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Patient Safety Learning

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  1. Patient Safety Learning
    A GP has been struck off the UK medical register after a tribunal found that she dishonestly recorded patients’ temperature, pulse, and other key variables without ever actually measuring them or carrying out a proper examination.
    Kathleen Bilton was an out-of-hours GP at Royal Glamorgan Hospital in south Wales in early 2018 when two complaints arose from patients she had sent home with antibiotic prescriptions. Both were admitted to hospital soon after and diagnosed with sepsis.
    Their medical records showed that Bilton had entered specific figures for their pulse, temperature, respiration, and other variables, but both complainants denied that she had taken such measurements.
    Read full story (paywalled)
    Source: BMJ, 15 October 2019
  2. Patient Safety Learning
    A Covid-19 test can deliver results in less than an hour has been approved under an FDA emergency authorization, marking the first test that clinicians can use at the bedside.
    Cepheid, a Silicon Valley molecular diagnostics company that’s a unit of Danaher Corp., announced Saturday it received an emergency authorisation from the U.S. Food and Drug Administration to use the test, making it the 13th Covid-19 test the agency has allowed on the market as long as the public health emergency exists.
    But it’s the first one that can be used at the point of care, meaning providers don’t have to send patient samples to a separate lab to be processed and then come back to the hospital or provider’s office. Cepheid said it expects to start shipping tests next week.
    “An accurate test delivered close to the patient can be transformative — and help alleviate the pressure that the emergence of the 2019-nCoV outbreak has put on healthcare facilities that need to properly allocate their respiratory isolation resources,” said David Persing, Cepheid Chief Medical and Technology Officer.
    Read full story
    Source: Bloomberg, 21 March 2020
  3. Patient Safety Learning
    People with chronic pain that can’t be explained by other conditions should not be prescribed opioids because they do more harm than good, the medicines watchdog has warned.
    The National Institute for Health and Care Excellence (NICE) has said people should instead be offered group exercise, acupuncture and psychological therapy.
    In new draft guidance, NICE said most of the common medications used for chronic primary pain has little or no evidence to support their use in patients aged over 16.
    Its latest guidance comes amid concerns over the level of opioid use. In September last year a review by Public Health England found 1 in 4 adults have been prescribed addictive medications with half of them taking the drugs for longer than 12 months.
    NICE’s new draft guidance said some antidepressants should be considered for people with chronic primary pain but it said paracetamol, non-steroidal anti-inflammatory drugs such as aspirin and ibuprofen, as well as benzodiazepines or opioids should not be given because of concerns they might do more harm than good.
    Read full story
    Source: The Independent, 4 August 2020
  4. Patient Safety Learning
    COVID-19 vaccines tend to alleviate the symptoms of long Covid, according to a large survey of more than 800 people that suggests mRNA vaccines, in particular, are beneficial.
    Although COVID-19 was initially understood to be a largely respiratory illness from which most would recover within a few weeks, as the pandemic wore on increasing numbers of people reported experiencing symptoms for months on end. There is no consensus definition of the condition of these people who have symptoms ranging from chronic fatigue to organ damage, let alone a standardised treatment plan.
    As vaccines hit the mainstream, concerns arose that vaccination could precipitate relapses or a worsening of symptoms. But conversely, anecdotal reports suggested that vaccines helped some people with long Covid.
    The analysis, which is yet to be peer reviewed, was conducted on the basis of a survey of 812 people (mostly white, female participants) with long Covid in advocacy groups in the UK and internationally who were contacted via social media. The participants (a small proportion of whom also said they had ME/CFS) were asked to wait at least a week after their first dose to avoid their responses conflating with side-effects of the vaccine.
    In general, those who received mRNA vaccines (Pfizer/BioNTech or Moderna) reported more improvements in symptoms, compared with those who got an adenovirus vaccine (Oxford/AstraZeneca). In particular, those who received the Moderna vaccine were more likely to see improvements in symptoms such as fatigue, brain fog and muscle pain, and less likely to report a deterioration, the analysis found.
    Read full story
    Source: The Guardian, 18 May 2021
  5. Patient Safety Learning
    Multiple failings have been found in the Parliamentary Health Service Ombudsman's (PHSO)  investigation into the death of a young woman with anorexia.
    PHSO has admitted to multiple failings in how it handled a three-and-a-half year investigation into the systemic failings by NHS providers in Cambridgeshire and Norfolk which led to the death of Averil Hart in 2012.
