be able to bar patients who inflict discriminatory or harassing behaviour on staff from receiving non-emergency care. Previously, individual NHS organisations could only refuse services to patients if they were aggressive or violent.
    Hospitals will be required to act reasonably and take into account the mental health of the patient or member of the public.
    Read full story
    Source: The Independent, 19 February 2020
  2. Patient Safety Learning
    Lives may be at risk unless the NHS reviews how stand-in doctors are recruited, a coroner has warned.
    Harry Richford's death after a series of failings at a hospital in Margate, Kent, was ruled "wholly avoidable". An inquest heard he was delivered by an "inexperienced" locum doctor who was new to the hospital.
    A national review into the recruitment, assessment and supervision of locums should be carried out, Christopher Sutton-Mattocks said in a report. The coroner wrote that particular emphasis should be considered upon the scope of locums' activities before they are left responsible for out-of-hours labour care.
    He issued 19 recommendations to prevent future deaths, including a request that NHS England and the Royal College of Obstetricians and Gynaecologists consider such a review, warning "there may be a risk to other lives both at this trust and at other trusts in the future".
    Read full story
    Source: BBC News, 19 February 2020
  3. Patient Safety Learning
    The Health Foundation will begin exploring the impact of data analytics and technology on health and care in the UK.
    The independent charity has launched its Data Analytics for Better Health strategy, which aims to tackle real-world problems that affect people’s health and develop a greater understanding of the role that technology and data plays in daily life. The strategy sets out how the Health Foundation aims to help policymakers, practitioners and the wider public get to grip with “seismic changes” taking place in the health sector.
    Dr Adam Steventon, Director of Data Analytics at the Health Foundation, said: “Data is being used to drive innovation in ways that can revolutionise health care, including early disease detection, easier access to care services and encouraging health promoting behaviours. But such technological advances also carry the risk of harm to patients. As a nation we need to advance our understanding of these fast-moving changes. This new programme of work will help us to do that, enabling us to explore how analytics and data-driven technology can create better heath and care for people across the UK.”
    Read full story
    Source: Digital Health, 6 February 2020
  4. Patient Safety Learning
    The NHS has launched a patient safety inquiry after a private contractor failed to send more than 28,000 pieces of confidential medical correspondence to GPs. 
    NHS bosses are trying to find out if any patients have been harmed after 28,563 letters detailing discussions at outpatient appointments were not sent because of a mistake by Cerner, an IT company. The letters should have been sent by doctors at Barnet and Chase Farm hospitals in north London to GPs after consultations with 22,144 patients between June last year and last month. However, a “clinical harm review” is under way after it was found they had not been dispatched.
    The incident has prompted concern among GPs and patient representatives. “Patients who have attended these two hospitals will now be very worried about whether their care might have been compromised by this IT bungle”, said Rachel Power, the chief executive of the Patients Association.
    Read full story
    Source: The Guardian, 18 February 2020
  5. Patient Safety Learning
    When orthopaedic surgeons plan a surgical procedure, they demand that safe implants be used. When a patient accepts to undergo surgery, he or she expects the implants used to be safe. When the manufacturer produces and delivers implantsto be used in patients, they take the implants through a meticulous investigation followed by an evaluation of the products by regulators and notified bodies, before the implant is released for free use on the European market by physicians. In this way, all “stakeholders” expect and desire to do their best to bring about safe implants that are used in surgery for patients, which fulfills patients’ expectations of receiving safe treatment.
    However, history has shown that, although all participants in this process do their job to treat the patient safely, some implants may still unexpectedly fail. We need to know why this occurs and the trends associated with such failures, such as whether the implant or patient’s characteristics led to the problem or if there is some unforeseen reason that caused the implant to fail.
    Incoming EFORT president Prof. Klaus-Peter Günther, of Dresden, Germany, has set up regular meetings to bring all 'stakeholders' in the safety of orthopaedic implants together to regularly discuss relevant issues related to safe implants used to safely treat patients. 
