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Patient Safety Learning

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  1. 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
  2. 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
  3. Patient Safety Learning
    Nearly 70,000 patients are injured while receiving care in Ontario's hospitals each year, the province's auditor general said Wednesday, calling for immediate government action to help reduce that number.
    In her 2019 annual report, Bonnie Lysyk said her team's audits of acute-care centres found that six in every 100 patients treated and discharged from provincial hospitals were harmed during care.
    "Each year, Ontario hospitals discharge one million people," Lysyk said. "Of those, about 67,000 people were harmed during their hospital stay."
    The audit found that hospitals are currently not required to report to the Ministry of Health so-called "never-events" — a medical error that should never happen, such as leaving a foreign object inside a patient.
    Lysyk said her team visited six of the 13 hospitals that track "never-events," and found that 214 such incidents had occurred since 2015.
    Ontario's rates of patient harm are the second-highest in Canada, after Nova Scotia.
    Read full story
    Source: Niagara Falls Review, 5 December 2019
  4. 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
  5. Patient Safety Learning
    Stakeholders from across various sectors in Australia attended a medicine safety forum convened in Canberra on Monday.
    Held by the Consumers Health Forum of Australia (CHF), Pharmaceutical Society of Australia (PSA), the Society of Hospital Pharmacists of Australia (SHPA), NPS MedicineWise and academic partners Monash University and University of Sydney, the forum challenged participants to ‘think differently’ on the safe use of medicines in Australia.
    This included brainstorming on what success in improving medicine safety would look like in 10 years.
    “Medicine safety is a priority for us all and we each have a role to play,” PSA National President Associate Professor Chris Freeman said. “It was inspiring to see the sector work together today to proactively identify those measures we can cooperatively pursue to make a real difference and protect patients.”
    Read full story
    Source: AJP.com.au
  6. Patient Safety Learning
    Several mental health trusts have reported spikes in incidents of physical restraint or seclusion on patients, driven by COVID-19 restrictions, HSJ has learned.
    Concerns have been raised nationally about the potential for incidents to increase during the pandemic, due to temporary measures which have had to be introduced such as visiting restrictions and communication difficulties due to personal protective equipment.
    Read full story
    Source: HSJ, 5 June 2020
  7. Patient Safety Learning
    Those harmed by the NHS will “have to pay again by losing access to justice” as a result of government plans to introduce fixed costs, campaigners have claimed.
    The Department of Health & Social Care has published long-awaited proposals for fixed recoverable costs for fast-track cases, and significantly chose to set the fees at levels recommended by defendant representatives, rather than higher ones proposed by the claimant side.
    Peter Walsh, chief executive of Action against Medical Accidents (AvMA), noted that the government consulted on similar proposals in 2017 and received a thumbs down from the majority of respondents.
    He said: “It is shocking that the government is still pushing to bring in these illogical and potentially unfair proposals rather than looking at the root causes of high costs and addressing them…
    “The government seems to have ignored the fact that the likely effect of these proposals would be that many people whose lives have been devastated by perfectly avoidable, negligent treatment will not be able to challenge denials or get access to justice.
    “In effect, the very people that the NHS has harmed through lapses in patient safety will have to pay again by losing access to justice. If lawyers are unable to claim for time they spend overcoming denials of liability, injured people will not be able to get legal representation.”
    Mr Walsh argued that the best way to save the NHS money was to improve patient safety to prevent these incidents in the first place, “and when mistakes do happen investigate them properly and make early, fair and appropriate offers of compensation without costly litigation”.
    Read full story
    Source: Legal Futures, 1 February 2022
  8. Patient Safety Learning
    The Care Quality Commission (CQC) has rated six mental health hospitals “inadequate”, just months after describing them as either “good” or “outstanding”, since the Whorlton Hall scandal was revealed.
    HSJ analysis shows that of the 13 mental health hospitals admitting people with learning disabilities or autism which have been rated “inadequate” by the CQC since May this year, six of them dropped at least two ratings in a short space of time. The six hospitals which dropped at least two ratings include Whorlton Hall — the County Durham hospital closed following a BBC Panorama report in May showing residents being mistreated — which the CQC rated as “good” in December 2017 before revising this to “inadequate” in May.
