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Patient Safety Learning

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  1. Patient Safety Learning
    A hospital trust has admitted that a young autistic boy should still be alive had they delivered the appropriate level of care.
    In an exclusive interview with ITV News, the day before the inquest into his death, Mattheus Vieira's heartbroken parents described him as "special", adding: "And special in a good way, not just special needs."
    "People may think because he was autistic he was difficult, but it's not the case, he was very easy.
    "He was the boss of the house, we just miss his presence."
    Mattheus, aged 11, was taken to King's Lynn Hospital, in Norfolk, with a kidney infection. He struggled to cope with medical staff taking observations, and his notes recorded him as "uncooperative".
    His dad, Vitor Vieira, told ITV News: "He doesn't like to be touched, even a plaster he doesn't like.
    "And they say 'Oh he does not co-operate'. He was an autistic boy, what do you expect?
    Mr Vieira believes staff did not understand his son's behaviour. Mattheus was non verbal and so unable to articulate his distress.
    Observations were dismissed as "inaccurate" by some medical staff. In fact, they were accurate and indicated that his kidney infection had developed into septic shock.
    He suffered a cardiac arrest and died, aged 11.
    Read full story
    Source: ITV News, 26 February 2024
  2. Patient Safety Learning
    NHS board members must speak up against discrimination, challenge others constructively and help foster a safe culture, under a new NHS England assessment framework.
    The new leadership competency framework, published today, sets out six domains which board members are required to assess themselves against as part of an annual “fitness” appraisal.
    Each domain (see below) contains competencies directors must exhibit, such as:
    Speak up against any form of racism, discrimination, bullying, aggression, sexual misconduct or violence, even when [they] might be the only voice; Challenge constructively, speaking up when [they] see actions and behaviours which are inappropriate and lead to staff or people using services feeling unsafe, or staff or people being excluded in any way or treated unfairly; and Ensure there is a safe culture of speaking up for [their] workforce. Each competency statement gives board members a multiple choice to assess themselves against, ranging from “almost always” to “no chance to demonstrate”. Organisations have been told to incorporate the six competency domains into role descriptions from 1 April, and use them as part of board member appraisals.
    Read full story (paywalled)
    Source: HSJ, 28 February 2024
  3. Patient Safety Learning
    Child and adolescent eating disorder services have never achieved NHS waiting time targets, and are not able to meet significant demand, according to analysis by the Royal College of Psychiatrists.
    Psychiatrists can identify and address many of the root causes of eating disorders, including neurodevelopmental conditions such as autism and ADHD. However, a current lack of capacity prevents this from happening.
    Due to a lack of resources, even children who meet the threshold for specialist eating disorder services are often in physical and mental health crisis by the time they are seen. Delays in treatment cause children with eating disorders physical and mental harm.
    NHS England set a target for 95% of children and young people with an urgent eating disorder referral to be seen within a week, and for 95% of routine referrals to be seen within four weeks. These standards have not been achieved nationwide, since they were introduced in 2021.
    RCPsych analysis of the latest data shows that just 63.8% of children and young people needing urgent treatment from eating disorder services were seen within one week.  Only 79.4% of children and young people with a routine referral were seen within four weeks.
    The College also warns that there is an unacceptable gap between the number of children being referred to specialist eating disorders services, and those being seen. This is driven by a shortfall in the number of trained therapists and eating disorders psychiatrists. 
    For Eating Disorders Awareness Week, the Royal College of Psychiatrists is calling on Government and Integrated Care Boards to invest in targeted support for children and young people to reverse this eating disorders crisis. The call is backed by the UK’s eating disorder charity Beat.
    Read full story
    Source: Royal College of Psychiatrists, 29 February 2024
    Further reading on the hub:
    For Eating Disorders Awareness Week, Patient Safety Learning has pulled together 10 useful resources shared on the hub to help healthcare professionals, friends and family support people with eating disorders. 
  4. Patient Safety Learning
    Staff have assaulted patients and falsified medical records following deaths, according to a shocking new report into a scandal-hit mental health hospital where Nottingham killer Valdo Calocane was a patient.