    The findings come as a senior coroner in Cambridgeshire investigates whether there are links between the failures in Averil’s care and that of four other women with an eating disorder who were under the care of the same services.
    The PHSO’s failings have been revealed in an internal review, published today, which ruled the regulator’s investigation took too long and should’ve been completed in half the time.
    It also found “insufficient” resource was allocated to the Averil’s investigation, despite staff requesting it, which led to significant delays.
    Read full story
    Source: HSJ, 10 January 2020
  6. Patient Safety Learning
    A GP who gave wrongly dated and misleading medical notes to police inquiring into the death of a 12 year old boy from undiagnosed Addison’s disease has been suspended from the UK medical register for nine months.
    Ryan Morse died in the early hours of 8 December 2012, hours after his mother rang the local Blaenau Gwent surgery twice in a day, reporting high temperature, extreme drowsiness, and involuntary bowel movement. The second time, she spoke to GP Joanne Rudling, telling her that the boy’s genitals had turned black.
    But Rudling failed to check the notes of the first call or give adequate weight to the fact that the mother was calling again, the tribunal found. She failed to obtain an adequate history or reach an appropriate conclusion about the change in genital colour.
    Read full story (paywalled)
    Source: BMJ, 25 November 2019
  7. Patient Safety Learning
    Thousands of bowel cancer cases are being missed due to “unacceptable” testing failures, research in the BMJ shows. 
    The UK research found that some providers carrying out colonoscopies were three times as likely as others not to spot signs of disease. At the worst units, almost one in ten cases which turned out to be bowel cancer were not picked up during the tests, the study led by the University of Leeds found. 
    Researchers said that almost 4,000 more cases could have been prevented or treated sooner had there been better screening over a nine year period tracked. 
    Researcher Roland Valori, Consultant Gastroenterologist from Gloucestershire Hospitals NHS Foundation Trust, said: “We are seeing unacceptable variation in post colonoscopy bowel cancers between providers in the English NHS and this variation in quality needs to be addressed urgently.” 
    Read full story
    Source: The Telegraph, 2019
  8. Patient Safety Learning
    Hospital bosses at scandal-hit Shrewsbury and Telford Hospital Trust were more concerned with reputation management than addressing patient safety concerns in its maternity department, according to a new NHS investigation.
    Families harmed by poor care at the trust have called for chairman Ben Reid to resign after the report by NHS England revealed how senior figures in the trust, including the former chief executive, tried to soften a report into maternity services that raised serious concerns over safety.
    The Royal College of Obstetricians and Gynaecologists (RCOG) report was not published until after the college had agreed to an “unprecedented” addendum report 12 months after its inspection in 2017, that presented the trust in a more positive light.
    When the final report was made public in July 2018 the addendum was placed at the front of the report.
    The original RCOG report warned: “Neonatal and perinatal mortality rates will not improve until areas of poor / substandard care are addressed.”
    Read full story
    Source: The Independent, 22 July 2020
  10. Patient Safety Learning
    Deborah Stanford is one of many women who have received a Boston Scientific implant and suffered complications. She has joined Shine Lawyers’ class action, which was filed today in the Australian Federal Court, to hold the manufacturers to account for the continuous pain she has endured since the Obtryx sling was implanted on 12 September 2012.
    Ms Stanford’s bladder was sitting in the birth canal and the sling was placed, on medical advice, to reposition her bladder.
    “It has been 9 years of suffering."
    “If I knew how hard this was going to be, I never would have gone through it,” said Ms. Stanford.
    Boston Scientific is the third pelvic mesh manufacturer to face a class action over their range of prolapse mesh and incontinence sling implants. Shine Lawyers has filed all three actions against Johnson & Johnson, Ethicon and American Medical Systems (AMS).
    Read full story
    Source: Shine Lawyers, 22 March 2021
  11. Patient Safety Learning
    The number of COVID-19 infections likely to have been acquired in hospital are rising again for the first time in three weeks and their proportion of all cases has reached record levels for the second wave, HSJ can reveal.
    NHS England data covering the week to 6 December (the latest available) shows 1,787 COVID-19 cases were acquired in-hospital – a rise of almost 14% on the week before. The number of hospital-acquired, or “nosocomial”, infections had been falling since the week to 15 November, when 1,794 were recorded.
