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Patient Safety Learning

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  1. 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
  2. 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
  3. 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
  4. Patient Safety Learning
    An ambulance trust has been accused of acting like a “criminal gang” and lying to dead patients’ families by an employee who repeatedly warned about paramedics’ mistakes being covered up.
    Paul Calvert, a coroner’s officer whose job was to produce reports on deaths, tried to raise concerns about managers at the North East Ambulance Service (NEAS) for three years before walking out last year on the verge of a breakdown.
    “My life was being made a misery,” said Calvert, who was previously a detective with Northumbria police. “They were basically like a criminal gang. I had tried everything I could to warn the proper authorities about how the service was destroying and concealing evidence meant for the coroner. I spoke to my managers, to human resources, to external auditors. I even made disclosures to the Care Quality Commission and Northumbria police. Nothing was done about it.”
    Despite their denials of a large-scale cover-up of mistakes, the NEAS this year offered Calvert £41,000 as part of a non-disclosure agreement it asked him to sign. One of the clauses meant destroying all the evidence he had collected. Another tried to stop him making any further disclosures to police.
    Reports and witness statements from ambulance staff were not being disclosed to the coroner “on a daily basis”, according to Calvert, amounting to key pieces of evidence relating to deaths being hidden from the public.
    Read full story (paywalled)
    Source: The Times, 29 May 2022
  5. Patient Safety Learning
    A home care worker who did not wear protective equipment may have infected a client with a fatal case of coronavirus during weeks of contradictory government guidance on whether the kit was needed or not, an official investigation has found.
    The government’s confusion about how much protection care workers visiting homes needed is detailed in a report into the death of an unnamed person by the Healthcare Safety Investigation Branch (HSIB), which conducts independent investigations of patient safety concerns in NHS-funded care in England. It was responding to a complaint raised by a member of the public in April.
    The report shows that Public Health England published two contradictory documents that month. One advised care workers making home visits to wear PPE and the other did not mention the need. The contradiction was not cleared up for six weeks.
    The government’s guidance had been a shambles that had placed workers and their vulnerable clients at risk, the policy director at the United Kingdom Homecare Association, Colin Angel, said on Wednesday. The association also accused the government of sidelining its expertise and publishing new guidance with little notice, sometimes late on Friday nights, meaning that it was not always noticed by the people it was intended for.
  6. Patient Safety Learning
    Plans for up to 150 new community diagnostic hubs to tackle the NHS’ ballooning diagnostic waiting lists are included in NHS England ‘blue print plans’ leaked to HSJ.
    The document pointed out the hubs “were highlighted in the phase 3 letter [from Sir Simon Stevens] and will be recommended as part of new service models for diagnostics in the forthcoming [Sir Mike] Richards’ Review of Diagnostics Capacity”.
    It said “at least 150 community diagnostic hubs should be established in the first instance (broadly equivalent to the number of acute hospitals)” although it appears many of these may be temporary facilities.
    The phase 3 letter said systems should mange the “immediate growth in people requiring cancer diagnosis and/or treatment returning to the service by… the development of community diagnostic hubs” among other measures
    The Richards review was commissioned by NHS England in 2019 as it had long been recognised that England has one of the lowest levels in Europe of diagnostic equipment as well as a shortage in facilities and staff. Last month think-tanks warned of significant worsening of cancer outcomes because of the backlog in diagnosis and treatment created by a fall in referrals during the pandemic..."
    Read full story (paywalled)
    Source: HSJ, 4 September 2020
  7. 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
  8. Patient Safety Learning
    In a keynote speech at the Healthtech Alliance on Tuesday, Secretary of State for Health and Social Care, Matt Hancock, stressed how important adopting technology in healthcare is and why he believes that it is vital for the NHS to move into the digital era. 
    “Today I want to set out the future for technology in the NHS and why the techno-pessimists are wrong. Because for any organisation to be the best it possibly can be, rejecting the best possible technology is a mistake.”