    Multiple incidents of staff physically assaulting patients and workers feeling too scared to report problems at Highbury Hospital have been uncovered by the Care Quality Commission (CQC).
    The watchdog revealed police have investigating the deaths of at least two patients in which staff involved were later found by the hospital to have falsified their medical records in a new report, published on Friday.
    The news comes after The Independent revealed Nottinghamshire Healthcare Foundation Trust, which runs Highbury Hospital, had suspended more than 30 staff members following allegations of mistreating patients and falsifying records of medical observations.
    The trust also faces a further CQC review, commissioned by health secretary Victoria Atkins, following the conviction of killer Valdo Calocane who was a patient of Highbury Hospital’s community service teams. This review is due to be published later this year.
    Read full story
    Source: The Independent, 1 March 2023
  5. Patient Safety Learning
    Whistleblower Dr Chris Day has won the right to appeal when a a Deputy High Court Judge Andrew Burns of the Employment Appeal Tribunal granted permission to appeal the November 2022 decision of the London South Employment Tribunal on six out of ten grounds at a hearing in London.
    The saga which has now being going on for almost ten years began when Dr Day  raised patient safety issues in intensive care unit at Woolwich Hospital in London. The Judge said today this was of the “utmost seriousness” and were linked to two avoidable deaths but their status as reasonable beliefs were contested by the NHS for 4 years using public money.
    In a series of twists and turns at various tribunals investigating his claims Dr Day has been vilified by the trust not only in court but in a press release sent out by the trust and correspondence with four neighbouring trust chief executives and the head of NHS England, Dr Amanda Pritchard and local MPs.
    This specific hearing followed a judgement in favour of the trust by employment judge Anne Martin at a hearing which revealed that David Cocke, a director of communications at the trust, who was due to be a witness but never turned up, destroyed 90,000 emails overnight during the hearing.
    A huge amount of evidence and correspondence that should have been released to Dr Day was suddenly discovered. The new evidence showed that the trust’s chief executive, Ben Travis, had misled the tribunal when he said that a board meeting which discussed Dr Day’s case did not exist and that he had not informed any other chief executive about the case other than the documents that were eventually disclosed to the court.
    Read full story
    Source: Westminster Confidential, 26 February 2024
  6. Patient Safety Learning
    GPs do not ‘face huge amounts of complexity’ and most of their appointments are ‘incredibly straightforward’, according to a former Conservative health minister.
    Speaking to BBC Radio 4 last week, Lord Bethell defended upcoming legislation that will bring physician associates (PAs) under GMC regulation, which could be struck down by the House of Lords this evening.
    Both the Doctors’ Association UK and the BMA had previously complained about the lack of debate in Parliament.
    Discussing the role of PAs on Friday, Lord Bethell said he had not seen ‘any evidence’ of patients being confused about whether they were seeing a doctor or an associate.
    "GPs don’t face huge amounts of complexity. Most interactions are incredibly straightforward. Certainly my own experience over the last 20 years of going to my GP, it really hasn’t required 10 years of training to deal with my small problems," he said.
    Lord Bethell added: ‘When they are complex, they should be escalated. But there’s a much wider group of people who have professional training who should be respected, celebrated – they shouldn’t be denigrated, they shouldn’t be in any way patronised by other professionals.’
    Read full story
    Source: Pulse, 26 February 2024
  7. Patient Safety Learning
    The NHS paid out tens of millions of pounds over maternity failings at a hospital trust which is the subject of a major inquiry.
    Including legal fees, £101m was paid in claims against Nottingham University Hospitals (NUH) between 2006 and 2023.
    NUH is facing the UK's largest-ever maternity review, with hundreds of baby deaths and injuries being examined.
    Experts say lives could be saved if the trust invested more in learning from its mistakes.
    The NHS paid the money in relation to 134 cases over failings at the Queen's Medical Centre (QMC) and City Hospital.
    The majority - £85m - was damages for families who were successful in proving their baby's death or injury was a result of medical negligence.