    This week, hospital acquired covid infections amounted to 21% of the 8,337 new cases which were recorded in hospitals – the highest proportion in the second wave. On 6 December alone, 24% of infections had probably been acquired in hospital rather than the community.
    Read full story (paywalled)
    Source: HSJ, 11 December 2020
  12. Patient Safety Learning
    A trust spent £460,000 on legal fees trying to fight a patient safety whistleblowing case that it lost, it can be revealed.
    An employment tribunal judge rejected the idea that a consultant nephrologist had done anything to bring about her dismissal from Portsmouth Hospitals University Trust.
    Jasna Macanovic was subjected to what the tribunal earlier this year called “a campaign of harassment”, after she warned colleagues that a procedure they were using was harming patients.
    After relationships broke down in the Wessex Kidney Unit, she was referred to a disciplinary panel at which two board members – the former nursing director and the current medical director – offered her a good reference if she would resign. She refused and was dismissed in March 2018. The judge noted the offer was clear evidence that the disciplinary process was a foregone conclusion.
    Read full story
    Source: HSJ, 8 March 2023
  13. Patient Safety Learning
    New rules will mandate trusts to supply references when NHS directors are given a new job, in a bid to stop the so-called “revolving door” for those who have failed.
    Officials at the Department of Health and Social Care are working on the proposal, originally made by Tom Kark QC in his report to the department, published in February, on the fit and proper person test regulations.
    Speaking at Patient Safety Learning's Annual Conference in London yesterday, Mr Kark, said he had been informed earlier this week that government had now accepted his recommendation for mandatory references.
    Read full story (paywalled) 
    Source: HSJ 2 September 2019
  14. Patient Safety Learning
    Digital training should be “embedded” into clinical curricula rather than being “bolted on”, the Chief Executive of ORCHA has said. Liz Ashall-Payne said more needed to be done to ensure appropriate digital training for clinicians or risk a “knowledge gap” forming between current and future staff.
    Dr Sandeep Bansal, Chief Executive of Medic Creations and mentor on the Royal College of GPs innovation mentorship programme, echoed calls for digital training to be incorporated in the medical school curriculum. 
    “Your organisation is only as strong as lowest digitally mature staff member. It is all very well educating our tech-savvy junior doctors, but we must make sure those less au fait with digital advancements are not left behind. That is where patient safety could be put at risk. After all the main purpose of digital innovation is to enhance our ability to care for patients, by enabling more effective, efficient and precise clinical practice.”
    Clive Flashman, Patient Safety Learning's Chief Digital Officer, agreed with the need for clinicians to receive digital training but with a focus on how to quickly evaluate an apps. “What is essential is that all clinicians, not just GPs, have access to advice, tools and support to enable them to prescribe and monitor the effectiveness of apps and digital therapies,” he told Digital Health News.
    Read full story
    Source: Digital Health, 29 October 2019
     
  15. Patient Safety Learning
    If ever there were an industry that could reap the benefits of artificial intelligence (AI), it is healthcare. The adoption of this technology to actually make medicine better is obvious. However, with this adoption comes a slew of ethical issues. With AI, there is always a human consequence beyond the tech storyline.
    Neil Raden suggests there are two storylines to consider: the usefulness of the application, and the ultimate effect, often unintended, on people.
    Read full article
    Source: Diginomica, 19 September 2019
  16. Patient Safety Learning
    A nurse with no qualifications gave a care home resident a fatal dose of the wrong drug, leading to her death before she then tried to cover up her mistake.
    Katherine Hutchinson gave Fiona Jayne Thorne a fatal overdose of a powerful anti-psychotic drug, which was meant for another patient, an inquest heard.
    She then tried to cover up her errors which contributed to the death of the 36-year-old with learning difficulties, Derbyshire Live reported .
    Ms Hutchinson had, at the time, been the nurse in charge at Whitwell Park Care Home, in Whitwell, Derbyshire despite not having any qualifications.
    She gave Miss Thorne clozapine, which had been intended for another resident, on October 6, 2010.
    Instead of owning up to what she did, Ms Hutchinson then tried to cover up her mistake by taking Miss Thorne to bed and leaving her there until she was discovered, Senior Coroner Dr Robert Hunter said.
    Miss Thorne was "found by the care support worker around midnight, when undertaking routine checks on residents”, the inquest heard.
    And then Ms Hutchinson’s mistake was only discovered after an audit was carried out of the medication trolley and a dosage of clozapine was found.
