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Patient Safety Learning

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  1. Patient Safety Learning
    The Care Quality Commission (CQC) staged an unannounced inspection after two deaths at a mental health unit which it had condemned as “not fit for purpose.”
    Two earlier CQC inspections – in 2017 and 2018 – had also been prompted by deaths on the same unit.
    The CQC visited the Abraham Cowley Unit, which is at St Peter’s Hospital in Chertsey and run by Surrey and Borders Partnership Foundation Trust, on 26 June. Two inpatients died in April and May on an inpatient ward for working age men.
    The deaths both involved “ligature harm” and have led to the trust reviewing its ligature minimisation strategy, according to board papers.
    Read full story (paywalled)
    Source: HSJ, 8 July 2020
  2. Patient Safety Learning
    Today, Sir Liam Donaldson is chairing a patient safety meeting at the World Health Organization (WHO) 'A Global Consultation – A decade of Patient Safety 2020–2030' to formulate a Global Patient Safety Action Plan. His introductory address this morning focused on the task ahead – to maintain the World Health Assembly resolution momentum and patient safety as a global movement. 
    "Patients are not empowered to prevent their own harm", Donaldson said, as he highlighted patient stories of unsafe care and the alarming parallels of patient and family experiences across the world. 
    So where is the power? Donaldson went on to to highlight how the six current power blocks are not doing enough to improve safety and that we need to engage and motivate these power blocks to achieve change:
    Designing of health systems – we have not seen much evidence of systems being designed for safety. Health leaders are not using their power to lead for reduced harm. Educational institutions – these have to happen faster to train staff in. Research community – has patient safety research led to sustainable reduction in risk? Data and information – how has this improved patient safety? Industry – pharma doing very little on medication packaging and labelling; medical devices industry also could do more.
  3. Patient Safety Learning
    Thousands of patients suffering with the long term symptoms of coronavirus can now access specialist help at more than 60 sites, NHS England announced today.
    The assessment centres are taking referrals from GPs for people experiencing brain fog, anxiety, depression, breathlessness, fatigue and other debilitating symptoms.
    NHS England has provided £10 million for the network of clinics, which started opening last month. There are now 69 operating across the country with hundreds of patients already getting help.
    The new centres bring together doctors, nurses, physiotherapists and occupational therapists to offer both physical and psychological assessments and refer patients to the right treatment and rehabilitation services.
    Ten sites are now operational in London, seven in the East of England, eight in the Midlands, South East and South West respectively, nine in the North West and a further 18 across the North East and Yorkshire.
    A further 12 sites are earmarked to launch in January in the East Midlands, Lancashire, Cornwall and Isle of Wight.
    The National Institute for Clinical Excellence (NICE) has today also issued official guidance on best practice for recognising, investigating and rehabilitating patients with long COVID.
    Patients can access services if they are referred by a GP or another healthcare professional, so that doctors can first rule out other possible underlying causes for symptoms.
    Read full story
    Source: NHS England, 18 December 2020
  4. Patient Safety Learning
    The surgeon at the centre of a body parts scandal operated on patients who were dangerously sedated so that their procedures could be carried out simultaneously, according to a leaked investigation seen by The Independent.
    Renowned hip surgeon Derek McMinn and two anaesthetists at Edgbaston Hospital, Birmingham, were accused of putting “income before patient safety” in the internal investigation for BMI Healthcare, which runs the hospital.
    It comes after a separate review found that McMinn had hoarded more than 5,000 bone samples from his patients without a licence or proper permission to do so over a period of 25 years, breaching legal and ethical guidelines. Police are investigating a possible breach of the Human Tissue Act.
    According to the report on sedation by an expert from another hospital, the two anaesthetists, Imran Ahmed and Gauhar Sharih, sedated patients for so long that their blood pressure fell to dangerous levels in order to allow McMinn to carry out near-simultaneous surgery.
    It found this meant long delays in the operations starting, with one sedated patient being subjected to prolonged anaesthesia for longer than one hour and 40 minutes – recommended best practice is 30 minutes.