    Listing examples from endless paperwork to old systems resulting in wasted blood samples, Hancock highlights why in order to retain staff and see a thriving healthcare, embracing technology must be a priority.
    He also announced a £140m Artificial Intelligence (AI) competition to speed up testing and delivery of potential NHS tools. The competition will cover all stages of the product cycle, to proof of concept to real-world testing to initial adoption in the NHS.
    Examples of AI use currently being trialled were set out in the speech, including using AI to read mammograms, predict and prevent the risk of missed appointments and AI-assisted pathways for same-day chest X-ray triage.
    Tackling the issue of scalability, Hancock said, “Too many good ideas in the NHS never make it past the pilot stage. We need a culture that rewards and incentivises adoption as well as invention.”
    Read full speech
  10. Patient Safety Learning
    Several trust procurement leads have expressed frustration with the government’s response to covid-19, with HSJ being told of shortages of crucial personal protective equipment, unpredictable deliveries and a lack of clarity from the centre
    NHS Supply Chain, which procures common consumables and medical devices for trusts, has been “managing demand” for an increasing number of PPE and infection control products for since the end of February to ensure “continuity of supply”. Some products, like certain polymer aprons, are unavailable altogether because of the increased demand and disrupted supply caused by the covid-19 outbreak. 
    One procurement lead told HSJ: “They aren’t supplying enough, they aren’t fulfilling orders. It’s completely chaotic.” Another said his trust had “just enough to manage for the time being.”
    Read full story (paywalled)
    Source: HSJ, 20 March 2020
  11. Patient Safety Learning
    The high proportion of pregnant women from black and ethnic minority (BAME) groups admitted to hospital with COVID-19 "needs urgent investigation", says a study in the British Medical Journal.
    Out of 427 pregnant women studied between March and April, more than half were from these backgrounds - nearly three times the expected number. Most were admitted late in pregnancy and did not become seriously ill. Although babies can be infected, the researchers said this was "uncommon".
    When other factors such as obesity and age were taken into account, there was still a much higher proportion from ethnic minority groups than expected, the authors said.
    But the explanation for why BAME pregnant women are disproportionately affected by coronavirus is not simple "or easily solved," says Professor Knight, lead author.
    "We have to talk to women themselves, as well as health professionals, to give us more of a clue."
    Gill Walton from the Royal College of Midwives says, "Even before the pandemic, women from black, Asian or ethnic minority backgrounds were more likely to die in and around their pregnancy,"
    She said they were "still at unacceptable risk" and getting help and support to affected communities was crucial. 
    Ms Walton added: "The system is failing them and that has got to change quickly, because they matter, their lives matter and they deserve the best and safest care."
    Read full story
    Source: BBC News, 8 June 2020
  12. Patient Safety Learning
    Endemic ill-health in England’s “left behind” neighbourhoods costs the country almost £30bn a year because people are often too ill to work and die earlier, a report claims.
    The cost of lost productivity results directly from those very deprived areas having much worse health than the rest of the country, according to parliamentarians and academics.
    Experts from the Northern Health Science Alliance (NHSA) have calculated that the economy would grow by that amount if health in those areas was improved to such an extent that local people began to enjoy the same health as those in better-off places.
    The report, by the NHSA and all-party parliamentary group for left behind neighbourhoods (LBNs), highlights the scale of the challenge Boris Johnson faces in meeting his pledge to level up England’s poorest and richest areas.
    “The health of people living in left behind neighbourhoods is considerably worse than the health of people living in the rest of the country,” said Dr Luke Munford, the report’s lead author and a lecturer in health economics at the University of Manchester. “This is true across all measures of health.”
    The report shows rates of obesity, lung conditions, high blood pressure, mental health problems and other diseases are much higher than the national average in the 225 LBNs. This means people there have less “healthy life expectancy” and also shorter lives and thus are less productive over their lifespan than those elsewhere.