    Read full story
    Source: Mirror, 8 April 2022
  17. Patient Safety Learning
    The Royal College of Obstetricians and Gynaecologists ( (RCOG) has today launched a Race Equality Taskforce to better understand and tackle racial disparities in women’s healthcare and racism within the obstetric and gynaecology workforce.
    Addressing health inequalities is a key priority area for RCOG President Dr Edward Morris, who is co-chairing the Taskforce alongside Dr Ranee Thakar, Vice President of the RCOG, and Dr Christine Ekechi, Consultant Obstetrician & Gynaecologist and RCOG Spokesperson for Racial Equality.
    Statistics show, for example, that black women are five times more likely to die in pregnancy, childbirth or in the six-month postpartum period compared with White women and the risk for Asian women is twice as high.

    During the pandemic, 55% of pregnant women admitted to hospital with coronavirus were from a Black, Asian or other minority ethnic background despite the fact 13% of the UK population identify themselves as BAME.

    It is also clear that there is a significant gap in understanding the factors that result in a higher risk of morbidity and mortality for Black, Asian and other ethnic minority women in the UK.

    The Taskforce will collaborate with groups across healthcare and government as well as individual women to address these concerning trends and will ensure that the work of the RCOG is reflective of its anti-racist agenda.
    Read full story
    Source: RCOG, 15 July 2020
  18. Patient Safety Learning
    A new study shows a quarter of mothers say their choices were not respected during childbirth, with some left with life-changing injuries as a result, despite Britain’s highest judges establishing women should be the primary decision makers during labour five years ago.
    A poll of 1,145 women, carried out by leading pregnancy charity Birthrights and shared exclusively with The Independent, also found that a third said healthcare professionals did not even seek their own opinions on the childbirth process, while 14& said their choices were overruled.
    One woman told The Independent she had been forced to give up her career as a lawyer following what she described as a “violent delivery”, while her baby daughter also sustained serious injuries to her face which can still be seen now – 12 years after she gave birth.
    Birthrights, which campaigns for respectful pregnancy care for women, pointed to the fact half a decade has passed since Nadine Montgomery’s Supreme Court case proved mothers-to-be are the primary decision-makers in their own care yet this is still not the reality for the majority of women.
    Read full story
    Source: The Independent, 3 September 2020
  19. Patient Safety Learning
    NHS Chief Executive Simon Stevens has announced that a new taskforce will be set up to improve current specialist children and young people’s inpatient mental health, autism and learning disability services in England.
    The NHS Long Term Plan sets out an ambitious programme to transform mental health services, autism and learning disability; with a particular focus on boosting community services and reducing the over reliance on inpatient care, with these more intensive services significantly improved and more effectively joined up with schools and councils.
    The NHS Chief Executive said: “This taskforce will place a spotlight on services and care for some of the most vulnerable young people in our society, bringing together families, leading clinicians, charities, and other public bodies to help make these services as effective, safe and supportive as possible for thousands of families."
    “The NHS Long Term Plan lays out a package of measures which will mean more than two million extra children and adults get the mental health care they need and while early intervention to stop ill health escalating is a priority, we are also determined to provide the strongest possible safety net for families living with the most acute conditions.”
    Read full story
    Source: NHS England, 10 October 2019
  20. Patient Safety Learning
    Thirteen trusts are facing billions of pounds of maintenance — in some cases, making it more cost-effective to rebuild the hospital — over ‘significant safety issues’ stemming from outdated construction methods. 
    Reinforced autoclaved aerated concrete planks were used when constructing public sector buildings in the 1960s, 70s and 80s, including a group of prefabricated hospitals under the government’s “Best Buy” building programme. However, RAAC planks used in buildings constructed prior to 1980 have now exceeded their shelf life, meaning affected trusts need to carry out frequent inspections and expensive maintenance.
    For at least three of the affected trusts — Mid Cheshire Hospitals FT, Airedale FT and The Queen Elizabeth Hospital King’s Lynn FT — it would be more cost-effective to build new hospitals than replace the planks in their existing facilities.
    Victoria Pickles, director of corporate affairs at Airedale FT, told HSJ 85% of the trust’s buildings’ floors, roofs and walls comprised RAAC planks, with one ward closing due to the risk.
    Read full story (paywalled)
    Source: HSJ, 3 December 2020
     
  21. Patient Safety Learning
    An independent investigation into working conditions at a unit of the NHS’s blood and organ transplant service has concluded that it is “systemically racist” and “psychologically unsafe.”
