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Patient Safety Learning

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  1. Patient Safety Learning
    Elderly people who fall may only be sent an ambulance after they have spent four hours on the floor, and some category 2 calls may not be responded to under one of the first agreements with ambulance unions about next week’s strikes.
    But the deal between South East Coast Ambulance Service and the GMB union will see many union staff continue to work on ambulances and in control rooms – and others may be asked to come off the picket line if operational pressures escalate.
    HSJ has seen the details of the deal – thought to be one of the first agreed before next Wednesday’s strike. Some other trusts are hoping to conclude negotiations shortly, but for several — such as in the North West and London — it is thought no strike “derogations” (exceptions) have so far been agreed, and managers are concerned that unions are resistant. Trusts have been pushing for more cover on strike days – especially around category 2 calls.
    Read full story (paywalled)
    Source: HSJ, 15 December 2022
  2. Patient Safety Learning
    NHS England has ordered the collection of identifiable patient data from hospitals by US data firm Palantir, for a pilot scheme aimed at accelerating recovery of elective waiting lists.
    The regulator has instructed NHS Digital, with which it will merge in January, to use Palantir’s Foundry platform to collect data about patients’ admission, inpatient, discharge and outpatient activity at acute hospitals.
    Identifiable data such as patients’ NHS numbers, date of birth, and postcode will be collected through Palantir’s software. Patients cannot opt out of having their data collected.
    But NHS Digital’s Caldicott Guardian – who is meant to safeguard use of data – has identified “risks” in the pilot and said it needs additional work before it can meet confidentiality requirements.
    The data collected will be “anonymised in accordance with the ICO’s (Information Commissioner’s) Anonymisation Code of Practice”. However, privacy campaigners Medconfidential claimed this code is not fit for purpose and warned that NHS chiefs were making the same mistakes as previous failed efforts to use patient data appropriately.
    Read full story (paywalled)
    Source: HSJ, 1 November 2022
  3. Patient Safety Learning
    NHS England has told integrated care board (ICBs) leaders they must intervene over failures in abortion services in their patches amid “unprecedented demand” for such provision, HSJ has learned.
    NICE guidance states people should be assessed within a week of requesting an abortion, while procedures should take place within a week of assessment.
    However, NHSE said in a letter to ICBs today that “significant service pressures” have driven up waiting times for surgical abortions – approximately 13% of procedures – to three weeks or longer.
    NHSE has told ICBs to work with providers to, by July 2024:
    Respond to cases of “acute service disruption” and instances where rising waiting times risk limiting access to services; Establish referral pathways and procedures to ensure smooth transfers of care between independent and NHS providers when required; Ensure contracts for 2024-25 are sustainable and follow guidance in the NHS payment scheme; and Commission services in a more managed and collaborative way, including coordination of provision locally to bring waiting times in line with NICE standards. Read full story (paywalled)
    Source: HSJ, 12 March 2024
  4. Patient Safety Learning
    A high-profile shift to admitting patients from A&E to wards irrespective of bed capacity has ‘turned the dial’ for an acute trust’s emergency care, its chief executive has told HSJ.
    Since introducing the model in July last year North Bristol Trust has seen a significant improvement in its performance against the national target, with the number of patients seen within four hours rising from 51% to 72% in August 2023 – with a peak of 80% in April 2023.
    The model attracted interest from NHS England last year, as well as some concern from the Nuffield Trust over patient safety – but NBT CEO Maria Kane said the trust was “happy, on balance” with the system.
    She said the model “won’t be for everyone and we never claimed it would be” but she added: “Engendering whole hospital conversations about the principles of flow and understanding of [the emergency department] is something we could all do.”
    Read full story (paywalled)
    Source: HSJ, 8 November 2023
  5. Patient Safety Learning
    The cost of living squeeze is a significant factor in some stillbirths, according to case reviews carried out in one of England’s most deprived areas.
    The review was undertaken in Bradford last year, and concluded: ”the current financial crisis is impacting on the ability of some women to attend essential antenatal appointments”. Missing these appointments was a factor in a range of maternity safety events, including stillbirths, it said. 
    The researchers are now calling for new national funding to help ensure expectant parents do not miss important appointments because they cannot afford to attend.