    Another patient was apparently "abandoned" for an hour and 26 minutes after their surgery was only partially completed while McMinn began operating on another patient.
    The report’s author, expert anaesthetist Dr Dhushyanthan Kumar of Coventry’s University Hospital, said this was unsafe practice by all three doctors and urged BMI Healthcare to carry out a review of patients to see if any had suffered lasting brain damage. Both anaesthetists work for the NHS – Ahmed at Dudley Group of Hospitals, Sharih at University Hospitals Birmingham – without restrictions on their ability to practise.
    Read full story
    Source: The Independent, 30 September 2020
  5. Patient Safety Learning
    Ambulance chiefs are looking at alternative defibrillators after coroners highlighted confusion over how to correctly use their existing machines.
    London Ambulance Service (LAS) Trust has received two warnings from coroners since 2016 after the delayed use of Lifepak 15 defibrillators “significantly reduced” the chances of survival for patients, including a 15-year-old boy.
    Coroners found some paramedics were unaware the machines had to be switched from the default “manual” mode to an “automatic” setting.
    The first warning came after the death of teenager Najeeb Katende in October 2016. A report by coroner Edwin Buckett said the paramedic who arrived had started the defibrillator in manual mode and did not detect a heart rhythm that was appropriate for administering the device, so it was not used until an advanced paramedic arrived on scene 24 minutes later.
    The report stated the defibrillator had been started in manual mode but it needed to be switched to automatic to detect a shockable heart rhythm. The coroner warned LAS that further deaths could occur if action was not taken to prevent similar confusion.
    But another warning was issued to the LAS in March this year, following the death of 35-year-old Mitica Marin. Again, a coroner found the paramedic, who was on her first solo shift, had started the machine in manual mode and had not detected a shockable rhythm. It was suggested this caused a four minute delay in the shock being administered.
    Coroner Graeme Irvine said this was “not an isolated incident” for LAS and noted the trust had reviewed other cases of delayed defibrillation. They found that the defibrillator’s manual default setting was a “contributing factor” to the delays.
    Read full story (paywalled)
    Source: HSJ, 10 August 2020
  6. Patient Safety Learning
    The Medicines and Healthcare products Regulatory Agency (MHRA) has published its response to the Independent Medicines and Medical Devices Safety Review.
    In its response, the MHRA said: “Today’s publication of the Independent Medicines and Medical Devices Safety Review is of profound importance for the MHRA, since the safety of the public is our first priority."
    "We therefore take this report and its findings extremely seriously. Throughout the Review’s work we have listened intently to the many distressing experiences of women and their families. We will now carefully study the findings and recommendations of the Report.
    We recognise that patient safety must be continually protected and that many of the major changes recommended by the Review cannot wait. We are therefore making changes without delay to ensure that we listen to patients and involve them in every aspect of our work.
    We are already taking steps to strengthen our collaboration with all bodies in the healthcare system and will strive to ensure that, working with these other bodies, the safety changes we advise are embedded without delay in clinical practice.
    We wholeheartedly commit to demonstrating to those patients and families who have shared their experiences during the Review, and anyone else who has suffered, that we have learned from them and are changing and improving because of what they have told us. We are determined to put patients and the public at the heart of everything we do."
    Read full statement
    Source: GOV.UK, 8 July 2020
  7. Patient Safety Learning
    South East Coast Ambulance Service NHS Foundation Trust (SECAmb) is the first ambulance service in the country to introduce new pioneering guidance aimed at improving the treatment of spinal injury patients.
    The guidance includes the ending of the use of neck braces or semi-rigid collars on spinal injury patients. The ground-breaking approach is only currently in place in three other countries – Australia, Norway and Denmark. While collars are often seen as synonymous with spinal care, there is growing evidence that they could cause further harm, while providing little or no benefit.
    Instead, for ‘standard patients’, spinal precautions will be undertaken with manual in-line stabilisation followed by head blocks, tape and placement on a scoop stretcher secured in a non-rigid vacuum mattress.