    EFORT held the first such meeting, “EFORT Implant & Patient Safety Initiative. Inauguration Workshop,” on 21 January 21 in Brussels. Fifty participants from the EU Commission, notified bodies, regulators, patient organizations, European orthopaedic specialty societies, manufacturers and EFORT board participated in this first initiative. 
    The next meeting on this initiative will be held on 10 June during the EFORT Congress in Vienna, Austria.
    Read full story
    Source: Orthopedics Today, 13 February 2020
  6. Patient Safety Learning
    Today the results of the National NHS Staff Survey 2019 are out. This is of the largest workforce surveys in the world with 300 NHS organisations taking part, including 229 trusts. It asks NHS staff in England about their experiences of working for their respective NHS organisations.
    The results found that 59.7% of staff think their organisation treats staff who are involved in an error, near miss or incident fairly. While an improvement on recent years (52.2% in 2015) work is needed to move from a blame culture to one that encourages and supports incident reporting.
    It also found that 73.8% of staff think their organisation acts on concerns raised by patients/service users. It is vital that patients are engaged for patient safety during their care and there is clear research evidence that active patient engagement helps to reduce unsafe care.
    Patient Safety Learning has recently launched a new blog series on the hub to develop our understanding of the needs of patients, families and staff when things go wrong and looking at how these needs may be best met.
     
  7. Patient Safety Learning
    A three-month-old boy died from sepsis after ‘gross failures’ by medics to give him antibiotics until it was too late, an inquest ruled. Lewys Crawford died a day after he was admitted to the University Hospital of Wales in Cardiff with a high temperature last March. Jurors at Pontypridd Coroner’s Court said the failure of doctors to treat his illness with antibiotics until seven hours after his arrival had ‘significantly contributed’ to his death. They found the little boy died from natural causes contributed to by neglect in his care.
    Read full story
    Source: The Metro, 15 February 2020
  8. Patient Safety Learning
    A trust unfairly dismissed a senior nurse after she tried to invoke its formal whistleblowing policy, an employment tribunal has ruled.
    North Tees and Hartlepool Foundation Trust had suspended Linda Fairhall for 18 months without a “meaningful or adequate” explanation prior to her dismissal, the judgment said. 
    Ms Fairhall, who led a team of 50 district nurses in Hartlepool, reported on the trust’s risk register that a “change in policy” by the local authority had directly led to increased workloads for her staff. The change meant staff had to monitor patients who had been prescribed medication “so as to ensure the correct medicines were being taken at the correct time”, the judgment said.
    She reported numerous concerns to senior management between December 2015 and October 2016, amounting to 13 protected disclosures according to the tribunal, ranging from work-related stress, sickness, absenteeism and a need to retrain healthcare assistants.
    A patient’s death triggered a meeting involving her and senior managers, which she said could have been prevented had her earlier concerns “been properly addressed”.
    Ms Fairhall told care group director Julie Parks she wanted to initiate the formal whistleblowing policy on 21 October 2016, before going on annual leave a few days later. When she returned, she was told she had been suspended for 10 days.
    The judgment, handed down at Teesside Justice Hearing Centre and published last week, added: “No reasonable employer, in all the circumstances of this case, would have conducted the investigation in this manner.”
    The judgment said the tribunal believed the principal reason for her dismissal was because she had made protected disclosures. It upheld her claim that her dismissal was automatically unfair.
    Read full story (paywalled)
    Source: HSJ, 17 February 2020
  9. Patient Safety Learning
    With a focus on pharmaceutical supply chain regulation, Bonafi is one of the latest companies to launch within the regtech startup sector.
    “Companies operating in the global pharma industry must verify that those they are buying from and selling to are authorised to handle medicinal products for human use in their own countries,” explains its founder, Katarina Antill. “At present, this verification process is manual. Companies are using screenshots as proof and relying on spreadsheets to track verification activities, which increases the risk of errors.”
