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Patient Safety Learning

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  1. Patient Safety Learning
    More than half a million patients a year will be treated in “hospitals at home” in an attempt to relieve pressure on A&E departments.
    Under the plans, elderly and frail patients who fall will be treated by video link, with ministers saying that a fifth of emergency admissions could be avoided with the right care.
    Health officials said the “virtual wards” would be backed up by £14 billion in extra spending on health and care services over the next two years, as the NHS tackles record backlogs, with seven million people on waiting lists.
    Rishi Sunak said the Urgent & Emergency Care Recovery Plan showed that the NHS was one of his “top priorities”.
    Read full story (paywalled)
    Source: The Telegraph, 29 January 2023
  2. Patient Safety Learning
    ‘Unprofessional’ behaviours, a lack of compassion, and tension among staff and managers are all contributing to pockets of ‘poor culture’ at an acute trust.
    A Freedom to Speak Up report presented to the board of Buckinghamshire Healthcare Trust found there had been an increase in bullying and reports of staff members being “humiliated” during the last three months.
    The report, which covers the first two quarters of 2021-22, highlighted a “lack of compassion, kindness, and understanding” between colleagues and noted “increasing levels of frustration” that people are not being held to account for “unprofessional” poor behaviours.
    The report added the findings were not surprising due to the pressures of the pandemic experienced by staff.
    It found: “There appears to be an increase in the proportion of concerns around interpersonal behaviours and communication issues as well as levels of frustration and tension amongst staff and managers.”
    Read full story (paywalled)
    Source: HSJ, 24 November 2021
  3. Patient Safety Learning
    More than four hours after an ambulance was called, Richard Carpenter, 71, who had had a suspected heart attack, began to despair. “Where are they?” he asked his wife, Jeanette. “I’m going to die.”
    She tried to reassure her husband that the crew must surely be close. Perhaps they were struggling to find their rural Wiltshire home in the dark. “But I could see I was losing him,” she said. She gave her husband CPR and urged him: “Don’t leave me.” But by the time the paramedics arrived another hour or so later, it was too late.
    Jeanette Carpenter, 70, a stoical and reasonable person, accepts it might have been impossible to save her husband. “But I think he would have had more of a chance if they had got here sooner,” she said.
    It is the sort of sad story that is becoming all too common. Across England, but in particular in the south-west, ambulances are too often not getting to patients in a timely manner.
    Before Covid, said one ambulance worker – who asked not to be named – he would do between six and 10 jobs in a shift. Now if the first person he is called to needs to go to hospital, he expects this will be his one job for the whole shift.
    “At some hospitals we are waiting outside hospitals for 10, 11 or 12 hours,” he said. “There’s nothing more demoralising than hearing a general broadcast going out for a cardiac arrest or road accident and there’s no resources to send. It’s terrible to think someone’s loved one needs help and we can’t do anything because we’re stuck at a hospital.”
    Read full story
    Source: The Guardian, 10 April 2022
  4. Patient Safety Learning
    Feeling manipulated into having medical procedures, dismissed by professionals and labelled with racial stereotypes are among the complaints of parents who responded to a national inquiry into racial injustice in UK maternity care.
    A panel established by the charity Birthrights is investigating discrimination ranging from explicit racism to racial bias and microaggressions that amount to poorer care.
    It comes as parliament is due on 19 April to debate the large racial disparity in maternal mortality in British hospitals, after a petition from the campaign group Five X More gathered 187,519 signatures. Black women are four times more likely than white women to die during pregnancy or childbirth in the UK.
    Testimonies include that of a British Bangladeshi woman who said her labour concerns were dismissed. “I felt unsafe and like maternity professionals are not used to being challenged by brown women,” she said. “There is a stereotype of Asian women that we are tame, quiet and compliant people who have no voice and will be obedient.
    “I was treated like a vessel, not like a human. The experience left me feeling humiliated, disempowered and ashamed.”
    Read full story
    Source: The Guardian, 13 April 2021
  5. Patient Safety Learning
    When Dan Scoble came down with the coronavirus in March, all the classic symptoms landed in one fell swoop. “I had everything under the sun: a fever, temperature, fatigue and chest pain,” he said. “My head felt like a balloon.”
    The 22-year-old, a personal trainer from Oxford who normally breezed through 10-mile runs, suddenly found himself bed-bound. He presumed it would soon blow over, but 12 weeks after falling ill as the country went into lockdown, he is still not back to normal.
    Dan has left his house just five times in three months — twice to see his GP and three times to hospital. He still suffers from crippling fatigue, recurrent migraines and a persistent sore throat, as well as abdominal and musculoskeletal pain.
    Read full story (paywalled)
    Source: The Times, 14 June 2020
  6. Patient Safety Learning
    Patients have described the effect on their health and wellbeing of the “new normal” of drug shortages in the UK, which has led to three-month delays and 80-mile round trips to acquire medication.