    The research findings include:
    ‘Did not attend’ rates increased due to lack of funds for transport to antenatal appointments; “Lack of credit on phones prevented communication between women and maternity services, for example, making [them] unable to rearrange scans or appointments”; Wide spread incidence of “digital poverty, [for example] a lady with type 1 [diabetes] was unable to monitor her glycaemic control over night due to only having one phone charger in the house”; and “Families with babies on a neonatal unit going without food in order to finance transport to and from the unit.” Read full story (paywalled)
    Source: HSJ, 25 August 2023
  6. Patient Safety Learning
    An ambulance trust that was the subject of a documentary involving covert filming by an employee has warned staff they could be subject to ‘disciplinary action and even prosecution’ if they take this type of action.
    East of England Ambulance Service Trust sent an all staff email yesterday outlining the potential consequences of filming covertly and reminding staff they must adhere to the trust’s social media and digital guidelines.
    The email, seen by HSJ, followed Channel 4 broadcasting a documentary called Undercover ambulance: NHS Chaos – Dispatches which featured footage filmed covertly by one of the trust’s apprentice emergency technicians, and laid bare the extreme pressures on hospital and ambulance staff.
    The message sent on Thursday by the trust’s interim officer Melissa Dowdeswell, said the apprentice who carried out the filming had since resigned and then set out what support staff could access from the trust if they had been affected by “an incredibly difficult couple of weeks”.
    Read full story (paywalled)
    Source: HSJ, 17 March 2023
  7. Patient Safety Learning
    Rishi Sunak’s pledge to cut the NHS waiting list backlog is being threatened by the crumbling concrete crisis as affected hospitals warn they will be forced to shut wards and theatres.
    Hospitals were told they had buildings prone to collapse in 2019 but four years later they are still dealing with the issue.
    In a report last year, West Suffolk NHS Foundation Trust leaders said that work to replace reinforced autoclaved aerated concrete (Raac) in its hospitals would hit general surgery, urology, gynaecology and orthopaedic care.
    Wards have had to close, piling pressure on a crowded A&E as patients can’t be offloaded due to lack of beds, and threatening its ability to hit government targets to reduce waiting lists, it added.
    The warning comes as Sir Keir Starmer used Prime Minister’s Questions to attack Mr Sunak over the crisis. He argued that “the cowboys are running the country” and asked the PM if he was “ashamed” of the scandal caused by 13 years of “botched jobs”.
    Read full story
    Source: The Independent, 6 September 2023
  8. Patient Safety Learning
    Trainee oncologists at a major cancer centre covered clinics and made “critical” decisions without senior supervision, including for cancers they were not trained for, HSJ has revealed.
    A Health Education England (HEE) reviews aid: “The review team was concerned to hear that trainees were still expected to cover clinics where no consultant was present, including clinics relating to tumour sites that they were unfamiliar with.”
    Guy’s and St Thomas’ Foundation Trust’s trainee clinical oncologists felt “they could only approach 50–75% of the consultants for critical decision-making”, the document said.
    The HEE “urgent concern review” report said: “The trainees also reported that there was a continued lack of clear consultant supervision for inpatient areas in clinical oncology, which meant that they were not able to access senior support for decision-making.”
    A trust spokesman said: “We recognise that senior support to the clinical team is a vital part of keeping our patients safe.”
    Read full story (paywalled)
    Source: HSJ, 16 January 2020
  9. Patient Safety Learning
    Senior sources have described a ‘culture battle’ in NHS England’s approach to urgent care recovery after systems were told to carry out “maturity” self-assessments, and appoint “champions” to drive improvements.
    Systems were last week told by NHSE to ”self assess” their compliance against key asks in the UEC recovery plan, and asked to nominate urgent care “recovery champions” to “create a community, close to the front line, who can help drive improvement” in emergency care.
    The “champions” and self-assessments are part of a new “universal offer” of support being drawn up by NHSE under its scheme for urgent care recovery, in which Integrated Care Boards are also being placed in “tiers” of intervention.
    It is the first project carried out under NHSE’s new service improvement banner, called “NHS Impact” or “improving patient care together”, which was established after an internal review recommended it should focus on a “small number of shared national priorities”.
