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Patient Safety Learning

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  1. Patient Safety Learning
    The NHS has ordered a new chair for the Nottingham maternity scandal review which is looking into hundreds of cases of alleged poor care.
    In a letter published late on Friday the NHS said there needed to be “urgent” changes to the way the review was being carried out and this included appointing a former NHS trust chair Julie Dent to lead the review.
    More than 100 bereaved families wrote to the health secretary Sajid Javid on 7 April calling for the review, to be overhauled and the chair Cathy Purt, to be replaced by Donna Ockenden who chaired the Shrewsbury maternity scandal inquiry.
    The Nottingham review, dubbed an “independent thematic review”, was launched in July 2021 and is being led by local NHS commissioners and NHS England.
    It was announced after The Independent and Channel 4 revealed millions had been paid out by the trust over 30 baby deaths and 46 incidents of babies left permanently brain damaged by Nottingham University Hospitals Foundation Trust.
    Sir David Sloman, the NHS chief operating officer, said in his letter on Friday: “Following discussions at both a regional and national level, it is clear that urgent changes to how the review is being delivered need to be made. A new chair needs to lead this review with sufficient senior experience to address the concerns and challenges faced at Nottingham University Hospitals, to speed up the process and to deliver a review that can bring about real change for women and babies in Nottingham.
    “It has therefore been agreed that the review will now have enhanced national oversight by NHS England and NHS Improvement and I am pleased to announce that Julie Dent CBE has agreed to take on the role of chair for this review and she will begin this work with immediate effect.”
    Read full story
    Source: The Independent, 23 April 2022
  2. Patient Safety Learning
    In a bid to fight against misinformation about the coronavirus vaccines, a group of scientists from all over the world have created an online guide to building a ‘truth sandwich’.
    The guide serves to arm people with practical tips, up-to-date information and evidence to talk reliably about the vaccines, and enable them to constructively challenge associated myths.
    The scientists, led by the University of Bristol, are appealing to everyone to understand the facts set out in the 'COVID-19 Vaccine Communication Handbook', follow the guidance and spread the word.
    Professor Stephan Lewandowsky, the lead author of the guide, said: “Vaccines are our ticket to freedom and communication about them should be our passport to getting everyone on board."
    “The way all of us refer to and discuss the COVID-19 vaccines can literally help win the battle against this devastating virus by tackling misinformation and improving uptake, which is crucial."
    Read full story
    Source: The Independent, 7 January 2021
  3. Patient Safety Learning
    An NHS children’s mental health unit has been closed down by the Care Quality Commission after being rated “inadequate” last week.
    A child and adolescent mental health ward run by Tees, Esk and Wear Valley’s Foundation Trust has been closed after the CQC took enforcement action to protect the safety of patients.
    In a statement today, a CQC spokesman said: ”[We have] taken urgent enforcement action at Tees, Esk and Wear Valley’s Foundation Trust which will lead to the closure of the child and adolescent mental health service units at West Lane Hospital. The Holly unit at West Park Hospital and Baysdale Unit at Roseberry Park are unaffected. The action follows continued concerns identified at earlier inspections in June and August, and the recent inspection on 20 and 21 August 2019."
    Read full story (paywalled)
    Source: HSJ, 23 August 2019
  4. Patient Safety Learning
    A woman has been awarded $10.5 million (£8m) in damages after medical staff left a sponge inside her body.
    The sponge – which measured 18-by-18 inches and was left behind during surgery – was inside the woman's body for years before she realised.
    It had been left in her body after she underwent heart surgery at a Kentucky hospital in 2011. The bypass surgery is said to have gone wrong, leaving a mess – and as nurses rushed to deal with the problems, the sponge was left inside her body. 
    It was not discovered for four years, until she had a CT scan in 2015. In the meantime, the sponge had moved around the woman's body, shifting around her intestines and causing pain as it did so. She had her leg amputated and was left with gastrointestinal issues after the sponge eroded into her intestine.
    The patient's lawyers said the case should be a reminder to hospitals to ensure that objects such as needles and other sharp objects, as well as sponges, are removed from patients after surgery.
    Read full story
    Source: The Independent, 1 January 2020
  5. Patient Safety Learning
    A major acute trust has confirmed the health service inspectorate has begun a criminal investigation into three incidents at its hospitals.
    University Hospitals Birmingham FT told HSJ the Care Quality Commission (CQC) has started a criminal investigation into incidents involving potential errors around the provision of anti-coagulant medication.