    For a group of ‘non-standard’ patients – which may include older patients, those who are frail or have pre-existing spinal conditions, those with communication difficulties, pregnant patients, young children, bariatric patients or agitated and uncooperative patients – transport on a scoop stretcher is not beneficial. In these cases, a position of comfort approach will be used to minimise spinal motion and a special lanyard will be applied to the patient in order to alert the receiving emergency department of the patient’s status.
    Soon to be adopted nationally by the Joint Royal Colleges Ambulance Liaison Committee, (JRCALC), SECAmb has been assigned as an ‘early adopter’ while the national guidelines are formalised.

    Read full story
    Source: South East Coast Ambulance Service, 15 July 2020
  8. Patient Safety Learning
    A fifth patient has been given the wrong blood at a major teaching hospital’s haematology department where patient safety concerns were raised by clinicians last year.
    The incident, at University Hospitals Birmingham Foundation Trust, is the fifth never event involving patients being transfused with the wrong blood at the trust since April 2020.
    Only 15 such never events have been recorded in England in the last two financial years, which means UHB accounted for a third of the total in 2020-21 and 2021-22.
    HSJ revealed last year that several clinicians had raised safety concerns at the trust’s haematology specialty after most of its services at Heartlands Hospital were moved to Queen Elizabeth Hospital as part of the trust’s pandemic response.
    The latest never event, which occurred in March, saw a patient being given an “unintentional transfusion of ABO-incompatible blood components” – according to papers provided to the trust’s council of governors.
    Read full story (paywalled)
    Source: HSJ, 14 June 2022
  9. Patient Safety Learning
    NHS trusts are to be told to remove devices linked to more than 120 never events caused by ‘unconscious errors’.
    A national patient safety alert from NHS England which urges trusts to remove all air flowmeters from wall medical gas outlets. It is likely to be published next month.
    The alert comes after 121 never events in the last three years involved staff members accidentally connecting patients to air instead of oxygen. This number is close to 10% of all never events recorded during that period.
    These types of never events have been recorded by 57 NHS organisations during 2018-19, 2019-20 and 2020-21.
    The incidents took place mostly on medical wards and in emergency departments. They occurred despite NHSE issuing a patient safety alert in 2016, which recommended removing the flowmeters from wall outlets when not in active use.
    According to NHSE documents - seen by HSJ - the never events often went undetected “for some time”, even when other staff responded to deteriorating patients or took over their care. The regulator concluded this makes it more likely that there have been other unreported incidents.
    Read full story (paywalled)
    Source: HSJ, 17 May 2021
  10. Patient Safety Learning
    NHS bosses have been accused of “burying” a damning report into child cancer services commissioned following complaints that patients were “dying in agony”. Completed in 2015, the document highlights failings at the Royal Marsden NHS Foundation Trust, one of the UK’s flagship cancer organisations. It found that, despite being supposedly a centre of excellence, children admitted for cancer treatment were routinely transferred between hospitals to get the care they needed.
    Compiled by Professor Mike Stephens, the report was commissioned after a coroner found “astonishing” failures in the care of a two-year-old girl, Alice Mason, leading to her suffering irreversible brain damage and dying in 2011. It recommended a radical shake-up of the Marsden’s services. The document was never made public, however, and former NHS medical director for London, Dr Andy Mitchell, accused the head of NHS England, Simon Stevens, and Cally Palmer, England’s National Cancer Director and Chief Executive of the Royal Marsden, of suppressing its publication.
    Dr Mitchell told the Health Service Journal (HJS): “I can’t imagine any other individuals having the power and influence to be able to stop this report moving forward.”
    NHS England has denied that its then Medical Director, Sir Bruce Keogh, was improperly leaned on and said the report remained unpublished because it made “implausible suggestions” which would have forced children with cancer to travel further for care. But Gareth Mason, Alice’s father, said: “To write a report, shelve it and not debate it, that is a cover-up [and] it has left children since Alice and danger, and the Marsden won’t acknowledge that.”
    The controversy surrounds the performance of a so-called “shared care system”, with the Marsden’s Sutton site forming part of a network for South London, Surrey, Sussex and Kent.