    The internal investigation was commissioned in response to numerous complaints from ethnic minority staff working in a unit of NHS Blood and Transplant (NHSBT) in Colindale, north London. The report, carried out by the workplace relations company Globis Mediation Group, concluded that the environment was “toxic” and “dysfunctional.”
    The report found evidence that ethnic minority employees had faced discrimination when applying for jobs and that white candidates had been selected for posts ahead of black applicants who were better qualified. “Recruitment is haphazard, based on race and class and whether a person’s ‘face fits,’” it said.
    “Being ignored, being viewed as ineligible for promotion and enduring low levels of empathy all seem to be normal,” the report noted. “These behaviours have created an environment which is now psychologically unsafe and systemically racist.”
    Chaand Nagpaul, BMA council chair, commented, “This report highlights all too painfully the racial prejudices and discrimination we are seeing across healthcare. We must renew efforts to challenge these behaviours and bring an end to the enduring injustices faced by black people and BAME healthcare workers here in the UK.”
    Read story
    Source: BMJ, 10 June 2020
  22. Patient Safety Learning
    We’re swiftly learning the symptoms of Covid-19 may last longer than previously thought. One in 10 people are reporting a longer tail of symptoms, which exceeds the suggested two-week recovery time.
    It’s thought around 30,000 people in the UK could be impacted by a prolonged version of the illness – what some are calling ‘long covid’. These people are months into their recovery from the virus and still fighting a range of persistent symptoms. In some cases, the symptoms disappear for a while before coming back. In others, they’re gradually improving over time.
    Research from the Covid-19 Symptom Study in the UK, led by Professor Tim Spector of King’s College London, shows after three weeks of first reporting symptoms, a group of people continue to experience fatigue, headaches, coughs, loss of smell, sore throats, delirium and chest pain.
    People with mild cases of the disease are more likely to have a wide range of symptoms that come and go over an extended period, Prof Spector found. And these people are often flying under the radar because they’re not in hospital.
    Those who believe they’ve had ‘long covid’ are now calling on the government to recognise their plight, invest in research and put support in place.
    Read full story
    Source: Huffpost, 2 July 2020
  23. Patient Safety Learning
    NHS England asked an “inadequate” hospital for people with learning disabilities and autism to admit a patient, despite the service having a “voluntary” ban on admissions in place — and shortly before inspectors decided to impose a legal restriction.
    The provider said it was an “exceptional case”, where the individual “had several failed placements”, and had stayed at the hospital — Jeesal Cawston Park in Norfolk — “in the past”. 
    However, it appears to highlight the shortage of good quality accommodation and placements available and pressure on commissioners to make use of “inadequate” facilities.
    Read full story (paywalled)
    Source: HSJ, 21 January 2020
  24. Patient Safety Learning
    Having spent 5 months in a hospital bed, Jame Hale, a disabled poet and essayist, urges us as we go into this election not to forget the damage that’s been done to the NHS – and the individual, human casualties that have resulted. 
    "High-quality staff are not enough if we put them in environments where they cannot do their best", Jame says to the Guardian newspaper. 
    "An NHS in this state is a stain on the country, and an ongoing risk to patient safety. It’s come about because of nine years of persistent underfunding and austerity, which has come on top of PFI hospital-building initiatives that have loaded hospital trusts with unsustainable repayments."
    Read full story
    Source: The Guardian, 7 November 2019
     
  25. Patient Safety Learning
    Nearly 900 children in a Pakistani city have tested positive for HIV after a rogue paediatrician allegedly reused infected syringes.
    About 200 adults have also tested positive for the virus since the epidemic in Ratodero was confirmed in April. But health officials fear the true number affected could be far higher, with less a quarter of city’s 200,000 residents tested so far.
    The outbreak was initially blamed on Dr Muzaffar Ghanghro, a paediatrician who at 16p a visit was one of the cheapest in the small central city. He was arrested and charged with negligence and manslaughter after his patients accused him of frequently reusing syringes on their children.
    Despite an initial investigation by police and health officials concluding Dr Ganghro’s “negligence and carelessness” as the “prime” reason for the outbreak, officials believe he is unlikely to be the sole cause. Visiting health workers often see doctors in Ratodero reusing syringes, while dentists use unsterilised tools in roadside surgeries and barbers use the same razor on various customers, The New York Times reported.
    Read full story
    Source: The Independent, 27 October  2019
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