    The trust received a letter from the CQC this month informing it that the regulator has begun the investigation under regulation 22 of the Health and Social Care Act 2008 (regulated activities) regulations 2014. The incidents happened at Queen Elizabeth Hospital in Birmingham and Good Hope Hospital — the trust’s two main sites.
    Regulation 22 says: “In order to safeguard the health, safety and welfare of service users, the registered person must take appropriate steps to ensure that, at all times, there are sufficient numbers of suitably qualified, skilled and experienced persons employed for the purposes of carrying on the regulated activity.”
    The CQC launched a prosecution into East Kent Hospitals University FT this month for failing to meet fundamental standards of care. The regulator also successfully prosecuted University Hospitals Plymouth Trust in September after it pleaded guilty to breaching the duty of candour. 
    Read full story (paywalled)
    Source: HSJ, 23 October 2020
  6. Patient Safety Learning
    Adult social care services are to receive millions of personal protective equipment products following a national audit of personal protective equipment (PPE), HSJ can reveal.
    The government will deliver more than 30 million items to local resilience forums in the coming days, for distribution among social care and other front-line services, according to a letter seen by HSJ.
    The stock should not be sent to acute trusts or ambulance services, the letter, from health and social care secretary Matt Hancock and housing, communities and local government secretary Robert Jenrick, stated.
    Describing an “urgent need” for PPE in front-line services, Mr Hancock and Mr Jenrick asked local planners to distribute this latest batch of stock “only where there is a clear and pressing need”.
    Read full story
    Source: HSJ, 6 April 2020
  7. Patient Safety Learning
    A young woman was left with a retained foreign object, after surgery in an India hospital. A checklist could have avoided her death. The response from the health officials was: “We have issued a show-cause notice to the staff seeking an explanation. We will initiate departmental action based on their replies and finding of our inquiry.”
    In the fields of healthcare quality and patient safety, such punitive measures of “naming and shaming” have not worked.
    T.S. Ravikumar, President, AIIMS Mangalagiri, Andhra Pradesh, moved back to India eight years ago with the key motive to improve accountability and safety in healthcare delivery. He believes that we have a long way to go in reducing “preventable harm” in hospitals and the health system in general.  "We need to move away from fixing blame, to creating a 'blame-free culture' in healthcare, yet, with accountability. This requires both systems design for safe care and human factors engineering for slips and violations".
    "Providing safe care without harm is a 'team sport', and we need to work as teams and not in silos, with mutual respect and ability to speak up where we observe any deviation or non-compliance with rules, says Ravikumar. Basic quality tools and root-cause analysis for adverse events must become routine. Weekly mortality/morbidity conferences are routine in many countries, but not a routine learning tool in India.
    He proposes acceleration of the recent initiative of the DGHS of the Government of India to implement a National Patient Safety Framework, and set up an analytical “never events” or sentinel events reporting structure.
    Read full story
    Source: The Hindu, 12 January 2020
  8. Patient Safety Learning
    Leadership behaviour from the “very top of the NHS” has led to an increase in bullying, according to an official strategy document produced by an acute trust.
    East and North Hertfordshire Trust published its new people and organisation strategy in its January board papers. Within it, the report said: “Leadership behaviour from the very top of the NHS, during this time of pressure has led to an increase in accusations of bullying, harassment and discrimination.”
    In a separate section, the paper noted the difficulties of being a healthcare professional, saying “many staff leave before they need to and many more cite bullying, over work and stress, as reasons for absence and mistakes”.
    Read full story (paywalled)
    Source: HSJ, 13 January 2020
  9. Patient Safety Learning
    Doctors too often "ignore" women's pain, Sajid Javid said as he called for change in the wake of the Shrewsbury maternity scandal.
    Writing for The Telegraph, the Health Secretary said the wider NHS needed to do much more to listen to women, adding that too many are left in pain and ignored by clinicians.
    On Wednesday, the Ockenden report revealed that the deaths of 201 babies and nine mothers at Shrewsbury and Telford NHS Trust could have been avoided, citing a failure to listen to women.
    Mr Javid wrote: "This week we have seen the tragic reality of what can happen when women's voices are not listened to when it comes to their care. 
    "Donna Ockenden's report into maternity failings at Shrewsbury and Telford Hospitals raises specific concerns for maternity services, but more widely we must address issues across the whole of the health and care system when it comes to listening to women's concerns and recognising their pain."
    In the joint piece with Maria Caulfield, the minister for women’s health, Mr Javid welcomed a "shift in the way we talk about women's health", with more open discussions about areas once seen as taboo.