    Critics say the format meant children were transferred between sites more regularly than they should have been and were put in danger because information was not properly shared.
    Read full story
    Source: The Telegraph, 19 June 2019  
  11. Patient Safety Learning
    An ‘outstanding’ London trust has come under fire for asking staff to communicate ‘only in English’ when around other people.
    A document published under the ‘trust values’ section of Homerton University Hospital Foundation Trust’s website, says: “I will only communicate in English in the presence of others.”
    The document has been widely shared on social media in the last 24 hours, with many criticising the trust for its wording. The document itself is dated 2014, but was reposted by the trust in 2019, and remained on its website as of midday today.
    NHS England’s director of equality – medical workforce, Partha Kar, who is also NHSE’s diabetes lead, questioned the document on Twitter. He also said: “I am not aware of any NHS England ‘diktat’ suggesting we must all only speak in English to uphold NHS values.”
    It follows a separate notice being posted on Twitter yesterday signed simply by “Matron”, by a doctor who claimed her friend saw it at her “hospital placement”. It seemingly threatened staff with “disciplinary action” if they spoke any other language other than English.
    It reads: “English is the only language to be spoken in the ward area – this includes the kitchen. Disciplinary action will be taken against staff who do not comply, including agency and bank.”
    The documents have prompted a backlash on Twitter, with many criticising them and raising concerns about racism and inclusivity of staff. NHSE’s chief nursing officer, Ruth May, has publicly queried where the document is from.
    Read full story (paywalled)
    Source: HSJ, 16 March 2022
  12. Patient Safety Learning
    Two patients at a hospital in West Lancashire came to “avoidable harm” after medical staff failed to act on concerns raised by nurses, according to a health watchdog.
    The issue was highlighted by the Care Quality Commission (CQC) following an inspection of children and young people’s services at Ormskirk Hospital in July and August.
    In there report CQC stated: “In children and young people’s services we found evidence that there had been occasions when medical staff had not responded to nursing concerns, which led to avoidable harm occurring to two patients.”
    The document added that the two serious incidents, which had both been reported by staff, were "relating to babies".
    Read full story
    Source: The Nursing Times, 3 December 2019
  13. Patient Safety Learning
    A surgeon has been accused of carrying out “unnecessary” shoulder operations on several NHS patients at a private hospital linked to the Ian Paterson scandal, with 217 patients recalled.
    HSJ has been told at least five patients, all commissioned by the NHS, have instructed solicitors to take legal action against Habib Rahman, a consultant orthopaedic surgeon at Spire Parkway Hospital in Solihull.
    Mr Rahman is accused of undertaking “unnecessary or inappropriate surgical procedures at Spire Healthcare hospitals” . Spire has confirmed it has recalled 217 patients over the concerns.
    The allegations come weeks before the findings are due from an independent inquiry into disgraced surgeon Ian Paterson – who was found guilty of wounding with intent after giving hundreds of patients unnecessary breast surgeries in Spire hospitals across the Midlands.
    Read full story (paywalled)
    Source: HSJ, 24 January 2020
  14. Patient Safety Learning
    Trying to strike a balance between free speech and public health, California’s Legislature on Monday approved a bill that would allow regulators to punish doctors for spreading false information about Covid-19 vaccinations and treatments.
    The legislation, if signed by Gov. Gavin Newsom, would make the state the first to try to legislate a remedy to a problem that the American Medical Association, among other medical groups and experts, says has worsened the impact of the pandemic, resulting in thousands of unnecessary hospitalisations and deaths.
    The law would designate spreading false or misleading medical information to patients as “unprofessional conduct,” subject to punishment by the agency that licenses doctors, the Medical Board of California. That could include suspending or revoking a doctor’s license to practice medicine in the state.
    While the legislation has raised concerns over freedom of speech, the bill’s sponsors said the extensive harm caused by false information required holding incompetent or ill-intentioned doctors accountable.
    “In order for a patient to give informed consent, they have to be well informed,” said State Senator Richard Pan, a Democrat from Sacramento and a co-author of the bill. A paediatrician himself and a prominent proponent of stronger vaccination requirements, he said the law was intended to address “the most egregious cases” of deliberately misleading patients.