    The BBC investigation prompted the CQC to investigate all similar mental health hospitals run by Cygnet, which took over the running of Whorlton Hall in January 2019. 
    Cygnet Newbus Grange in Darlington — which was rated “outstanding” in a report published in February 2019 – was judged “inadequate” by September, while Cygnet Acer Clinic in Chesterfield fell from “good” in November 2018 to “inadequate’ in a report published 12 months later.
    The other three hospitals were the Breightmet Centre for Autism in Bolton, Kneesworth House in Hertfordshire and The Woodhouse Independent Hospital in Staffordshire.
    It comes as the CQC prepares to publish independent reports on its role in relation to the Whorlton Hall scandal. NHS England — one of the commissioners, along with local authorities and clinical commissioning groups, of learning disability inpatient care — also last month initiated a “taskforce” on the issue.
    The CQC has acknowledged it needed to “strengthen” its assessments of this type of care and said it had begun to do so, and was reviewing them further “from a human rights perspective”.
    Read full story (paywalled)
    Source: HSJ, 2 December 2019
  9. Patient Safety Learning
    Experts have warned hundreds of “hidden” children who rely on machines to help them breathe at home are at significant risk of harm due to staff shortages, poor equipment and a lack of training.
    The number of children who rely on long-term ventilation is rising but new research has shown the dangers they face with more than 220 safety incidents reported to the NHS between 2013 and 2017.
    In more than 40% of incidents the child came to harm, with two needing CPR after their hearts stopped. Other children had to have emergency treatment or were rushed back to hospital.
    Many parents reported concerns with the skills of staff looking after their children or reported paid carers falling asleep while caring for their child. Families reported having to cover multiple night shifts due to staff shortages, while also having to care for their child during the day. Other patient safety incidents including broken or faulty equipment or information on packaging that did not match the item or incorrect equipment being delivered.
    Consultant Emily Harrop, who led the study, said it was “easy for the plight of individual complex children to slip down the agenda”.
    She warned: “This is a very hidden group of very vulnerable children who are at risk without investment in staffing, access to training and good communication."
    Read full story
    Source: The Independent, 18 December 2019
  10. Patient Safety Learning
    The daughter of a man with dementia who died after being pushed by another patient in a care facility, has said her family has been let down by authorities.
    John O'Reilly died a week after sustaining a head injury at a dementia care unit in County Armagh. The 83-year-old was pushed twice by the same patient in the days leading up to the fatal incident. His family were not made aware of this until after his death.
    On 4 December 2018, Mr O'Reilly was pushed by another dementia patient causing him to hit his head off a wall. His family have said he was pushed with such force that it left a dent in the wall. He was admitted to Craigavon Area Hospital with severe head injuries and died a week later.
    Last week, an inquest heard that the dementia patient who pushed Mr O'Reilly had a history of aggressive behaviour linked to dementia.
    The Southern Trust is carrying out as Serious Adverse Incident (SAI) investigation into Mr O'Reilly's death.
    Maureen McGleenon said: "Our experience of the SAI process has been dreadful. In our view it allows the trust to park the fact that something catastrophic has happened to a family. We were told it would be a 12-week process. It's over a year now and we've expended so much energy trying to figure out this process and find things out for ourselves."
    She added: "The system just knocks you down and makes you want to give up."
    "We'll never get over what happened to dad and we can't give up on trying to understand it."
    Read full story
    Source: BBC News, 20 January 2020
  12. Patient Safety Learning
    The procurement of digital tools to support online primary care services during the coronavirus outbreak are to be fast-tracked for providers who don’t have the resources.
    In a letter sent to primary care providers and commissioners, GP surgeries were told to move to a triage-first model of care as soon as possible as the NHS bolsters its response to COVID-19.
    The letter, sent by medical director for primary care, Nikita Kanani, and director of primary care strategy and NHS contracts, Ed Waller, states practices and commissioners should promote online consultation services where they are in place or “rapidly procure” them.
    “Rapid procurement for those practices that do not currently have an online consultation solution will be supported through a national bundled procurement,” wrote in the letter.
    Read full story
    Source: Digital Health, 30 March 2020
  13. Patient Safety Learning
    More than a third of critical care units in the East of England are either at or have exceeded their maximum surge capacity, information leaked to HSJ reveals, and all but one are above their normal capacity.