    Read full story
    Source: BBC News, 28 February 2024
  8. Patient Safety Learning
    Great Ormond Street Hospital has written to the families of all children treated by one of its former surgeons after concerns were raised about his practice.
    Yaser Jabbar, a consultant orthopaedic surgeon, has not had a licence to practise medicine in the UK since 8 January, the medical register shows.
    Independent experts are now reviewing the concerns raised.
    The hospital trust said the Royal College of Surgeons (RCS) was asked to review its paediatric orthopaedic service following concerns raised by family members and staff.
    The RCS then raised concerns about Mr Jabbar, which the trust said were being taken "incredibly seriously" and would be reviewed by independent experts from other paediatric hospitals.
    A spokesman for the trust said: "We are sorry for the worry and uncertainty this may cause the families who are impacted.
    "We are committed to learning from every single patient that we treat, and to being open and transparent with our families when care falls below the high standards we strive for."
    The spokesperson said Mr Jabbar, reported to be an expert in limb reconstruction, no longer worked at the hospital.
    Read full story
    Source: BBC News, 28 February 2024
  9. Patient Safety Learning
    People experiencing Long Covid have measurable memory and cognitive deficits equivalent to a difference of about six IQ points, a study suggests.
    The study, which assessed more than 140,000 people in summer 2022, revealed that Covid-19 may have an impact on cognitive and memory abilities that lasts a year or more after infection. People with unresolved symptoms that had persisted for more than 12 weeks had more significant deficits in performance on tasks involving memory, reasoning and executive function. Scientist said this showed that “brain fog” had a quantifiable impact.
    Prof Adam Hampshire, a cognitive neuroscientist at Imperial College London and first author of the study, said: “It’s not been at all clear what brain fog actually is. As a symptom it’s been reported on quite extensively, but what our study shows is that brain fog can correlate with objectively measurable deficits. That is quite an important finding.”
    Read full story
    Source: The Guardian, 29 February 2024
  10. Patient Safety Learning
    NHS waiting lists will take more than three years to be reduced to pre-pandemic levels, according to a new analysis.
    Despite recent reductions in the waiting list in England, the Institute for Fiscal Studies (IFS) think tank said that it is “unlikely that waiting lists will reach pre-pandemic levels” by December 2027 – even under a “best-case scenario”.
    The latest figures show that the waiting list for routine hospital treatment in England has fallen for the third month in a row.
    An estimated 7.6 million treatments were waiting to be carried out at the end of December, relating to 6.37 million patients, down slightly from 7.61 million treatments and 6.39 million patients at the end of November, according to NHS England figures.
    Cutting NHS waiting lists is one of Prime Minister Rishi Sunak’s top priorities. However, the PM admitted earlier this month he would not meet his promise to reduce waiting lists.
    However, the new IFS analysis highlights how the NHS waiting list was already growing before the pandemic, but it rose “rapidly” during the crisis. The IFS report suggests a range of scenarios about how the waiting list could look in December 2024.
    Under a “more pessimistic scenario”, waiting lists will remain at the same elevated level while an “optimistic scenario” would see them fall to 5.2 million by December 2027.
  11. Patient Safety Learning
    The medical regulator failed to sound the alarm over Covid vaccine side effects and should be investigated, MPs have said. 
    The Medicines and Healthcare products Regulatory Agency (MHRA) is responsible for approving drugs and devices and monitors side effects caused by treatments.
    But the all-party parliamentary group (APPG) on pandemic response and recovery, an influential group of MPs, has raised “serious patient safety concerns”. It has claimed that “far from protecting patients” the regulator operates in a way that “puts them at serious risk”.
    Some 25 MPs across four parties have written to the health select committee asking for an urgent investigation. In reply, Steve Brine, the health committee chairman, has said an inquiry into patient safety is “very likely”. 
    In a letter to Mr Brine, the APPG said that there was reason to believe that the MHRA had been aware of post-vaccination heart and clotting issues as early as February 2021, but did not highlight the problems for several months.