    Read full story (paywalled)
    Source: New York Times, 29 August 2022
  15. Patient Safety Learning
    A senior surgeon has raised concerns about the way whistleblowers are dealt with, claiming he was sacked after speaking out.
    Serryth Colbert told the BBC that following attempts to "stop wrongdoing", he was investigated by the trust at Bath's Royal United Hospital.
    As a result, he said he was dismissed for gross misconduct in October 2023.
    The RUH said it has "never dismissed anybody for raising concerns and never will".
    It added that Mr Colbert's dismissal related to "significant concerns about bullying" and its investigation into his conduct was "thorough" and "robust".
    Mr Colbert said he raised safety concerns without regard for the impact it might have on his career.
    "It was never a question in my mind. This is wrong. I'm stopping the wrongdoing. I stand for justice. I stand to protect patients," he said.
    The BBC has seen no evidence his most serious concern was ever investigated and Mr Colbert is now taking the RUH to an employment tribunal.
    Read full story
    Source: BBC News, 9 February 2024
  16. Patient Safety Learning
    The Care Quality Commission's chief executive Ian Trenholm has said he is sceptical about the need to appoint an NHS patient safety commissioner, one of the key recommendations of the recently published Cumberlege review.
    In a wide-ranging interview with HSJ, Mr Trenholm also revealed that he wants the Care Quality Commission to review the collaboration of every health system in England.
    Mr Trenholm told HSJ he is “not sure” a patient safety commissioner was needed and that it would need to perform a “role that was different from what’s already in place” for it to add value.
    He said: “If you look at the work we’re doing on patient safety, the work that HSIB are doing on patient safety, and then we’ve got people within the NHS itself doing work on patient safety, I think there are enough people playing. The question is, are we all working together as effectively as we possibly could be.
    “If another player helps that work [then] great, but I’m not sure that’s something that is necessary.”
    Read full story (paywalled)
    Source: HSJ, 24 August 2020
  17. Patient Safety Learning
    A 7-year-old boy who has spent most of his life being branded naughty and disruptive has won a settlement of more than £30m after it was discovered that he had sustained a brain injury after negligent delays in his delivery at University College Hospital in London.
    The settlement is thought to be one of only a handful of NHS clinical negligence payouts to exceed £30m.
    Read full story (paywalled)
    Source: BMJ, 1 November 2019
  18. Patient Safety Learning
    The NHS’ mental health director has branded abuse exposed at a city inpatient unit as “heartbreaking and shameful” and ordered a national review of safety across all providers.
    In a letter to all leaders of mental health, learning disability and autism providers, shared with HSJ, Claire Murdoch responded to BBC Panorama’s exposure of patient abuse at the Edenfield Centre run by Greater Manchester Mental Health FT by warning trusts they should leave “no stone unturned” in seeking to eradicate and prevent poor care.
    An investigation by the programme found a “toxic culture of humiliation, verbal abuse and bullying” at the medium-secure inpatient unit in Prestwich near Manchester.
    In response, Ms Murdoch said the mindset that “it could happen here” must be at the front and centre of national and local approaches, adding that trusts which already adopt this outlook are most likely to identify and prevent toxic and closed cultures.
    She also urged all boards to urgently review safeguarding of care in their organisations and identify any immediate issues requiring action now, such as freedom to speak up arrangements, complaints, and care and treatment reviews. A separate national probe into the quality of inpatient care is due to launch imminently.
    Read full story (paywalled)
    Source: HSJ, 30 September 2022
  19. Patient Safety Learning
    NHS bosses have been accused of using a 2013 report to “maintain a false narrative” about maternity services in Shropshire, which meant poor practices and conditions went unchallenged for years.
    The Independent has obtained a 2013 report, commissioned by NHS managers in Shropshire, which concluded maternity services at the Shrewsbury and Telford Hospital Trust were “safe”, of “good quality”, and “delivered in a learning organisation”.