    Simon Bell, a 43-year-old data analyst from Tyne and Wear, has cystic fibrosis and requires medication that allows him to digest food. “For people with cystic fibrosis, the part of our pancreas which releases enzymes and allows us to digest food doesn’t work, so we have to take these tablets, which does the job of what’s missing from our pancreas,” he says.
    Since the outbreak of the coronavirus pandemic, Bell says he has been experiencing shortages of Creon 25000, the drug he takes, and once was unable to get his medication for more than three months.
    Bell decided he had no choice but to stockpile the medication when he could get it, as the effects of going without the drug are much graver than taking a lower dose.
    “I went three months without getting any, so after that I started just to build up stock by not taking my full amount of medication every month, so now I always keep three months’ supply. Doctors would never advise this but I feel like I have no choice,” Bell says.
    The situation has prompted concerns for Bell that his other medications will begin experiencing shortages, which could make him seriously ill. “Kaftrio is an expensive drug that if we stop taking would make us really seriously ill,” he says. “If I couldn’t get hold of that medication that would have serious implications in terms of health, long-term health and my ability to work. It could be quite devastating.”
    Read full story
    Source: The Guardian, 18 April 2024
  7. Patient Safety Learning
    Some hospitals are suspending supplies of gas and air, after it was found to pose health risks to midwives. What can be done to ensure pregnant women still get the help they need?
    When Leigh Milner was expecting her first baby, she knew exactly how she wanted her labour to go. Her birth plan included an epidural for the pain and she was hoping, she says ruefully, for “all the drugs”. But that is not how things worked out. Milner, 33, a BBC presenter, ended up giving birth to Theo at Princess Alexandra hospital in Harlow last month with nothing but paracetamol for pain relief, in what she calls a positively “Victorian” experience.
    “I kept begging over and over again – ‘I need something for pain relief’ – and the only thing they could give me was paracetamol because they didn’t have gas and air. I was quite frightened, I didn’t know what else to do,” says Milner.
    "Birth is painful, but it shouldn’t be traumatic.”
    Read full story
    Source: The Guardian, 16 March 2023
  8. Patient Safety Learning
    "I thought she would be safe at Chadwick Lodge,” said Natasha Darbon, recalling how she felt in April 2019 when her 19-year-old daughter, Brooke Martin, was admitted to the mental health hospital in Milton Keynes.
    Eight weeks later, Brooke took her own life.
    The jury at the inquest found that Brooke’s death could have been prevented and that the private healthcare provider Elysium Healthcare, which ran the hospital, did not properly manage her risk of suicide. It also found that serious failures of risk assessment, communication and the setting of observation levels contributed to her death. Elysium accepted that had she been placed on 24-hour observations, Brooke would not have died.
    In 2018, Brooke, who was autistic, was repeatedly sectioned under the Mental Health Act because of her escalating self-harm and suicide attempts. After a spell in an NHS facility in Surrey she moved to Chadwick Lodge, which specialises in treating personality disorders.
    After a few weeks there, Brooke was doing well and staff were pleased with her progress. She was due to move to Hope House, a separate unit at the hospital, to start more specialist therapy for emotionally unstable personality disorder, and was keen to make the switch.
    But then the teenager’s mental health deteriorated again. On 5 June 2019 she tried to kill herself. Five days later she was seen twice that evening secretly handling potential ligatures, but no appropriate action was taken. A few minutes later she was found unresponsive in her room. She received CPR but died the next day in Milton Keynes university hospital.
    After hearing the evidence about the care Brooke received in her final days, Tom Osborne, the coroner at the inquest, took the unusual step of issuing a prevention of future deaths notice. He sent it to Sajid Javid, the health secretary, and to Elysium Healthcare, as the owner of Chadwick Lodge.
    It set out the detailed criticisms that the jury had made of Elysium’s interaction with Brooke after her attempt to take her own life on 5 June. They cited the hospital’s failures to communicate information regarding Brooke’s suicide attempt, to search her room after she was found handling potential ligatures on the night she died, and to place Brooke on constant observations afterwards.
    Read full story
    Source: The Guardian, 24 April 2022
  9. Patient Safety Learning
    Women working in the NHS are suffering from serious stress and exhaustion in the wake of the coronavirus crisis, a troubling new report has found.
    Some 75% of NHS workers are women and the nursing sector is predominantly made up of women – with 9 out of 10 nurses in the UK being female.
    The report, conducted by the NHS Confederation’s Health and Care Women Leaders Network, warns the NHS is at risk of losing female staff due to them experiencing mental burnout during the global pandemic.
    Researchers, who polled more than 1,300 women working across health and care in England, found almost three quarters reported their job had a more damaging impact than usual on their emotional wellbeing due to the COVID-19 emergency.