    Read full story (paywalled)
    Source: The Telegraph, 27 February 2024
    Related reading on the hub:
    Interview with Charlet Crichton, founder of UKCVFamily  
  12. Patient Safety Learning
    Death threats, physical abuse and racist slurs aimed at NHS workers has prompted one hospital to make it easier for staff to “red card” violent and abusive patients.
    Aggressive patients or visitors could be banned from Barking, Havering and Redbridge University Hospitals NHS Trust for up to 12 months.
    The trust has also started using a series of body cameras in a bid to curb violence and aggression towards health workers after cases at the East London/Essex trust have doubled in the last three years.
    Trust workers have been punched, subject to racist slurs – including being told to “go back to the jungle” – and had their teeth broken by violent patients.
    As a result, hospital bosses have launched a new campaign – ‘No Abuse, No Excuse’ – to reduce violence and aggression towards staff, which includes:
    The introduction of 60 body cameras for staff in areas such as A&E and frailty units. Easier policies to ban patients or visitors, with bans which can last for up to a year. An increased visibility of security staff. A “de-escalation” training course for trust employees. Read full story
    Source: Medscape, 26 February 2024
  13. Patient Safety Learning
    Long A&E waits have got worse at more than one in five acute trusts, despite an improving trend nationally.
    Around 30 acute trusts have reported an increase in long accident and emergency waits, bucking the national trend.
    According to data covering the nine months to December, the proportion of waits more than 12 hours from time of arrival has improved to 6.3%, down from 8% during the same period in 2022. However, 28 out of 119 acute trusts reported a rise of up to 3 percentage points.
    HSJ’s analysis, which used published and unpublished data, showed 11 of these trusts had worsened despite improving their headline performance against the four-hour target.
    Adrian Boyle, of the Royal College of Emergency Medicine, said the emphasis on the four-hour target “incentivises focus on the people who are being sent home, and takes effort and attention away from the people who are being admitted to hospital”.
    He added: “The harms of long waits are greatest for people being admitted to hospital. We are disappointed by the current lack of focus in the planning guidance to help our most vulnerable patients.”
    Read full story (paywalled)
    Source: HSJ, 27 February 2024
  14. Patient Safety Learning
    Deaths of newborn babies should be more thoroughly investigated by health boards in Scotland, experts have said after reviewing an increase in infant mortality.
    The team found inquiries into baby deaths conducted by health boards were “poor quality, inconsistent and incomplete”.
    The experts added that information about staffing levels on maternity wards at the time of the deaths was so poor that they could not draw any conclusions.
    They were also unable to determine if health boards enlisted independent, external advisers when considering if deaths could have been prevented.
    Helen Mactier, a retired neonatologist and chairwoman of the Neonatal Mortality Review, said: “This review has helped to get a clearer understanding of the increase in neonatal deaths that occurred in 2021-22.
    “We understand that there are still unanswered questions, and our recommendations are focused on ensuring that future opportunities to learn are not missed and acted on in a timely and comprehensive manner.”
    Read full story (paywalled)
    Source: The Times, 27 February 2024
  15. Patient Safety Learning
    Drugs used to treat ADHD are being openly traded in "potentially lethal" doses to UK buyers on encrypted apps, a BBC North West investigation has found.
    Criminals are cashing in on a national shortage to offer the prescription tablets in a secret mail-order service.
    The BBC found an unregulated online market stacked with medication which high street chemists were struggling to stock.
    It is feared patients are turning to the black market in desperation, but one psychiatrist has warned some of the drugs could contain other potentially harmful chemicals.
    Thousands of people with ADHD have been unable to get prescribed medication amid a major supply shortage.
    The BBC has heard how the situation has left children and adults in limbo and with the shortage set to last until December many are believed to be turning to illegitimate traders to help treat the condition.
    The BBC took these findings to Dr Morgan Toerien, associate specialist in mental health at Beyond Clinics in Warrington, who said: "A lot of these drugs are potentially lethal, not just dangerous - particularly if you weren't used to taking them and if you took a higher dose.
    "During my work in illicit drug treatment, we've tested people alleged to have taken a lot of the drugs seen on this channel and they don't actually contain what they say they do."