    Read full story (paywalled)
    Source: HSJ, 18 July 2023
  10. Patient Safety Learning
    Bosses at hospitals where police are investigating dozens of deaths have been criticised for “bullying” and fostering a “culture of fear” among staff in a damning review by the Royal College of Surgeons in England.
    The review focused on concerns about patient safety and dysfunctional working practices in the general surgery departments at the Royal Sussex County hospital in Brighton and the Princess Royal hospital in nearby Haywards Heath.
    But the reviewers were so alarmed by reports of harassment, intimidation and mistreatment of whistleblowers that they suggested executives at the University Hospitals Sussex trust may have to be replaced.
    They concluded: “Consideration should be given to the suitability, professionalism and effectiveness of the current executive leadership team, given the concerning reports of bullying.”
    The report comes as Sussex police continue to investigate allegations of medical negligence and cover-up in the general surgery department and neurosurgery department, involving more than 100 patients, including at least 40 deaths, from 2015 to 2021.
    The investigation was prompted by concerns from a general surgeon, Krishna Singh, and a neurosurgeon, Mansoor Foroughi, who lost their jobs at the trust after blowing the whistle over patient safety.
    Read full story
    Source: The Guardian, 6 February 2024
  11. Patient Safety Learning
    The Care Quality Commission (CQC) has raised serious concerns about a major teaching trust’s maternity services and taken action to prevent patients coming to harm.
    The watchdog has imposed conditions on the registration of Nottingham University Hospitals Trust’s maternity and midwifery services at Nottingham City Hospital and Queen’s Medical Centre and rated them “inadequate”. 
    Following an inspection in October, the CQC identified several serious concerns, including leaders lacking the skills to effectively head up the service, a lack of an open culture where staff could raise concerns, and staff failing to complete patient risk assessments or identify women at risk of deterioration. 
    In its findings, the CQC reported how “fragile” staff wanted to escalate their concerns directly to the regulator, particularly around the leadership’s response to the “verbal outcome of the inspection”. The regulator called this “further evidence of the deep-rooted cultural problems” and escalated these concerns directly to trust CEO Tracy Taylor, who would be “personally overseeing the improvement process required”.
    Inspectors also found the service did not have enough staff with the right skills, qualifications and experience to “keep women safe from avoidable harm”.
    The CQC also issued the trust a warning notice over concerns around documenting risk assessments and IT systems. The trust has three months to make improvements. 
    Read full story (paywalled)
    Source: HSJ, 2 December 2020
  12. Patient Safety Learning
    Deliberate attempts were made to “conceal the extent of racial discrimination” at a national NHS agency, according to a report leaked to HSJ.
    A highly critical internal report at NHS Blood and Transplant (NHSBT) also said fewer than half the recommendations made in 2020 by external mediation experts, around issues of racism, had so far been actioned.
    A review conducted by Globis Mediation Group in 2020 found “systemic racism” among management at the agency’s large Colindale site in north London, with ethnic minority staff being “ignored, being viewed as ineligible for promotion and enduring low levels of empathy”.
    It made nine recommendations, including exploring whether similar issues existed at the other 15 NHSBT sites.
    Read full story
    Source: HSJ, 16 March 2023
  13. Patient Safety Learning
    Most nurses warn that staffing levels on their last shift were not sufficient to meet the needs of patients, with some now quitting their jobs, new research reveals.
    A survey of more than 20,000 frontline staff by the Royal College of Nursing (RCN) suggested that only a quarter of shifts had the planned number of registered nurses on duty.
    The RCN said the findings shone a light on the impact of the UK’s nursing staff shortage, warning that nurses were being “driven out” of their profession.
    In her keynote address to the RCN’s annual congress in Glasgow, general secretary Pat Cullen will warn of nurses’ growing concerns over patient safety.
    Four out of five respondents said staffing levels on their last shift were not enough to meet all the needs and dependency of their patients.
    The findings also indicated that only a quarter of shifts had the planned number of registered nurses, a sharp fall from 42% in 2020 and 45% five years ago, said the RCN.
    Ms Cullen will say: “Our new report lays bare the state of health and care services across the UK.
    “It shows the shortages that force you to go even more than the extra mile and that, when the shortages are greatest, you are forced to leave patient care undone.