    Read full story
    Source: The Guardian, 13 January 2022
  13. Patient Safety Learning
    The pharmaceutical giant Johnson and Johnson has agreed to pay an undisclosed sum to settle a legal action by hundreds of Scottish women who claimed they suffered serious injuries from the company’s pelvic mesh implants.
    The settlement came as four lead cases brought by women who suffered pain and other serious side effects from the implants, made by Johnson and Johnson subsidiary Ethicon, were about to reach court in Edinburgh.
    Read full story (paywalled)
    Source: BMJ, 2 June 2020
  14. Patient Safety Learning
    An acute trust’s record of eight never events in the last six months has raised concerns that quality standards have slipped since it was taken out of special measures.
    The never events occurred at Royal Cornwall Hospitals Trust. They included three wrong site surgeries within the same speciality and an extremely rare incident in which a 30cm (15 inch) wire was left in a cardiology patient.
    Kate Shields, chief executive of the trust, said the incidents have led to a “great deal of soul searching”.
    Prior to the incidents the trust had gone 13 months without recording a never event, and Ms Shield acknowledged that pressure created by the pandemic was likely to have been a contributing factor behind the cluster of never events.
    She stressed that none of the patients affected had suffered physical harm.
    Read full story (paywalled)
    Source: HSJ, 12 November 2020
  15. Patient Safety Learning
    NHS England has shelved priorities on Long Covid and diversity and inclusion – as well as a wide range of other areas – in its latest slimmed down operational planning guidance, HSJ analysis shows.
    NHSE published its planning guidance for 2023-24, which sets the national “must do” asks of trust and integrated care systems, shortly before Christmas.
    HSJ has analysed objectives, targets and asks from the 2022-23 planning guidance which do not appear in the 2023-24 document.
    The measures on which trusts and systems will no longer be held accountable for include improving the service’s black, Asian and minority ethnic disparity ratio by “delivering the six high-impact actions to overhaul recruitment and promotion practices”.
    Another omission from the 2023-24 guidance compared to 2022-23 is a target to increase the number of patients referred to post-Covid services, who are then seen within six weeks of their referral.
    Several requirements on staff have been removed, including to ”continue to support the health and wellbeing of our staff, including through effective health and wellbeing conversations” and ”continued funding of mental health hubs to enable staff access to enhanced occupational health and wellbeing and psychological support”. 
    Read full story (paywalled)
    Source: HSJ, 4 January 2022
  16. Patient Safety Learning
    As part of the NHS Digital Child Health programme, Personal Child Health Records or “Redbook” will receive a digital makeover.

    NHS Digital has considered the limitations of the physical Redbook and decided that digitalisation is the way forward for parents to easily access important health and development information.

    Nurturey has been evolving its product to align with NHS' Digital Child Health programme. It aims to be an app that can make the digital Redbook vision a reality and currently in the process of completing all the necessary integrations and assurances.

    It is hoped that by using smart digital records, parents will be more aware of their child’s health information like weight, dental records, appointments and other developmental milestones.  

    Tushar Srivastava, Founder and CEO of Nurturey, said:

    “Imagine receiving your child's immunisation alert/notification on the phone, clicking on it to book the immunisation appointment with the GP, and then being able to see all relevant immunisations details on the app itself. As a parent myself, I see the huge benefit of being able to manage my child’s health on my fingertips. We are working hard to deliver such powerful features to parents by this summer.”
    Read full story
    Source: National Health Executive, 5 February 2020
  17. Patient Safety Learning
    The BMA has written to the government to call for new legislation to ensure accountability for safe staffing levels and that “individual clinicians are not blamed when the system places them under unmanageable pressure.”
    The call came as the BMA published a year long study looking at the changes needed to improve care of patients and the working lives of doctors in the NHS, alongside a “manifesto for change” outlining all the recommendations.
    Read full story (paywalled)
    Source: BMJ, 13 September 2019
  18. Patient Safety Learning
    An acute trust has been fined £2.5m after pleading guilty to charges of failing to provide safe care after the deaths of two patients.