    He said people could be taking a tablet purporting to be to treat ADHD, but could be "far more dangerous".
    Read full story
    Source: BBC News, 28 February 2024
  16. Patient Safety Learning
    Health systems will be asked to deliver the same amount of elective activity next year as they were tasked with completing in 2023-24, HSJ understands.
    Local leaders have been issued with varying interim targets for 2024-25 that produce an average national threshold of 7% more activity than pre-covid levels, on a value-weighted basis.
    It means the target for the current year has effectively been rolled over into next, suggesting the elective recovery is a year behind schedule.
    Even if systems hit their thresholds next year, they will still fall well short of the central target set out in the elective recovery plan in 2022.
    Recent weeks have seen other elective ambitions ditched or watered down, including the prime minister’s headline pledge to bring the overall waiting list down. It is likely a result of the government accepting it cannot push more elective activity due to ongoing strikes and overspending.
    Read full story (paywalled)
    Source: HSJ, 27 February 2024
  17. Patient Safety Learning
    An inquiry into birth trauma has received more than 1,300 submissions from families.
    It is estimated that 30,000 women a year in the UK have suffered negative experiences during the delivery of their babies, while 1 in 20 develop post-traumatic stress disorder.
    The investigation is a cross-party initiative, led by MPs Theo Clarke and Rosie Duffield, in collaboration with the Birth Trauma Association.
    Ms Clarke the Conservative MP for Stafford, triggered the first ever parliamentary debate on the issue in October.
    In an emotional exchange in the House of Commons, she described her own experience following her daughter's birth at the Royal Stoke University Hospital in 2022.
    She bled heavily after suffering a tear and had to undergo two-hour surgery without general anaesthetic, due to an earlier epidural.
    The Birth Trauma Association, which is administering the inquiry, invited the public to submit written accounts of their own experiences.
    Dr Kim Thomas, from the association, said she had received an "overwhelming" number of personal accounts. Some cases date back as far as the 1960s.
    Read full story
    Source: BBC News, 25 February 2024
  18. Patient Safety Learning
    Accountability is top of the wishlist from the Covid inquiry as it comes to Wales, say bereaved families and those charged with protecting vulnerable people.
    Over the next three weeks the focus will largely be on the decisions made by the Welsh government during the pandemic.
    From the timings of lockdowns to the rationale of doing things differently to the UK government, the hearings will scrutinise actions taken in Wales.
    For many, it will be a chance to hear the justifications for policies that they say left them feeling unsupported and alone.
    Ann Richards did not get to say a final goodbye to her husband Eirwyn before he died from hospital-acquired Covid in January 2021.
    Ann still wonders if non-urgent healthcare had been fully up and running, could Eirwyn have been discharged sooner, or perhaps even avoided a hospital admission altogether?
    Additional rules put in place to reduce the spread of the virus meant there were delays in getting a purpose-built wheelchair – delaying his discharge from hospital.
    "I understand there had to be rules in place," said Ann. "But it's the wellbeing of the patients I think they lost a lot of."
    Read full story
    Source: BBC News, 26 February 2024
  19. Patient Safety Learning
    NHS England is looking to ditch a key elective target that aimed to deliver large reductions in follow-up appointments, HSJ has learned.
    Senior sources privately admit progress has not been made against the target to cut the volume of the most common type of outpatient follow-up by 25 per cent target.
    This is supported by publicly available data. While this only gives a partial picture, the data suggests the volumes have actually increased compared to pre-covid levels.
    The volume-based target is widely viewed as unrealistic and senior figures told HSJ it had also “masked” some genuine progress trusts have made in reforming outpatient services and reducing less productive appointments.
    Sources familiar with discussions said having a volume-based target to reduce a subset of patients while trying to increase overall activity volumes had been logistically complex.
    NHSE is instead pushing for a new “ratio-based” target which sources said would be a better measure to reduce the least productive types of outpatient follow-ups and be a fairer measure of progress.
    Read full story (paywalled)
    Source: HSJ, 26 February 2024
  20. Patient Safety Learning
    Cancer patients in the UK wait up to seven weeks longer to begin radiotherapy or chemotherapy than people in comparable countries, research has revealed.