    Read full story
    Source: The Independent, 6 June 2022
  14. Patient Safety Learning
    A trust director has stepped down after a row with consultants about the leadership culture within her department, HSJ  has learned.
    Pratima Gupta quit as director of women’s services at University Hospitals Birmingham Foundation Trust last week after a group of consultants expressed “no confidence” in her leadership. They claimed there was “intimidating and bullying behaviour” by individual managers.
    However, Ms Gupta said the allegations are untrue, and said she has faced “obstruction at almost every step” from some consultants when trying to improve training and culture within the department.
    Trainee doctors in obstetrics and gynaecology have previously expressed concerns around a lack of support from consultants, with the trust recently receiving a further warning around this from the General Medical Council and Health Education England.
    Read full story (paywalled)
    Source: HSJ, 1 June 2023
  15. Patient Safety Learning
    The NHS has been hit by a shortage of epidural kits to give mothers-to-be, a key form of pain relief during childbirth, as well as the drug that women are offered as an alternative.
    Supplies of epidural kits and the painkiller Remifentanil are now under such pressure that some hospitals cannot offer pregnant women their usual right to choose which one they want to reduce labour pains.
    Anaesthetists have told the Guardian that the simultaneous shortage of both forms of pain management has led to “difficult discussions” with women who had been told during their antenatal care that they would have that choice but were upset to learn that it was not available.
    The disruption to supplies of epidural kits is so acute that NHS Supply Chain (NHSSC), the health service body that ensures hospitals in England and Wales receive regular supplies of drugs and equipment, to ration deliveries to just one week’s worth of stock.
    Childbirth organisations voiced their concern and warned that the disruption to supplies meant some women in labour were already facing long delays before they received pain relief.
    “Offering a choice of options during birth is an integral element of good maternity care, and this includes pain relief. It is concerning that the shortage of epidural kits and Remifentanil could be denying many that right”, said Jo Corfield, the NCT’s head of communications and campaigns.
    “We don’t yet fully understand the impact this shortage is having but we have heard of long waiting times to receive pain relief and epidurals.”
    Read full story
    Source: The Guardian, 7 August 2022
  16. Patient Safety Learning
    A chief executive has compared a lack of investment into mental health estate to ‘institutionalised discrimination’, after no new schemes were accepted on to the ‘40 new hospitals’ programme.
    HSJ revealed that almost 50 capital projects from mental health trusts attempted to win one of the final places on the “new hospitals programme”, but all were taken by new acute schemes.
    Some of the trusts that submitted unsuccessful bids are using buildings which are more than 100 years old and were constructed without modern care practices in mind. Many of the bids raised safety concerns about the current estates.
    Joe Rafferty, chief executive of Mersey Care Foundation Trust, told HSJ: “If there’s been a priority order, mental health has been at the back of the queue.
    “It’s almost a sort of institutionalised discrimination in a way… there is a risk that the system itself is stigmatised or discriminated against mental health patients.
    Read full story (paywalled)
    Source: HSJ, 31 May 2023
  17. Patient Safety Learning
    Next week’s launch of the ‘Wayfinder’ waiting time information service on the NHS App will give patients “disingenuous” and “misleading” information about how long they can expect to wait for care, senior figures close to the project have warned.
    Briefing documents seen by HSJ show the figure displayed to patients will be a mean average of wait times taken from the Waiting List Minimum Data Set and the My Planned Care site.
    However, it was originally intended that the metric displayed would be the time waited by 92% of relevant patients. This is more commonly known as the “9 out of 10” measure.
    Mean waits are likely to be about “half the typical waiting time” measured under the 9 out of 10 metric, according to the waiting list experts consulted by HSJ.
    Ahead of The Wayfinder service’s launch on Tuesday, NHS trusts and integrated care boards have been sent comprehensive information on how to publicise it, including a “lines to take” briefing in case of media inquiries. This mentions the use of an “average” time but does not provider any justification for this approach.
    HSJ’s source said the mean average metric was “the worst one to choose” as it would be providing patients with “disingenuous” information that will leave them disappointed. They added that the 92nd percentile metric would be a “far more realistic” measure “for a greater number of people”.
    They concluded that “using an average” would create false expectations “because in reality nobody will be seen in the amount of time it is saying on the app.”