    The Care Quality Commission brought charges against The Dudley Group Foundation Trust earlier this year over care failings in two separate cases which the regulator said exposed two patients to “significant risk of avoidable harm”.
    The trust pleaded guilty to the charges in July and was fined during a sentencing hearing today.
    The cases, involving 33-year-old mother of six Natalie Billingham, and 14-year-old Kaysie-Jane Bland [also known as Kaysie-Jayne Robinson], were both in 2018 and  related to care at the trust’s Russells Hall Hospital in Dudley.
    Ms Billingham was admitted to Dudley’s Russells Hall Hospital with numbness in her right foot on 28 February 2018 and died on 2 March of organ failure caused by a “time critical” infection.
    The court was told she was initially thought to have a deep vein thrombosis after a three-minute triage that failed to identify "disordered" observations. The hospital then had multiple reasons to reconsider the initial diagnosis, but opportunities for review were "missed or ignored".
    In the case of Kaysie-Jane, who had cerebral palsy, an "early warning score" was inaccurate, meaning a sepsis screening tool was not triggered.
    The CQC said the care both patients received at Russells Hall Hospital was undermined by the Dudley Group’s failure to address known safety failings which the regulator repeatedly raised with the trust in the months before their deaths. The CQC said the trust did not take all reasonable steps to make improvements, despite its intervention. The trust has denied it did not react to the concerns raised. 
    Failings included errors in the hospital’s initial assessments and monitoring of both patients, which hindered the timely escalation of concerns.
    A lawyer acting on behalf of the Dudley Group NHS Foundation Trust had admitted the trust failed to provide treatment in a safe way, resulting in harm, in February and March 2018.
    Read full story (paywalled)
    Source: HSJ, 19 November 2021
  20. Patient Safety Learning
    An epilepsy drug that caused disabilities in thousands of babies after being prescribed to pregnant women could be more dangerous than previously thought.
    Sodium valproate could be triggering genetic changes that mean disabilities are being passed on to second and even third generations, according to the UK’s medicines regulator.
    The Medicines and Healthcare Products Regulatory Agency (MHRA) has also raised concerns that the drug can affect male sperm and fertility, and may be linked to miscarriages and stillbirths.
    Ministers are already under pressure after it emerged in April that valproate was still being prescribed to women without the legally required warnings. Six babies a month are being born after having been exposed to the drug, the MHRA has said. It can cause deformities, autism and learning disabilities.
    Cat Smith, the Labour chairwoman of the all-party parliamentary group on sodium valproate, said: “This transgenerational risk is very concerning. There have been rumours that this was a possibility, but I had never heard it was accepted until last week by the MHRA."
    “The harm from sodium valproate was caused by successive failures of regulators and governments, and this news means it could be an order of magnitude worse than we first thought. It underlines the need for the Treasury to step up to their responsibilities around financial redress to those families.”
    Read full story (paywalled)
    Source: Sunday Times, 19 June 2022
  21. Patient Safety Learning
    Women who are operated on by a male surgeon are much more likely to die, experience complications and be readmitted to hospital than when a woman performs the procedure, research reveals.
    Women are 15% more liable to suffer a bad outcome, and 32% more likely to die, when a man rather than a woman carries out the surgery, according to a study of 1.3 million patients.
    The findings have sparked a debate about the fact that surgery in the UK remains a hugely male-dominated area of medicine and claims that “implicit sex biases” among male surgeons may help explain why women are at such greater risk when they have an operation.
    “In our 1.3 million patient sample involving nearly 3,000 surgeons we found that female patients treated by male surgeons had 15% greater odds of worse outcomes than female patients treated by female surgeons,” said Dr Angela Jerath, an associate professor and clinical epidemiologist at the University of Toronto in Canada and a co-author of the findings.
    “This result has real-world medical consequences for female patients and manifests itself in more complications, readmissions to hospital and death for females compared with males.