    “Manual processes are very labour intensive not least because companies must deal with multiple registries across multiple countries,” she says. “Most pharma manufacturers and wholesalers don’t have the resources to reverify their trading partners more than once a year, which is the current minimum legal requirement, and this too creates a potential vulnerability that can ultimately have an impact on patient safety and increase corporate risk.
     “I could see that this huge volume of manual work was a threat to patient-safety and extremely inefficient,” she adds. “Our solution gives companies much greater control over their compliance activities because they no longer have to rely on manual processes. It can also retrieve and aggregate data from multiple registers across multiple countries and has a constant monitoring and alert system, quality management dashboards, electronic signatures and workflows and will strengthen the attributes of traceability, transparency and security. It is all designed to help companies to be pro-active in their compliance activities, enabling them to go beyond compliance alone to reduce corporate risk and patient risk.”
    Read full story
    Source: The Irish Times, 13 February 2020
  10. Patient Safety Learning
    The Equality and Human Rights Commission have launched a legal challenge against the Secretary of State for Health and Social Care over the repeated failure to move people with learning disabilities and autism into appropriate accommodation.
    Their concerns are about the rights of more than 2,000 people with learning disabilities and autism being detained in secure hospitals, often far away from home and for many years. These concerns increased significantly following the BBC’s exposure of the shocking violation of patients’ human rights at Whorlton Hall, where patients suffered horrific physical and psychological abuse.
    The Equality and Human Rights Commission have sent a pre-action letter to the Secretary of State for Health and Social Care, arguing that the Department of Health and Social Care (DHSC) has breached the European Convention of Human Rights (ECHR) for failing to meet the targets set in the Transforming Care program and Building the Right Support program.
    These targets included moving patients from inappropriate inpatient care to community-based settings, and reducing the reliance on inpatient care for people with learning disabilities and autism.
    Rebecca Hilsenrath, Chief Executive of the Equality and Human Rights Commission, said: 'We cannot afford to miss more deadlines. We cannot afford any more Winterbourne Views or Whorlton Halls. We cannot afford to risk further abuse being inflicted on even a single more person at the distressing and horrific levels we have seen. We need the DHSC to act now."
    "These are people who deserve our support and compassion, not abuse and brutality. Inhumane and degrading treatment in place of adequate healthcare cannot be the hallmark of our society. One scandal should have been one too many."
    Read full story
    Souce: Equality and Human Rights Commission, 12 February 2020
  11. Patient Safety Learning
    The government has announced an independent review into maternity services at an NHS trust where a number of babies have died.
    “Immediate actions” have also been promised and an independent clinical team has been placed “at the heart” of East Kent Hospitals University NHS Foundation Trust. It comes amid reports that at least seven preventable baby deaths may have occurred at the trust since 2016, including that of Harry Richford.
    Harry died seven days after his emergency delivery in a “wholly avoidable” tragedy, contributed to by neglect, in November 2017, an inquest found.
    Speaking in the House of Commons, the health minister Nadine Dorries confirmed the independent review would be carried out by Dr Bill Kirkup, who led the investigation into serious maternity failings at Morecambe Bay. It will look at preventable and avoidable deaths of newborns to ensure the trust learns lessons from each case and will put in place appropriate processes to safeguard families.
    The review is expected to begin shortly and work in partnership with affected families.
    Read full story
    Source: 13 February 2020
  12. Patient Safety Learning
    A double amputee suffered fatal pressure sores caused by "gross and obvious failings" in her hospital treatment.
    Janet Prince, from Nottingham, developed the sores after being admitted to Queen's Medical Centre (QMC) in July 2017. The 80-year-old died in January 2019.
    Assistant Coroner Gordon Clow issued a prevention of future deaths report to Nottingham University Hospitals NHS Trust (NUH).
    Nottingham Coroner's Court had heard Ms Prince was taken to QMC in Nottingham with internal bleeding on 15 July 2017. The patient was left on a trolley in the emergency department for nine hours and even though she and daughter Emma Thirlwall said she needed to be given a specialist mattress, she was not given one.