    Read full story (paywalled)
    Source: HSJ, 26 January 2024
  18. Patient Safety Learning
    Infection control rules in hospitals are ‘now disproportionate to the risks’ posed by covid and should be relaxed, some of the NHS’s most senior leaders have warned.
    The government rules – such as not allowing covid-positive staff to work, and separating out services for covid, non-covid and covid-contact patients – make a big dent in hospital capacity and slows down services.
    Glen Burley, who is chief executive of three Midlands trusts and involved in national-level discussions on elective matters, told HSJ: “Pretty much every pathway has a covid and non-covid route, which slows down flow and staff productivity.
    “There is a growing argument that these rules are now disproportionate to the risks. With covid cases in the community also rising now, we may have to question again the relative risks of continuing to isolate staff.”
    NHS Confederation director of policy Layla McCay told HSJ: “Healthcare leaders are concerned the current [IPC] measures are having a serious knock-on effect on capacity and that the measures in their current form are reducing efficiency and capacity within healthcare settings.
    “We need more clarity on if and how current measures can be safely adjusted so [the NHS] can further increase bed capacity and patient throughput, as well as the ability to transport patients more quickly and efficiently.”
    But NHS Providers, which has previously said relaxing the IPC guidance would not enable a “rapid” increase in the NHS’ capacity to tackle the elective care backlog and could pose significant “risks”, remains more cautious.
    Read full story (paywalled)
    Source: HSJ, 21 March 2022
  19. Patient Safety Learning
    Do-not-resuscitate orders were wrongly allocated to some care home residents during the COVID-19 pandemic, causing potentially avoidable deaths, the first phase of a review by England’s Care Quality Commission (CQC) has found.
    The regulator warned that some of the “inappropriate” do not attempt cardiopulmonary resuscitation (DNACPR) notices applied in the spring may still be in place and called on all care providers to check with the person concerned that they consent.
    The review was prompted by concerns about the blanket application of the orders in care homes in the early part of the pandemic, amid then prevalent fears that NHS hospitals would be overwhelmed.
    The CQC received 40 submissions from the public, mostly about DNACPR orders that had been put in place without consulting with the person or their family. These included reports of all the residents of one care home being given a DNACPR notice, and of the notices routinely being applied to anyone infected with Covid.
    Some people reported that they did not even know a DNACPR order had been placed on their relative until they were quite unwell.
    “There is evidence of unacceptable and inappropriate DNACPRs being made at the start of the pandemic,” the interim report found, adding that the practice may have caused “potentially avoidable death”.
    Read full story
    Source: The Guardian, 3 December 2020
  20. Patient Safety Learning
    Allowing staff enough rest has been ‘the key’ to elective recovery for an acute trust which has the lowest number of 52-week waiters in England, it has said.
    Maidstone and Tunbridge Wells (MTW) Trust currently has just one patient who has waited 52 weeks or more on its lists, compared with a high of 976 at one point in April 2021.
    MTW is one of a handful of trusts with very few long waiters. All are relatively small trusts – and are not regional centres for specialist/tertiary patients – but their 52-week-waiters also represent less than 1% of their total list.
    MTW chief of service for the surgery division Greg Lawton told HSJ its success in tackling long waiters was down to “attention to detail” in tracking each patient, and not expecting staff to run too many extra sessions.
    “Any problems patients are having getting through their pathways are identified early and addressed,” he said. "Treatment had been prioritised on the grounds of clinical need, he added, with cancer treatments still going ahead and cancer targets being met."
    The trust, in the South East, has put on extra operating sessions to clear some of its backlog of patients but these had been limited in number, Dr Lawton said.
    “What we have never done is try to run too many and I think that may be the key. If you try to do too much you will burn staff out,” he said. The trust had “been mindful that staff need a break,” he added. “Morale is very important.”
    Read full story (paywalled)
    Source: HSJ, 16 February 2022
  21. 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
  22. Patient Safety Learning
    In Kisii town, south-west Kenya, a rundown roadside building houses a pharmacy. Like many others in the area, the pharmacy doubles as a clinic.
    Lilian Kemunto (not her real name), a former surgical nurse, set it up after she retired in 2018. She mainly does health check-ups but has also offered female genital mutilation (FGM) services on request.