    Data from the region’s critical care network shows that as of 11 January, seven of the region’s 19 critical care units were either at 100% of, or had exceeded, what is known as ”maximum safe surge” capacity. This represents the limit of safe care, mostly based on available staffing levels. The units have opened more beds, but they require dilution of normal staffing levels.
    Across the East of England, 482 of the region’s current 491 intensive care beds, after the opening of surge capacity, were occupied. This included 390 patients in intensive care with confirmed covid-19, six with suspected covid and 86 non-covid patients.
    It gives a regional occupancy rate of 91 per cent against total “safe surge” capacity.
    Published government figures show the rapid increase in demand for intensive care in the East of England in the last two weeks — the number of patients with covid in mechanical ventilation beds is more than double what it was just after Christmas.
    Read full story (paywalled)
    Source: HSJ, 11 January 2021
  14. Patient Safety Learning
    Children’s cancer services in south London are to be reconfigured after a new review confirmed they represented an “inherent geographical risk to patient safety” — following HSJ revelations last year of how serious concerns had been “buried” by senior leaders.
    Sir Mike Richards’ independent review was commissioned after HSJ revealed a 2015 report linking fragmented London services to poor quality care had not been addressed, and clinicians were facing pressure to soften recommendations which would have required them to change.
    The review, published in conjunction with Thursday’s NHS England board meeting, recommended services at two sites should be redesigned as soon as possible to improve patient experience.
    Read full story (paywalled)
    Source: HSJ, 31 January 2020
  15. Patient Safety Learning
    Lawyers have begun legal action on behalf of 200 UK women against the makers of a sterilisation device, after claims of illness and pain.
    The device, a small coil called Essure, was implanted to prevent pregnancies.
    Manufacturer Bayer has already set aside more than $1.6bn (£1.2bn) to settle claims from almost 40,000 women in the US. It has withdrawn the device from the market for commercial reasons but says it stands by its safety and efficacy.
    The metal coil was inserted into the fallopian tube to cause scarring, blocking the tube and preventing pregnancy. 
    Introduced in 2002, it was promoted as an easy, non-surgical procedure - a new era in sterilisation. But many women who had the device fitted have now either had hysterectomies or are waiting for procedures to remove the device.
    Tracey Pitcher, who lives in Hampshire, felt she had completed her family and did not want any more children.
    Her doctor strongly encouraged her to have an Essure device fitted, she says. But after it had been, she began to feel very unwell.
    "I just started to have heavy periods, migraines, which I had only ever had when I was pregnant so they were hormonal," she says. "My back was so painful I'd wake up crying in the middle of the night with pains in my hips and my back."
    Tracey says she battled to persuade doctors to take her symptoms seriously. But the only information she received was from a Facebook group.
    "... there's nobody there, there's no support apart from people that we've found ourselves, no-one will listen, because it's just 'women's things'."
    Read full story
    Source: BBC News, 15 November 2020
  16. Patient Safety Learning
    A coroner has criticised an NHS trust for “suboptimal care” and “missed opportunities” in the treatment of 10 patients with cancer at a urology department where relationships were “dysfunctional.”
    Coroner Penelope Schofield said that all 10 had died of natural causes but that missed opportunities, suboptimal care, and in three cases “neglect” had contributed to the deaths.
    The patients, who died from prostate or bladder cancer from 2006 to 2015, were under the care of Paul Miller, a consultant urologist at East Surrey Hospital in Redhill. 
    Read full story (paywalled)
    Source: BMJ, 25 October 2019
  17. Patient Safety Learning
    Hospital bosses have been accused of launching a witch hunt to find a whistleblower who told a widower about blunders in the treatment his wife received.
    The row emerged as an inquest began into the death of Susan Warby who died five weeks after bowel surgery. The 57-year-old died at West Suffolk Hospital in Bury St Edmunds after a series of complications in her treatment.
    Her family received an anonymous letter after her death highlighting errors in her surgery, the inquest in Ipswich heard, and both Suffolk Police and the hospital launched investigations. These investigations confirmed that there had been issues around an arterial line fitted to Ms Warby during surgery, Suffolk’s senior coroner Nigel Parsley said.