    "No specific measures of any kind were implemented during that period of more than nine hours to reduce the risk of pressure damage, even though it should have been easily apparent to those treating her that [she] needed such measures to be in place," Mr Clow said.
    Ms Prince was later transferred to different wards, but a specialist mattress was only provided for her a few days before she was discharged on 9 August, by which time Mr Clow said her wounds "had progressed to the most serious form of pressure ulcer (stage four) including a wound with exposed bone".
    Mr Clow said there were "serious failings" over finding an appropriate mattress and other aspects of her care while at the QMC, including "a gross failure" to prevent Ms Prince's open wounds coming into contact with faeces.
    Mr Clow said the immediate cause of her death was "severe pressure ulcers", with bronchopneumonia a contributory factor. Recording a death by "natural causes, contributed to by neglect", he said he was "troubled by the lack of evidence" of any changes to wound management at NUH.
    NUH medical director Keith Girling apologised for the failings in Ms Prince's care, claiming the trust had "learnt a number of significant lessons from this very tragic case".
    Read full story
    Source: BBC News, 14 February 2020
     
  13. Patient Safety Learning
    Dedicated to caring for the sick and vulnerable, junior ­doctors should expect to be ­supported and valued as they carry out their vital work. However, hundreds have revealed they are subjected to bullying and harassment at overstretched hospitals that have been plunged into a staffing crisis by a decade of savage health cuts.
    A Mirror investigation uncovered harrowing stories of young medics being denied drinking water during gruelling shifts, working for 15 hours on their feet non-stop and of uncaring managers tearing into them for breaking down in tears over the deaths of patients.
    One was even accused of “stealing” surgical scrubs she took to wear after suffering a miscarriage at work. The distraught woman finished her shift wearing blood-soaked trousers, instead of going home to rest.
    Doctors are now quitting in their droves, leaving those left ­struggling to cope with a growing ­workload. The Mirror investigation reveals the reality of working for an NHS which has been subject to a record funding squeeze and is 8,000 medics short.
    Health chiefs vowed to ­investigate the Mirror’s evidence from 602 ­testimonials submitted to the lobbying group Doctors Association UK.
    Chairman Dr Rinesh Parmar said: “These heartbreaking stories from across the country show the extent of bullying and harassment that frontline doctors face whilst working to care for patients".
    Read full story
    Source: The Mirror, 12 February 2020
  14. Patient Safety Learning
    A baby with a serious heart condition has died after she received an infection from mould in a Seattle hospital's operating room, her mother says. 
    Elizabeth Hutt was born with a heart condition that she battled for the entirety of her six-month-long life. The young child underwent three open heart surgeries, and after the third one is when it's believed she contracted an Aspergillus mould infection in the hospital's operating room. 
    The mould in the hospital's operating rooms was first detected in November, around the same time as the child's third surgery. 
    It was later determined the infection was contracted from the mould discovered in three of the 14 operating rooms at the hospital in November. The mould came from the hospital's air-handling units in the operating rooms, and 14 patients have developed infections from the mould since 2001, the hospital revealed. Seven of those 14 children have since died from their infections. 
    Elizabeth's parents have joined a class action suit against Seattle Children's Hospital in January, which alleges facility managers knew about the mould since 2005 and failed to fix the problem. 
    Read full story
    Source: The Independent, 14 February 2020
     
  15. Patient Safety Learning
    Pioneering robotic surgery to remove hard-to-reach head and neck cancers has been performed in Wales for the first time.
    More than 20 patients a year from across Wales are expected to benefit from the new service at the University Hospital of Wales in Cardiff.
    Surgeons use a precision robot with several arms to remove tumours and improve the chances of recovery. The first patient is recovering well from his operation in December.
    A human surgeon's wrist can turn 180 degrees, whereas the robot's four 'hands' can rotate four or five times.
    This dexterity reduces the need for more invasive surgery – in some cases this might have involved breaking the jaw open – and patients can recover much more quickly.