    The report, written by rheumatologist Dr Josh Dixey (now high sheriff of Shropshire), delivered a glowing assessment of the care given to women and babies and appeared to gloss over hints of deeper problems within the service.
    Sources within the Shropshire and Telford clinical commissioning groups (CCGs), which paid £60,000 for the report, said since it was written it had been “proven to be wrong, inaccurate and to have come to the wrong conclusions and recommendations”, but also stressed it was based on the information received from the trust at the time.
    A leaked report last month revealed dozens of mothers and babies had died at the Shrewsbury and Telford Hospital Trust, with incidents of poor care stretching over four decades, due to repeated failures to learn from mistakes.
    Read full story
    Source: The Independent, 4 December 2019
  20. Patient Safety Learning
    There were almost 10,000 unexplained extra deaths among people with dementia in England and Wales in April, according to official figures that have prompted alarm about the severe impact of social isolation on people with the condition.
    The data, from the Office for National Statistics, reveals that, beyond deaths directly linked to COVID-19, there were 83% more deaths from dementia than usual in April, with charities warning that a reduction in essential medical care and family visits were taking a devastating toll.
    “It’s horrendous that people with dementia have been dying in their thousands,” said Kate Lee, chief executive officer at Alzheimer’s Society. “We’ve already seen the devastating effect of coronavirus on people with dementia who catch it, but our [research] reveals that the threat of the virus extends far beyond that.”
    The charity thinks the increased numbers of deaths from dementia are resulting partly from increased cognitive impairment caused by isolation, the reduction in essential care as family carers cannot visit, and the onset of depression as people with dementia do not understand why loved ones are no longer visiting, causing them to lose skills and independence, such as the ability to speak or even stopping eating and drinking.
    Another factor may be interruptions to usual health services, with more than three-quarters of care homes reporting that GPs have been reluctant to visit residents.
    Read full story
    Source: The Guardian, 5 June 2020
  21. Patient Safety Learning
    Inquests into coronavirus deaths among NHS workers should avoid examining systemic failures in provision of personal protective equipment (PPE), coroners have been told, in a move described by Labour as “very worrying”.
    The chief coroner for England and Wales, Mark Lucraft QC, has issued guidance that “an inquest would not be a satisfactory means of deciding whether adequate general policies and arrangements were in place for provision of PPE to healthcare workers”.
    Lucraft said that “if there were reason to suspect that some human failure contributed to the person being infected with the virus”, an inquest may be required. The coroner “may need to consider whether any failures of precautions in a particular workplace caused the deceased to contract the virus and so contributed to death”.
    But he added: “An inquest is not the right forum for addressing concerns about high-level government or public policy.”
    Labour warned the advice could limit the scope of investigations into the impact of PPE shortages on frontline staff who have died from COVID-19.
    “I am very worried that an impression is being given that coroners will never investigate whether a failure to provide PPE led to the death of a key worker,” said Lord Falconer, the shadow attorney general. “This guidance may have an unduly restricting effect on the width of inquests arising out of Covid-19-related deaths.”
    Read full story
    Source: The Guardian, 29 April 2020
  22. Patient Safety Learning
    Delays to follow-up appointments for glaucoma patients leaves them at risk of sight loss, the Healthcare Investigation Safety Branch (HSIB) warns in their new report.
    The report highlights the case of a 34-year old woman who lost her sight as a result of 13 months of delays to follow-up appointments.
    Lack of timely follow-up for glaucoma patients is a recognised national issue across the NHS. Research suggests that around 22 patients a month will suffer severe or permanent sight loss as a result of the delays. In HSIB’s reference case, the patient saw seven different ophthalmologists and the time between her initial referral to hospital eye services (HES) and laser eye surgery was 11 months. By this time her sight had deteriorated so badly, she was registered as severely sight impaired.
    The investigation identified that there is inadequate HES capacity to meet demand for glaucoma services, and that better, smarter ways of working should be implemented to maximise the current capacity. The report makes several safety recommendations focused on the management and prioritisation of appointments. 