    Doctors were reportedly asked for fingerprints as part of the hospital’s investigation, with an official from trade union Unison describing the investigation as a “witch hunt” designed to identify the whistleblower who revealed the blunders.
    Read full story
    Source: The Independent, 17 January 2020
  18. Patient Safety Learning
    A double amputee suffered fatal pressure sores caused by "gross and obvious failings" in her hospital treatment.
    Janet Prince, from Nottingham, developed the sores after being admitted to Queen's Medical Centre (QMC) in July 2017. The 80-year-old died in January 2019.
    Assistant Coroner Gordon Clow issued a prevention of future deaths report to Nottingham University Hospitals NHS Trust (NUH).
    Nottingham Coroner's Court had heard Ms Prince was taken to QMC in Nottingham with internal bleeding on 15 July 2017. The patient was left on a trolley in the emergency department for nine hours and even though she and daughter Emma Thirlwall said she needed to be given a specialist mattress, she was not given one.
    "No specific measures of any kind were implemented during that period of more than nine hours to reduce the risk of pressure damage, even though it should have been easily apparent to those treating her that [she] needed such measures to be in place," Mr Clow said.
    Ms Prince was later transferred to different wards, but a specialist mattress was only provided for her a few days before she was discharged on 9 August, by which time Mr Clow said her wounds "had progressed to the most serious form of pressure ulcer (stage four) including a wound with exposed bone".
    Mr Clow said there were "serious failings" over finding an appropriate mattress and other aspects of her care while at the QMC, including "a gross failure" to prevent Ms Prince's open wounds coming into contact with faeces.
    Mr Clow said the immediate cause of her death was "severe pressure ulcers", with bronchopneumonia a contributory factor. Recording a death by "natural causes, contributed to by neglect", he said he was "troubled by the lack of evidence" of any changes to wound management at NUH.
    NUH medical director Keith Girling apologised for the failings in Ms Prince's care, claiming the trust had "learnt a number of significant lessons from this very tragic case".
    Read full story
    Source: BBC News, 14 February 2020
     
  19. Patient Safety Learning
    Five NHS trusts in the South West have been ordered to make immediate improvements after the death of a 20-year-old prisoner who needed healthcare.
    Lewis Francis was arrested in Wells, Somerset, in 2017 after stabbing his mother while “acutely psychotic” and taken into custody. Although his condition mandated a transfer to a medium secure mental health hospital, there was “no mechanism” in place to move Mr Francis and he was taken to prison, where he died by suicide two days later, according to a coroner.
    Contributory factors to his death included “insufficient collaboration, communication and ownership between and within organisations… together with insufficient knowledge of… the Mental Health Act,” according to Nicholas Rheinberg, the assistant coroner for Exeter and Greater Devon.
    In a Prevention of Future Deaths report, Mr Rheinberg said a memorandum of understanding was in place for the transfer of “mentally ill prisoners direct from police custody” in the West Midlands, and he called on the South West Provider Collaborative to agree a similar deal with “relevant organisations and agencies”.
    Read full story (paywalled)
    Source: HSJ, 14 July 2020
  20. Patient Safety Learning
    A doctor and mother of two with just months left to live has warned of a “hidden epidemic” of asbestos-related cancers among NHS staff and patients because hospitals have failed to properly handle the toxic material.
    Kate Richmond, 44, has spoken out to raise awareness after she won a legal case against the NHS for negligently exposing her to asbestos while she was working as a medical student and junior doctor.
    An investigation by The Independent has learnt there have been 13 prosecutions linked to NHS breaches of regulations for the handling of asbestos since 2010, while 381 compensation claims have been made by NHS staff for work-related diseases, including exposure to asbestos, since 2013, costing the health service more than £26m.
    According to data from the Health and Safety Executive, between 2011 and 2017, a total of 128 people working in health and social care roles died from mesothelioma, the same asbestos-related cancer which is killing Kate Richmond.
    She described how maintenance staff removed asbestos ceiling tiles with no protective measures, allowing dust and debris to fall on to wards where patients were in their beds and staff were working. Managers at the Walsgrave Hospital in Coventry failed to heed warnings by workers that they were putting people at risk.