    Read full story
    Source: BBC News, 14 February 2020
  16. Patient Safety Learning
    The boss of an NHS trust at the centre of concerns about preventable baby deaths has claimed the scale of the failings is not clearly defined.
    Susan Acott, Chief Executive of East Kent Hospitals Trust, said there had only been "six or seven" avoidable deaths at the trust since 2011. However, the BBC revealed on Monday that the trust previously accepted responsibility for at least 10.
    Ms Acott said some of the baby deaths were "not as clear-cut".
    A series of failings came to light during the inquest of Harry Richford who died seven days after his birth at the Queen Elizabeth the Queen Mother Hospital in Margate in November 2017. A coroner ruled Harry's death was "wholly avoidable" and was contributed to by hospital neglect.
    Ms Acott added she had not read a key report from 2015 drawing attention to maternity problems at the trust until December 2019.
    Ms Acott claims that from 2011 to 2020 there were "about six or seven" baby deaths that were viewed as preventable. She says the other deaths were being investigated adding "these things aren't always black and white".
    Read full story
    Source: BBC News, 12 February 2020
  17. Patient Safety Learning
    An NHS trust has been criticised for advising pregnant women to stay at home for as long as possible during labour to increase the chances of a “normal birth”. University Hospitals Bristol NHS Trust also suggested mothers should avoid having epidurals or inductions and should try to have a home birth.
    The advice has been described as “shocking” by experts, who said the guidance was contrary to evidence and could be “dangerous” for mothers and babies. Others criticised the language used by the trust which suggested women who needed medical help were somehow “abnormal”.
    Earlier this month, the Bristol trust paid out £5.8m in compensation to the family of a six-year-old boy after he was left brain damaged at birth following complications during labour.
    After being contacted by The Independent, the trust deleted the childbirth advice from its website and accepted it was “outdated”.
    Read full story
    Source: The Independent, 13 February 2020
  18. Patient Safety Learning
    The current pharmacy system in the US needs to to change now, according to Thomas Menighan, APhA Executive Vice President and CEO in a recent blog. 
    "The current system sets pharmacists up to fail, and in turn, pharmacists are burning out at high rates", says Thomas. "This is an issue that not only puts patients at risk but deprives pharmacists of the opportunity to provide the kind of patient care we all got into pharmacy to provide". 
    "During my time as a community pharmacist, I cherished the relationships I established with patients and understood the great responsibility that came with the trust they placed in me. Pharmacists take an oath to, among other things, “assure optimal outcomes” for patients. I can attest to the emphasis our profession places on patient safety. When it comes to medication-related errors, even one is too many."
    Thomas suggests the solution comes from taking a hard look at how pharmacies are reimbursed and who profits from inadequate patient care. Meanwhile, state and local pilot projects that compensate pharmacists for greater involvement in team-based care have proven that when pharmacists are allowed to provide a full range of services, costs go down and patient outcomes improve.
    "It’s perverse that we pharmacists are begging for the opportunity to practice the kind of pharmacy we were extensively educated and trained to practice. And who benefits from this warped system? Here’s a hint: it’s not pharmacies or patients."
    "We must regulate the pharmacy benefit managers who make obscene sums of money without doing a single thing to serve patients. They say they keep prices and premiums down but simultaneously fight attempts to force them to be transparent about how they supposedly achieve this. If it’s not greedy, let’s see how it works. If it really helps patients, tell us how. But they won’t. It’s indefensible."
    Read full story
    Source: APhA, 11 February 2020
     
  19. Patient Safety Learning
    Delays diagnosing and treating children with arthritis are leaving them in pain and at a higher risk of lifelong damage, a national charity has warned.
    Arthritis is commonly thought to affect only older people, but 15,000 children have the condition in the UK. 
    Versus Arthritis says many children are not getting help soon enough. 
    The NHS said: "Arthritis in young people is rare and diagnosing it can be difficult because symptoms are often vague and no specific test exists."