    The stark findings are yet more damning evidence of the extent to which the UK lags behind other nations, as experts warn that people’s chances of survival are being affected by long waits for treatment.
    In the first research of its kind, experts at University College London analysed data from more than 780,000 cancer patients diagnosed between 2012 and 2017 in four comparable countries: Australia, Canada, Norway and the UK. Eight cancer types were included: oesophageal, stomach, colon, rectal, liver, pancreatic, lung and ovarian cancer.
    The two studies, published in the Lancet Oncology, were the first to examine treatment differences for eight cancer types in countries across three continents. UK patients experienced the longest waits for treatment, the research found.
    The average time to start chemotherapy was 48 days in England, 57 in Northern Ireland, 58 in Wales and 65 in Scotland. The shortest time was 39 days in Norway.
    In radiotherapy, the UK fared even worse. It took 53 days on average for treatment to begin in Northern Ireland, 63 in England, 79 in Scotland and 81 in Wales.
    Cancer Research UK, which part-funded the two studies, said delays to begin treatment were partly a result of the UK government’s lack of long-term planning on cancer in recent years. Countries with robust cancer strategies backed by funding had seen better improvements in survival rates, it said.
    Read full story
    Source: The Guardian, 27 February 2024
  21. Patient Safety Learning
    "Taking medication meant my brain was quiet for the first time; it was amazing, I cried because I was so happy," Jass Thethi, whose life was transformed after an ADHD diagnosis just over a year ago, told a BBC North West investigation.
    But the 34-year-old's joy was short-lived because, like more than 150,000 others who live with the condition and are reliant on medication, Jass has been affected by a UK-wide medicine shortage that started in September.
    Jass, who lives in Levenshulme, Greater Manchester, said: "When the medication shortage started I had to go back to white knuckling everyday life… I had to take the decision to change things and I had to quit the job I was doing."
    The charity ADHD UK said it had recorded a "significant decline" in the availability of medicines, with only 11% having their normal prescription in January, a drop from 52% in September.
    The Department of Health and Social Care (DHSC) said increased global demand and manufacturing issues were behind the shortages.
    Dr Morgan Toerien, associate specialist in mental health at Beyond Clinics in Warrington, said Jass's experience was not unique and many patients' lives had been "completely destabilised".
    Read full story
    Source: BBC News, 27 February 2024
    Have you (or a loved one) ever been prescribed medication that you were then unable to get hold of at the pharmacy? 
    To help us understand how these issues impact the lives of patients and families, please share your experience and insights in our Community post.
    We would also like to hear from pharmacists working in community or hospital settings, and others who have insights to share on this issue. 
  22. Patient Safety Learning
    Major progress made in sepsis care during the previous decade has been significantly reversed amid repeated failures in recognising and treating the condition.
    HSJ has identified 31 deaths in the last five years where coroners have warned of systemic problems with diagnosing and treating sepsis, including nine cases relating to children. Many of the deaths were deemed avoidable.
    Meanwhile, investigations suggest a majority of acute trusts are failing to record their treatment rates for sepsis, which is deemed a crucial aspect of driving improvements.
    Repeated shortcomings raised by coroners, including 10 separate cases in 2023, include delays or failures to administer antibiotics, not following protocols for identifying sepsis, and inaccurate, missed or skipped observations.
    Health ombudsman Rob Behrens, who issued a report on sepsis failures last year, said the same mistakes were “clearly being repeated time and time again”.
    He added: “What is chilling to me is that these [coroners’ reports] fit in almost exactly with the issues we raised in our sepsis report… and even the 2013 sepsis report issued by my predecessor, including unnecessary delays, wrong diagnosis, and failure to provide adequate plans for sepsis.”
    Read full story (paywalled)
    Source: HSJ, 27 February 2024
  23. Patient Safety Learning
    Mothers of babies who died or suffered brain damage from a Group B Strep (GBS) infection say routine screening is needed.
    Oliver Plumb, from the charity Group B Strep Support, said it was a "small number of babies" exposed to the bacteria that developed a serious and potentially fatal infection.