    Read full story
    Source: The Independent, 9 February 2020
  21. Patient Safety Learning
    Bereaved families have been left feeling like their efforts to improve patient safety have been ‘in vain’ as progress of a government programme instigated by Jeremy Hunt appears to have ‘stalled’.
    The Learning from Deaths programme board, which was set up in 2017 to develop guidance for trusts working with families on investigations of deaths, has not met since June 2019.
    Josephine Ocloo and David Smith, two bereaved family members who were on the board, have written to HSJ, saying the programme’s progress has “stalled”.
    They added many of the issues it was set up to consider have not yet been addressed, including the need for a national inquiry into unresolved historical cases, the independence of the NHS’ investigatory systems, lack of effectiveness of the duty of candour, and the disproportionate impact on ethnic minorities and those with mental ill-health or learning disabilities.
    They said: “We now have serious concerns that what these families went through [in November 2017] in recalling — and effectively reliving — their experiences, in order to ensure the terrible things that happened to them could not happen to others, was in vain…
    “If [the issues] are not to be addressed by the new board, the families will have every right to feel betrayed and to feel as if they have been used as pawns in a political game. Once again, harmed and let down by a system that has used us and then cast us aside.”
    Read full story (paywalled)
    Source: HSJ, 26 February 2021
  22. Patient Safety Learning
    Incoming Health Education England chief executive Navina Evans said the momentum created by the death of George Floyd and the Black Lives Matter movement meant there was now increased “pressure on white leaders” to act on racism and discrimination in the service.
    Dr Evans praised a letter written by Birmingham and Solihull Mental Health Foundation Trust chief executive Roisin Fallon-Williams, in which she admitted to being “culpable” and “complicit” in failing to fully understand the inequality and discrimination faced by people with black, Asian or other minority ethnic backgrounds.
    “That was great to see, and as you can see from the reactions to her letter people were really, really pleased to have it acknowledged,” she said.
    However, Dr Evans added: “As well as that [acknowledgement] there needs to be action”.
    Read full story
    Source: HSJ, 22 June 2020
  23. Patient Safety Learning
    The medical device complaint management market is experiencing significant growth due to the increasing focus on patient safety and regulatory compliance. As medical devices become more complex and the regulations governing them become more stringent, it has become essential for manufacturers to have effective complaint management systems in place to ensure the safety and satisfaction of their customers.
    The global medical device complaint management market is expected to grow at a CAGR of 6.3% from 2021 to 2026. 
    One of the key factors driving the growth of the medical device complaint management market is the increasing emphasis on patient safety. In recent years, there has been a growing awareness of the potential risks associated with medical devices, and patients are increasingly demanding higher levels of safety and quality. This has led to a greater focus on complaint management among medical device manufacturers, who are now investing in advanced complaint handling systems to ensure that they are able to identify and address issues before they become major problems.
    Read full story
    Source: Digital Journal, 20 April 2023
  24. Patient Safety Learning
    In a report published today, AvMA, the charity Action Against Medical Accidents, reveals serious delays in NHS trusts implementing patient safety alerts, which are one of the main ways in which the NHS seeks to prevent known patient safety risks harming or killing patients.
    The report, authored by Dr David Cousins, former head of safe medication practice at the National Patient Safety Agency, NHS England and NHS Improvement, identifies serious problems with the system of issuing patient safety alerts and monitoring compliance with them. Compliance with alerts issued under the now abolished National Patient Safety Agency and NHS England are no longer monitored – even though patient safety incidents continue to be reported to the NHS National Reporting and Learning System.
    David said: “The NHS is losing it memory concerning preventable harms to patients. Important known risks to patient safety are being ignored by the NHS. The National Reporting and Learning System, the NHS Strategy and new format patient safety alerts, all managed by NHS Improvement, now ignore the majority of ‘known/wicked harms’ which have been the subject of patient safety alerts in the past and have now been archived."
    “Implementation of guidance in new Patient Safety Alerts can be delayed, for years in some cases. The Care Quality Commission that inspects NHS provider organisations also no longer appear to check that safeguards to major risks, recommended in patient safety alerts, have been implemented, or continue to be implemented, as part of their NHS inspections.
    Read full story
     
    Source: AvMA, 28 January 2020
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