    Zoe Chivers, Head of Services at Versus Arthritis, said: "We know that young people often face significant delays getting to diagnosis simply because even their GPs don't recognise that it's a condition that can affect people as young as two. It's often considered that they're just going through growing pains or they've just got a bit of a viral infection and that's not the case."
    Read full story
    Source: BBC News, 12 February 2020
  20. Patient Safety Learning
    Leaving the EU means the UK has greater control over the training of healthcare professionals. The Department of Health and Social Care (DHSC) has announced that nurses and other allied healthcare professionals will be able to retrain as doctors ‘more quickly’ now the UK has left the EU.
    Under training standards set by the EU, existing healthcare professionals wishing to move into another area would have to complete a set standard of training, regardless of any existing health background or qualifications. Under the potential new system, a nurse who has been in the job for 10 years could benefit from training standards based upon experience and qualifications, rather than strict time-frames.
    Health Secretary Matt Hancock said: “Our incredible NHS is full of highly-qualified and dedicated professionals – and I want to do everything I can to help them fulfil their ambitions and provide the best possible care for patients. Without being bound by EU regulations, we can focus on ensuring our workforce has the necessary training which is best suited to them and their experience, without ever compromising on our high standards of care or on patient safety. The plans we are setting out today mean that we can retrain healthcare workers and get them back to the frontline faster. This is good for patients, and good for our NHS."
    Nursing leaders warn that the move needs to come without compromising patient care. Andrea Sutcliffe CBE, Chief Executive and Registrar at the Nursing and Midwifery Council (NMC) said: “Having enough health and care professionals with the right knowledge, skills and values is vital to meet the individual needs of people across all four countries of the UK now and in the future."
    “The NMC supports the wish to explore how education and training for registered nurses and midwives may be achieved in more flexible ways while ensuring our high standards are maintained and not compromised. Every nursing and midwifery professional must be safe and competent to provide the best care and support possible."
    Read full story
    Source: Nursing Notes, 9 February 2020
  21. Patient Safety Learning
    The number of British cases of coronavirus has doubled to eight – with two healthcare workers among those testing positive – while a GP surgery in Brighton was closed amid fears of the infection spreading.
    Brighton’s County Oak medical centre closed on Monday with a warning notice on its door telling patients it was “closed due to operational difficulties”.
    According to reports, one of those infected was a GP, who was at work for one day but did not see any patients. Workers wearing protective suits were pictured cleaning the surgery and pharmacy on Monday afternoon.
    The government has since classified the virus, which has infected more than 40,000 people in China and led to the death of more than 1,000, as a “serious and imminent threat” to public health while activating emergency powers that can see it force people to remain in quarantine.
    “I will do everything in my power to keep people in this country safe,” Matt Hancock, the Health Secretary, said in a statement. “We are taking every possible step to control the outbreak of coronavirus. NHS staff and others will now be supported with additional legal powers to keep people safe across the country.”
    Read full story
    Source: The Independent, 11 February 2020
  22. Patient Safety Learning
    The Streatham terrorist attack has again highlighted one of the most difficult decisions the emergency services face – deciding when it is safe to treat wounded people.
    In the aftermath of the stabbings by Sudesh Amman, a passer-by who helped a man lying on the pavement bleeding claimed ambulance crews took 30 minutes to arrive. The London Ambulance Service (LAS) said the first medics arrived in four minutes, but waited at the assigned rendezvous point until the Metropolitan police confirmed it was safe to move in.
    Last summer, the inquest into the London Bridge attack heard it took three hours for paramedics to reach some of the wounded. Prompt treatment might have saved the life of French chef Sebastian Belanger, who received CPR from members of the public and police officers for half an hour. A LAS debriefing revealed paramedics’ frustration at not being deployed sooner.
    A group of UK and international experts in delivering medical care during terrorist attacks have highlighted alternative approaches in the BMJ. In Paris in 2015, the integration of doctors with specialist police teams enabled about 100 wounded people in the Bataclan concert hall to be triaged and evacuated 30 minutes before the terrorists were killed. The experts writing in the BMJ believe the UK approach would have delayed any medical care reaching these victims for three hours.