    He said around 800 babies a year developed the infection - which is about two babies a day - and about one a week will die, while another a week will be left with a lifelong disability.
    "It's a heart-breaking start to life for families and that often the first they hear of Group B Strep is when their baby is sick or in intensive care".
    The charity has called for GBS to be a notifiable disease to make it a legal responsibility for infections to be reported. It added that current figures could be "missing around one fifth of the infections".
    There was a "postcode lottery" in terms of how many families will hear about GBS, he said. The charity also backed calls for screening.
    "In the UK we don't sadly have a routine testing programme, that's at odds with much of the rest of the high-income world. "
    A DHSC spokesperson said a public consultation on the notifiable diseases list was carried out last year.
    "DHSC and UKHSA are considering the responses and confirmation of any changes will be published in due course," they said.
    Several reasons for not recommending routine screening have been given by the committee, including that results can change in the last few weeks of labour, and that GBS does not cause infection in every baby.
    Read full story
    Source: BBC News, 26 February 2024
    Further reading on the hub:
    Leading for safety: A conversation with Jane Plumb, Founder of Group B Strep Support  
  24. Patient Safety Learning
    The number of people in the UK who have avoidant restrictive food intake disorder (Arfid), in which those afflicted avoid many foods, has risen sevenfold in five years, figures show.
    The eating disorders charity Beat received 295 calls about Arfid in 2018 – comprising 2% of its 20,535 inquiries that year. However, it received 2,054 calls last year, which accounted for one in 10 of its 20,535 requests for help. Many were from children and young people or their parents.
    Andrew Radford, Beat’s chief executive, said: “It’s extremely worrying that there has been such a dramatic increase in those seeking support for Arfid, particularly as specialist care isn’t always readily available.”
    Patchy provision of NHS help meant many people were experiencing long delays before accessing support, he added.
    Eight in 10 eating disorder service providers did not state on their website whether or not they offered Arfid care, research by Beat found.
    “All too often we hear from people who have been unable to get treatment close to home or have faced waits of months or even years to get the help they need,” Radford said.
    Arfid is much less well-known than anorexia or bulimia. It is “an eating disorder that rarely gets the attention it deserves”. The sharp increase in cases should prompt NHS chiefs to end the postcode lottery in care for Arfid and ensure that every region of England had a team of staff fully trained to treat it, he added.
    “Unlike other eating disorders such as anorexia or bulimia, Arfid isn’t driven by feelings around [someone’s] weight or shape,” Radford said. “Instead, it might be due to having sensory issues around the texture or taste of certain foods, fear about eating due to distressing experiences with food, for example choking, or lack of interest in eating.”
    Read full story
    Source: The Guardian, 26 February 2024
  25. Patient Safety Learning
    A newly installed electronic patient record contributed to the “preventable” death of a 31-year-old woman in an emergency department, a trust has been warned.
    Emily Harkleroad died at University Hospital of North Durham in December 2022 following “failures to provide [her] with appropriate and timely treatment” for a pulmonary embolism, a coroner has said.
    The inquest into her death heard emergency clinicians had raised concerns about a newly installed electronic patient record, provided by Oracle Cerner, which they said did not have an escalation function which could clearly and quickly identify the most critical patients.
    The inquest heard the new EPR, installed in October 2022, did not have a “RAG rating” system in which information on patient acuity “was easily identifiable by looking at a single page on a display screen” – as was the case with the previous IT system.
    The software instead relied on symbols next to patients’ names which indicate their level of acuity when clicked on, but did “not [provide] a clear indication at first glance” of their level of acuity.
    Rebecca Sutton, assistant coroner for County Durham and Darlington, said that “errors and delays” meant Ms Harkleroad did not receive the anticoagulant treatment that she needed and “which would, on a balance of probabilities, have prevented her death”.
    “It is my view that, especially in times of extreme pressure on the emergency department, a quick and clear way of identifying the most critically ill patients is an important tool that could prevent future deaths.”
    Read full story (paywalled)
    Source: HSJ, 23 February 2024
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