    Kemunto has performed cuts since the 90s, after receiving training in basic surgical techniques from male colleagues in the local hospital where she worked. She would do the cuts in the hospital at night, but it was risky, she says, because management didn’t approve. “They would tell us: ‘Just do it, but if you’re caught, you’re on your own.’”
    She preferred cutting girls in a private home, in the middle of the night, saying it was much easier: “By 6am, the girls are back in their own homes, like nothing happened.”
    In Kisii county, medicalisation is standard. Two out of three cases of cutting are performed by health practitioners, in contrast to much of the country, where 70% of FGM cases are performed by traditional practitioners.
    Kemunto says she tries to avoid mishaps, and at a minimum requires some anaesthesia, a surgical blade, sterile towels, and cleaning solution to proceed.
    She also claims to use a non-invasive procedure: a small incision of the clitoris that practitioners call a “signature”. Kisii’s FGM practice is considered less severe than other areas, and anti-FGM campaigners are concerned that there’s a growing acceptance of the practice as more safe, hygienic and cosmetic.
    FGM rates in Kenya have gone down significantly over the past decade. The country passed strong laws in 2011, imposed hefty fines on practitioners, and stepped up surveillance and enforcement. But medicalisation is posing a new challenge for the east African nation, which has a 15% medicalisation rate: one of the highest in Africa.
    Earlier this month, Kenyan president William Ruto backed the country’s chief justice who said that FGM “should not be a conversation we are having in Kenya in the 21st century”, and reiterated his administration’s commitment to eradicating the practice.
    Read full story
    Source: The Guardian, 15 December 2022
  23. Patient Safety Learning
    The availability of dialysis equipment used to treat more than a quarter of ventilated COVID-19 patients has reached “critical” levels, HSJ has learned.
    Concerns are growing over an “exceptional shortage” of specialist dialysis machines used to treat intensive care patients with acute kidney failure.
    Although hospitals are able to deploy alternative machines which are not typically used in intensive care, this is logistically challenging and can carry increased risks for patients.
    Read full story
    Source: HSJ, 22 April 2020
  24. Patient Safety Learning
    Long waits in A&E departments may have caused around 30,000 ‘excess deaths’ last year, according to new estimates.
    Using a methodology backed by experts, HSJ analysis of official data has produced an estimate of 29,145 ‘excess deaths’ related to long accident and emergency delays in 2022-23, up from 22,175 in 2021-22, and 9,783 related deaths in 2020-21.
    For the first time, the analysis has also produced estimates of excess mortality related to long A&E delays for every acute trust.
    The data suggests the rate of excess deaths from 2022-23 has so far continued into 2023-24.
    The analysis followed a methodology used in a peer-reviewed study published in the Emergency Medicine Journal, which found delays to hospital admission for patients of more than five hours from time of arrival at A&E were associated with an increase in all-cause mortality within 30 days.
    Data scientist Steve Black, one of the authors of the EMJ study, said: “Long waits in A&E should never happen and 12-hour waits should be something like a never event. They should be intolerable anywhere. If we want to fix them it’s helpful to know which trusts have the worst problems with long waits.”
    Read full story (paywalled)
    Source: HSJ, 7 November 2023
  25. Patient Safety Learning
    There was an “unacceptable delay” and “failure to act with candour” in how a trust responded to a serious risk from staff nitrous oxide exposure, an independent investigation has found.
    Mid and South Essex Foundation Trust found levels of nitrous oxide far above the workplace exposure limit at Basildon Hospital’s maternity unit during routine testing in 2021. However, staff were only notified and a serious incident declared more than a year later.
    The exposure related to a mixture of nitrous oxide and oxygen, commonly known as gas and air, used during births. While short-term exposure is considered safe, prolonged exposure to nitrous oxide could lead to potential health issues.
    Chief executive Matthew Hopkins has apologised, after a report by the Good Governance Institute said: “The inquiry found that there was an unacceptable delay in responding to and mitigating a serious risk that had been reported… As a result of this failure to act on a known risk, midwives and staff members on the maternity unit were exposed to unnecessary risk or potential harm from July 6 2021 to October 2022."
    Read full story (paywalled)
    HSJ, 14 February 2024
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