    These are perilously hard judgment calls. Policymakers and commanders on the scene have to balance the likelihood that long delays in intervening will lead to more victims dying from their injuries against the increased risk to the lives of medical staff who are potentially putting themselves in the line of fire by entering the so-called 'hot zone'.
    First responders themselves need to be at the forefront of this debate. As the people who have the experience, face the risks and want more than anyone to save as many lives as possible, their leadership and insights are vital.
    In the wake of the Streatham attack the government is looking at everything from sentencing policy to deradicalisation. Deciding how best to save the wounded needs equal priority in the response to terrorism.
    Read full story
    Source: The Guardian, 7 February 2020
  23. Patient Safety Learning
    A BBC News investigation has uncovered more preventable baby deaths at an NHS trust that has already been criticised for its maternity services.
    Four families said their babies would have survived had East Kent Hospitals NHS Trust provided better care. The NHS's Healthcare Safety Branch is investigating 25 maternity cases at the hospitals in Margate and Ashford.
    The trust has apologised for the care provided in two of the cases and said they were investigating a third. It has denied any wrongdoing in the fourth case.
    The government is due to receive the Healthcare Safety Branch's report into the 25 cases later, as well as a Care Quality Commission report from an inspection carried out in January.
    Last month, the BBC discovered at least seven preventable deaths may have occurred at the trust since 2016. Four further families have now spoken out, saying their babies would not have died if medics had provided better care. In two of the cases, the mothers said the actions of the trust left them feeling they were to blame for their babies' deaths.
    In a statement, East Kent Hospitals Trust it had set up a board sub-committee "to ensure we are complying with national safety standards and ensure we are implementing the coroner's recommendations fully and swiftly".
    "We are deeply saddened by the stories of families who have suffered the death of a much-loved baby, and we are extremely sorry for their loss," it added.
    Read full story
    Source: BBC News, 10 February 2020
  24. Patient Safety Learning
    A woman described as a "high risk" anorexia patient faced delays in treatment after moving to university, an inquest has heard.
    Madeline Wallace, 18, from Cambridgeshire, was told there could be a six-week delay in her seeing a specialist after moving to Edinburgh.
    The student "struggled" while at university and a coroner said there appeared to be a "gap" in her care. Ms Wallace died on 9 January 2018 due to complications from sepsis.
    A parliamentary health service ombudsman report into her death was being written at the time of Ms Wallace's treatment in 2017 and issues raised included moving from one provider to another and higher education.
    Coroner Sean Horstead said Ms Wallace only had one dietician meeting in three months, despite meal preparation and planning being an area of anxiety she had raised.
    Dr Hazel said she had tried to make arrangements with the Cullen Centre in Edinburgh in April 2017 but had been told to call back in August. The Cullen Centre said it could only accept her as a patient after she registered with a GP and that an appointment could take up to six weeks from that point.
    Read full story
    Source: BBC News, 10 February 2020
  25. Patient Safety Learning
    The ghosts of medical errors haunt Dr. Peter Pronovost. Two deaths, both caused by mistakes. First, his father’s, who died as the result of a cancer misdiagnosis. Then a little girl, a burn victim who succumbed to infection and diagnostic missteps at the hospital where Pronovost worked early in his career.
    Those deaths led Pronovost to pursue a medical career dedicated to patient safety, and to create the medical checklist he has become known for worldwide.
    Now, he’s implementing his second act, at University Hospitals in the USA, as its Chief Transformation Officer, a job he has held since late 2018. His goal: To transform a $4 billion health care system by reducing shortcomings in medical care and increasing the quality of treatment.
    The challenge fits Pronovost, says one of his former Johns Hopkins University professors, Dr. Albert Wu. “He’s one of the few people for whom the title might be appropriate, because his work has led to significant changes and innovations in how we deliver health care in the United States.
    “He’s a once-in-a-generation guy.”
    Read full story
    Source: Cleveland.com, 9 February 2020

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