    Helen Lee, RNIB Policy and Campaigns Manager, said: “This report has brought vital attention to a serious and dangerous lack of specialist staff and space in NHS ophthalmology services across the country. We know that thousands of patients in England are experiencing delays in time-critical eye care appointments, which is leading to irreversible sight loss for some."
    “Without immediate action, the situation will only continue to deteriorate as the demand for appointments increases. RNIB urges full and immediate implementation of the recommendations set out in this report to improve the capacity, efficiency and effectiveness of ophthalmology services.”
    Read full story
    Source: HSIB, 9 January 2020
  23. Patient Safety Learning
    Police are preparing to investigate alleged mistreatment of patients at a mental health unit. The Edenfield Centre based in the grounds of the former Prestwich Hospital in Bury is at the centre of the claims.
    The unit cares for adult patients. The Manchester Evening News understands that action was taken after the BBC Panorama programme embedded a reporter undercover in the unit and then presented the NHS Trust which runs it with their evidence.
    A spokesperson for Greater Manchester Police said: "We are aware of the allegations and are liaising with partner agencies to safeguard vulnerable individuals and obtain all information required to open an investigation."
    A spokesperson for Greater Manchester Mental Health NHS Foundation Trust said: "We can confirm that BBC Panorama has contacted the Trust, following research it conducted into the Edenfield Centre. We would like to reassure patients, carers, staff, and the public that we are taking the matters raised by the BBC very seriously".
    "Immediate action has been taken to address the issues raised and to ensure patient safety, which is our utmost priority. We are liaising with partner agencies and stakeholders, including Greater Manchester Police. We are not able to comment any further on these matters at this stage."
    Read full story
    Source: Manchester Evening News, 14 September 2022
  24. Patient Safety Learning
    The suicide of a woman with severe mental illness has prompted a review into the care of hundreds of other patients, according to her family.
    Frances Wellburn, 56, was under the care of Tees, Esk and Wear Valley Foundation Trust’s community mental health team in York, which before the coronavirus pandemic had categorised her as “medium risk”.
    This meant she should have had regular contact from the service, but an internal serious incident report into her death, seen by HSJ, found no contact was made with her for three months.
    In June 2020 she required admission to an inpatient unit for three weeks, but she deteriorated again after being discharged and took her own life in August.
    Her family have said Ms Wellburn was making a “good recovery” from episodes of psychosis prior to the pandemic, but the lack of support in the spring of last year had contributed to a major deterioration in her condition.
    According to sister, Rebecca Wellburn, the trust’s director of nursing Elizabeth Moody confirmed in a meeting with the family that a wider review had now been launched into the care of hundreds of patients under its York-based community services.
    Read full story
    Source: HSJ, 28 April 2021
  25. Patient Safety Learning
    THE NHS has announced plans to scrap prescriptions for 35 conditions in a bid to save the money it spends on drugs available over-the-counter (OTC). The body said it will no longer issue treatments for a range of minor conditions, such as diarrhoea, oral thrush and ailments associated with pain.
    The health body will no longer prescribe drugs for 35 conditions listed below, which patients will have to purchase from their local pharmacy or supermarket going forward. The plan to dial back on prescriptions was devised with the aim of allocating funds to treatments for more serious conditions, according to the health body. Many of the conditions are able to resolve on their own, but prescriptions may still be issued if an exemption applies.
    Acute sore throat Conjunctivitis Coughs, colds, and nasal congestion Cradle cap Dandruff Diarrhoea Dry eyes / sore tired eyes Earwax Excessive sweating Haemorrhoids Head live Indigestion and heartburn Infant colic Infrequent cold sores of the lip Infrequent constipation Infrequent migraine Insect bites and stings Mild acne Mild burns and scalds Mild cystitis Mild dry skin Mild irritant dermatitis Mild to moderate hay fever Minor conditions associated with pain, discomfort and fever (e.g. aches and pain, headache, period pain, back pain) Mouth ulcers Nappy rash Oral thrush Prevention of tooth decay Ringworm/athlete’s foot Sunburn Sun protection Teething / mild toothache Threadworms Travel sickness Warts and verrucae Read full story
    Source: Express, 20 May 2022
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