    “We have demonstrated in our paper that we are failing some female patients and that some are unnecessarily falling through the cracks with adverse, and sometimes fatal, consequences.”
    Read full story
    Source: The Guardian, 4 January 2022
  22. Patient Safety Learning
    Doctor shortages are jeopardising patient safety and rota gaps are pushing the NHS to “breaking point”, Scottish physicians have warned.
    A lack of doctors in NHS Scotland due to unfilled vacancies, sick leave and a shortage of staff is often putting patients’ welfare at risk, a survey of consultants has found. More than a third of Scottish doctors (34%) reported, in the Royal Colleges’ annual census, that trainee rota gaps occurred at least daily, while 16% warned they are causing “significant patient safety problems”.
    A further 78% of those who responded said rota gaps potentially cause patient safety problems, but that there are solutions in place.
    Read full story
    Source: The Scotsman, 14 October 2019
  24. Patient Safety Learning
    On January 2020, Patient Safety will be on the G20 agenda (among other five health key priorities), but Abdulelah M. Alhawsawi, Saudi Patient Safety Center, asks "what is patient safety doing on an economic forum like the G20?"
    Patient harm is estimated to be the 14th leading cause of the global disease burden. This is comparable to medical conditions such as tuberculosis and malaria. In both US and Canada, patient safety adverse events represent the 3rd leading cause of death, preceded only by cancer and heart disease. In the US alone, 440,000 patients die annually from healthcare associated infections. In Canada, there are more than 28,000 deaths a year due to patient safety adverse events. In low-middle income countries,  134 million adverse events take place every year, resulting in 2.6 million deaths annually. 
    In addition to lives lost and harm inflicted, unsafe medical practice results in money loss. Nearly, 15 % of the health expenditure across Organization of Economic Cooperative Development countries is attributed to patient safety failures each year, but if we add the indirect and opportunity cost (economic and social), the cost of harm could amount to trillions of dollars globally.
    When a patient is harmed, the country loses twice. The individual will be lost as a revenue generating source for society and the individual will become a burden on the healthcare system because he or she will require more treatment. Unless we do something different about patient safety, we would risk the sustainability of healthcare systems and the overall economies. 
    Alhawsaw proposed establishing a G20 Patient Safety Network (Group) that will combine Safety experts from healthcare and other leading industries (like aviation, nuclear, oil and gas, other), and economy and fFinancial experts
    This will function as a platform to prioritise and come up with innovative patient safety solutions to solve global challenges while highlighting the return on investment (ROI) aspects. 
    This multidisciplinary group of experts can work with each state that adopts the addressed global challenge to ensure correct implementation of proposed solution.
    Read full story
    Source: The G20 Health & Development Partnersip, 10 February 2020
  25. Patient Safety Learning
    A ‘culture of distrust’ between consultants and the use of incident reporting as a tool of ‘reprisal’ impacted patient care at a trust’s cardiology department, a review has concluded.
    An external review undertaken for Hull University Teaching Hospitals Trust has made a series of recommendations after looking into allegations of bullying and several examples of poor care within its cardiology services.
    In a report published in the trust’s board papers, the Royal College of Physicians reported a “perceived tendency to downplay clinical incidents, and, to undermine those who wanted to raise patient safety issues”.
    It added: “We met a group of individual consultants who did not work well as a team. There is a culture of distrust, a lack of departmental cohesion and allegations of bullying in the department. All of which reinforce a clear divide between the interventional and non-interventional consultant cardiologists."
    “There have been a number of allegations of belittling, intimidation and undermining…The review team heard accounts of a culture where datix has been used as a tool for possible personal reprisal along with ignoring/downplaying incidents that have been raised.”
    The review concludes: “This behaviour is impacting on patient care and therefore, all medical staff should be reminded of good medical practice as the [General Medical Council] code of conduct of how doctors must work collaboratively with colleagues.”
    Read full story (paywalled)
    Source: HSJ, 16 November 2021
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