    But the pair said more needed to be done – specifically to improve the treatment of endometriosis, an extremely painful gynaecological condition.
    "We must ensure all women feel confident in going to their GP when they experience symptoms of endometriosis and, when they do, that they are listened to," they said. Too many were "spending too long in pain waiting for a diagnosis, often feeling ignored by clinicians", they warned.
    Later this year the Government will publish a women's health strategy, which will examine issues including fertility, menopause, and prevention and treatment of diseases.
    Read full story (paywalled)
    Source: The Telegraph, 31 March 2022
  10. Patient Safety Learning
    Dr Julia Patterson of campaign group EveryDoctor tells why she quit health service "cut back to its very bones". 
    “Doctors love their jobs, and most wouldn’t do anything else,” she said. “It’s our vocation to care for our patients. However, the level of stress endured by frontline NHS staff is unbelievable. Understaffing leaves doctors feeling isolated and stretched. There is often pressure to take on more patients, to work extra shifts, to stretch themselves thinner and thinner.”
    New findings shared exclusively with the Observer by legal support service the Medical Protection Society (MPS) confirm the deep discontent in Britain’s medical profession. It has found that 52% of doctors working in the UK are dissatisfied with their work-life balance, 46% feel guilty about taking time off, and almost 40% believe their employer does not give them the support they need to do their job well.
    Read full story
    Source: The Guardian, 29 September 2019
  11. Patient Safety Learning
    The Care Quality Commission (CQC) missed multiple opportunities to identify abuse of patients at a privately run hospital and did not act on the concerns of its own members, an independent review has found.
    Bosses at the CQC have been criticised in an independent report by David Noble into why the regulator buried a critical report into Whorlton Hall hospital, in County Durham, in 2015.
    His report published today said the CQC was wrong not to make public concerns from one of its inspection teams in 2015.
    “The decision not to publish was wrong,” his report said, adding: “This was a missed opportunity to record a poorly performing independent mental health institution which CQC as the regulator, with the information available to it, should have identified at that time.”
    Read full story
    Source: The Independent, 22 January 2020
  12. Patient Safety Learning
    More than 550 objects have been unintentionally left in Canadian medical and surgery patients between 2016 and 2018, and the problem appears to be getting worse.
    A new report released by the Canadian Institute for Health Information says 553 foreign items – such as sponges and medical instruments – were left behind over that two-year period. That's a 14%  increase between the most recent data collected in 2017–2018 and statistics collected five years earlier.
    It's also more than two times the average rate of 12 reporting countries, including Sweden, the Netherlands and Norway, which had the next highest rates.
    The information was examined as part of a broad look at how Canada's health-care system compares to other member nations of the Organisation for Economic Co-operation and Development.
    Read full story
    Source: CTV News, 7 November 2019
  13. Patient Safety Learning
    The leadership of a prominent cancer trust acted in a ‘defensive and dismissive’ manner when serious concerns were raised about bullying behaviours and multiple failings in the handling of a major research contract, an external review has found.
    As previously revealed by HSJ, NHS England commissioned the review into events at The Christie Foundation Trust after whistleblowers raised numerous concerns over a research project with pharmaceutical giant Roche, and about the way they were treated as a result of speaking out.
    The NHSE review, which was led by Angela Schofield, chair of Harrogate and District FT, was published earlier today within trust board papers. It described the trust’s research division as “ineffective” and said it had “allowed inappropriate behaviours to continue without challenge”.
    The review added: “It may… be thought to be surprising that NHSE/I found it necessary to commission an external rapid review to look into concerns which had been raised by colleagues within the research and innovation division."
    “The root cause of this seems to be an apparent failure by those people in leadership positions who were aware of the concerns that had been raised, in the circumstances covered by the review, to listen to and take notice of a number of people who have some serious issues about the way they are treated and wish to contribute to an improvement in the culture."
    It also summarised the experiences of 20 current and former staff members who said they suffered “detriment as a result of raising concerns”, although it did not make a clear judgement on whether their claims were justified.
    They said: “An experience of bullying, harassment and racial prejudice was described along with lack of respect at work… Patronising behaviour, humiliation and verbal aggression by managers and clinicians in public and private spaces contributed to the perception that working environments were emotionally unsafe.”
    Read full story (paywalled)
    Source: HSJ, 27 January 2022
  14. Patient Safety Learning
    The first baby born using entirely digital maternity notes in north Cumbria has been born at West Cumberland Hospital in Whitehaven. The new digital system replaces the traditional paper-based system with notes being held digitally for staff and linking to a phone app so women no longer need to carry their notes to appointments.
    The app which expectant and new mothers can use is called ‘Maternity Notes’. It helps women track their pregnancy journey and contains lots of information about the baby’s development as they move through their pregnancy, and up to six weeks post-birth. The new system is safer too, with women no longer needing to carry paper maternity notes.
    Since going live on 1 April, 100% of women registering a new pregnancy have signed up to the app.
    North Cumbria University Hospitals NHS Trust is one of only 14 Trusts across the country to implement electronic maternity notes.
    Read full story
    Source: Health Tech Digital, 2 September 2019
  15. Patient Safety Learning
    Gowns for front-line staff were not included in the national pandemic stockpile of personal protective equipment, procurement chiefs have been told.
    Trust procurement leads have raised concerns over dwindling gown supplies. Health Care Supply Association chief officer Alan Hoskins tweeted he could not order the products through NHS Supply Chain, even after escalating the matter to NHS England.
    Mr Hoskins’ tweet on Sunday, which has since been deleted, said: “What a day, no gowns NHS Supply Chain. Rang every number escalated to NHS England, just got message back — no stock, can’t help, can send you a PPE pack. Losing the will to live, god help us all.”
    Read full story (paywalled)
    Source: HSJ, 30 March 2020
  16. Patient Safety Learning
    A group of 95 people who developed health problems or lost relatives as a result of rare side-effects of the Oxford-AstraZeneca Covid-19 vaccine say they have been let down by the "out-of-date" government payment scheme.
    One woman whose fiancé died after the jab was awarded £120,000 this week.
    BBC News has since learned two more people have been told they will receive payments. But many more are still waiting for their cases to be assessed, despite some having final death certificates meaning senior doctors and lawyers have concluded the vaccine caused their loved one's death.
    As of May, more than 1,300 claims had been made to the Vaccine Damage Payment Scheme (VDPS) but only 20 referred for medical assessment.
    Meanwhile, some fear their genuine but rare cases are being drowned out by a flurry of people making unproven claims about vaccine damage online.
    Claire Hibbs was unable to work for a year after developing vaccine-induced immune thrombotic thrombocytopenia (VITT) and struggles with chronic fatigue, migraines and brain fog and fears her job could be at risk - but believes she will not be considered 60% disabled.
    Like others in the group, she has been upset by suggestions she might be opposed to vaccines - "it's a pro-vaccination campaign," Ms Moore says.
    But Ms Hibbs acknowledges false claims about damage from Covid vaccines have been widely circulated online - and research suggests such claims can increase vaccine hesitancy and put people's lives at risk.
    Members of the group, Vaccine, Injured, Bereaved UK (VIB UK) have all received official confirmation of a link to the vaccine. But underneath many of its factual posts, other accounts share reams of false and misleading claims about the vaccine
    Read full story
    Source: BBC News, 23 June 2022
  17. Patient Safety Learning
    England’s most senior nurse has called on the NHS’ million-plus frontline workers to protect themselves and their patients this year by taking up their free flu jab.
    Ruth May, the Chief Nursing Officer for England, is spearheading this year’s drive to ensure that as many NHS staff as possible get vaccinated against seasonal flu – meaning they are both less likely to need time off over the busy winter period, and less likely to pass on the virus to vulnerable patients.
    Since September, hospitals and other healthcare settings across the country have been laying on special activities designed to highlight the importance of the flu vaccine, and celebrate those staff who choose to protect themselves and their patients. A record 70% of doctors, nurses, midwives and other NHS staff who have direct contact with patients took up the vaccine through their employer last year, with most local NHS employers achieving 75% or higher.
    Ruth has been joined in writing an open letter to NHS staff by other heads of professions like the NHS National Medical Director, Professor Stephen Powis, Chief Allied Health Professions Officer, Suzanne Rastrick, Chief Midwifery Officer, Professor Jacqueline Dunkley-Bent, and Chief Pharmaceutical Officer, Dr Keith Ridge. In it they urge every member of the NHS’ growing frontline workforce to work together to achieve even higher level of coverage this year.
    Read full story
    Source: NHS England, 25 November 2019
  18. 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
  19. Patient Safety Learning
    Several patients were harmed after leaders at an acute trust failed to act on multiple concerns being raised about a surgeon, documents obtained by HSJ suggest.
    The documents reveal a catalogue of governance and safety concerns over the trauma and orthopaedics department at University Hospitals of Morecambe Bay Foundation Trust in the last three years.
    They include an external review which described the process for investigating clinical incidents as akin to “marking your own homework” and found the T&O department at Royal Lancaster Infirmary driven by “internecine squabbles”.
    It comes as the trust, which is widely known for a patient safety scandal within its maternity department, also faces a major investigation into whistleblowing concerns over its urology services.
    Read full story (paywalled)
    Source: HSJ, 17 November 2020
  20. Patient Safety Learning
    For too long, medicine has been a cult that deifies workaholism and mocks those who “fuss” about sleep, say Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Head of Research and Development at University Hospital of Wales, and Peter Brindley, Professor of Critical Care Medicine, Medical Ethics, Anesthesiology at the University of Alberta, Canada.  But we know that lack of sleep kills. Data have consistently shown how it kills slowly and silently by increasing the likelihood of cancer, heart disease, immunosuppression and weight gain. Poor sleep also kills suddenly and loudly through motor vehicle crashes and workplace trauma. More and better sleep is needed for all but the question is do we care enough to do the right thing? 
    Regardless of whether insomnia is limited to medicine or is, instead, a society wide issue, we can likely all agree that we need a cultural shift. This starts by senior folks speaking up and standing side by side with junior colleagues. We should not, cannot, and need not stand by as doctors work hours that we would never condone for pilots or bus drivers. Lessons must be heeded. Fortunately, these are lessons that we have known for decades. Patient safety matters, and so does practitioner safety. 
    Read full story
    Source: BMJ Opinion, 28 July 2019
  21. Patient Safety Learning
    Relatives of patients who died after receiving "dangerous" levels of painkillers at Gosport War Memorial Hospital have called for new inquests. 
    An inquiry found 456 patients died after being given opiate drugs at the hospital between 1987 and 2001, but no charges have ever been brought.
    Four families told the BBC they have requested judge-led "Hillsborough-style" hearings with a jury. The Attorney General's Office said it was reviewing the application.
    Police began a fresh inquiry in 2019 into 700 deaths after the Gosport Independent Review Panel found there was a "disregard for human life" at the hospital in Hampshire.
    Coroner-led inquests in 2009 found drugs administered at the hospital contributed to five deaths.
    However, lawyers representing some of the families told the BBC more wide-ranging inquests similar to those that examined the events of the Hillsborough disaster should be undertaken.
    Read full story
    Source: BBC News, 5 February 2021
  24. Patient Safety Learning
    The NHS and the national medical regulator could face legal action over the shortage of intravenous feed supplies for hundreds of UK patients, HSJ has learned. 
    The law firm acting for more than a dozen patients affected by the shortage of feed supplies has confirmed to HSJ it has been instructed to take action against NHS England, the Department of Health and Social Care, the Medicines and Healthcare products Regulatory Agency and the company responsible for producing the feed, Calea. 
    Since June, hundreds of patients who rely on IV feed known as total parenteral nutrition have gone without deliveries of their bespoke feed. More than 40 people have been admitted to hospital as a result.
    Read full story (paywalled)
    Source: HSJ, 29 August 2019
  25. Patient Safety Learning
    Mother Natalie Deviren was concerned when her two-year-old daughter Myla  awoke in the night crying with a restlessness and sickness familiar to all parents. Natalie was slightly alarmed, however, because at times her child seemed breathless.
    She consulted an online NHS symptom checker. Myla had been vomiting. Her lips were not their normal colour. And her breathing was rapid. The symptom checker recommended a hospital visit, but suggested she check first with NHS 111, the helpline for urgent medical help. To her bitter regret, Natalie followed the advice.
    She spoke for 40 minutes to two advisers, but they and their software failed to recognise a life-threatening situation with “red flag” symptoms, including rapid breathing and possible bile in the vomit.
    Myla died from an intestinal blockage the next day and could have survived with treatment.
    The two calls to NHS 111 before the referral to the out-of-hours service were audited. Both failed the required standards, but Natalie was told that the first adviser and the out-of-hours nurse had since been promoted. She discovered at Myla’s inquest that “action plans” to prevent future deaths had not been fully implemented. The coroner recommended that NHS 111 have a paediatric clinician available at all times.
    In her witness statement at her daughter’s inquest in July, Natalie said: “You’re just left with soul-destroying sadness. It is existing with a never-ending ache in your heart. The pure joy she brought to our family is indescribable.”
    Read full story
    Source: The Times, 5 January 2020
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