    Read full story
    Source: The Independent, 25 August 2020
  10. Patient Safety Learning
    As a teenager, Kelly Moran was incredibly sporty: she loved to run and went to dancing lessons four times a week. But by the time she hit 29, she could barely walk or even drive, no longer able to do all the activities she once enjoyed. She had pain radiating into her legs.
    Her pain was repeatedly dismissed by doctors, who told her it was in her head. She moved back to her parents’ house in Manchester and left her job. She decided to seek treatment privately and was told she had endometriosis. Soon, with the right treatment, her life improved.
    Kelly is among dozens of women who got in touch to share their stories with the Guardian on the topic of women’s pain. Women are almost twice as likely to be prescribed powerful and potentially addictive opiate painkillers than men, a Guardian analysis shows. Data from the NHS Business Services Authority, which deals with prescription services in England, shows a large disparity in the number of women being given these drugs compared with men, with 761,641 women receiving painkiller prescriptions compared with 443,414 men, or 1.7 times, and the pattern is similar across broad age categories.
    The women who reached out said they felt that they were often “fobbed off” with painkillers when their problems required medical investigation.
    Read full story
    Source: The Guardian, 16 February 2021
  11. Patient Safety Learning
    Dee Dickens, 52, from Pontypridd, made the difficult choice to seek private healthcare even though she is ideologically opposed to it. After discovering a lump in her breast she was referred for a scan on the NHS’s two-week rule for suspected cancer. But after waiting six weeks, and being continually being told the waiting time was going up, eventually to a three-month wait, she was forced to pay for her own scan and appointment privately.
    “In February last year, I found a lump in my breast, and went to the doctor that day. The doctor examined me and said, ‘I don’t like that.’ She said the lump was the size of the top of her index finger and she would rush me through for an urgent screening that would take no longer than two weeks.
    “Two weeks later, I’d heard nothing so I gave them a call. They said that because of Covid, things had slowed down and it might take four weeks. 
    “A week later, one of my breasts had swelled up. It was itching and hot and it felt like it was infected. I felt unwell, too. But I was stressed to the gills. Every day, I was worried I was going to die. We know that we’re against the clock when it’s cancer.
    “I went straight back to the doctor and she rang the hospital. They said, ‘We will put your patient right at the top of the waiting list, but it will now be six weeks.’
    “At six weeks, I still hadn’t heard anything, so I called the hospital. They said that I was at the top of the list still, but it would now be 10 weeks. The wait was going up because, during the worst of Covid, they hadn’t seen anyone so they were now on catchup."
    “I’d had enough. Every single day I was more and more worried and my mental health was worse and worse, and my family was having to deal with me crying over stupid things. been talking about going private. But I’d been resistant – we’re both very leftwing and believe passionately in the NHS.
    However, in the Dee made an appointment with a private clinic. She was seen immediately.
    “After the scan, the doctor told me that the lumps were glandular tissue. The swelling, the pain and itching – were all stress related. As soon as he said, ‘You’re not going to die,’ they stopped.
    “The NHS is the only thing I’m truly proud of in the UK. What worries me is I can see it disappearing, if not in my lifetime then in my children’s lifetime. That’s one of the reasons I didn’t want to go private. It felt absolutely awful to have to make the choice I did.
    “On the one hand, I knew I would have an answer. But on the other, I knew there were so many women who wouldn’t be able to do what I was doing. I felt guilty, I felt I’d put my own life above my principles."
    Read full story
    Source: The Guardian, 11 September 2022
  12. Patient Safety Learning
    Young people with eating disorders are coming to harm and ending up in A&E because they are being denied care and forced to endure long waits for treatment, GPs have revealed.
    NHS eating disorders services are so overwhelmed by a post-Covid surge in problems such as anorexia that they are telling under-19s to rely on charities, their parents or self-help instead.
    The “truly shocking” findings about the help available to young people with often very fragile mental health emerged in a survey of 1,004 family doctors across the UK by the youth mental health charity stem4.
    The shortage of beds for children and young people with eating disorders is so serious that some are being sent hundreds of miles from home or ending up on adult psychiatric wards, GPs say.
    “The provision is awful and I worry my young patients may die,” one GP in the south-east of England told stem4. Another described the specialist NHS services available in their area as “virtually non-existent and not fit for purpose”.
    Read full story
    Source: The Guardian, 22 March 2023
  13. Patient Safety Learning
    A nurse whistleblower has described her eight years of hell as she fights the NHS over its failure to properly investigate claims she was sexually harassed by a colleague.
    Michelle Russell, who has 30 years of experience, first raised allegations of sexual harassment by a male nurse to managers at the mental health unit where she worked in London in 2015.
    Years of battling her case saw the trust’s initial investigation condemned as “catastrophically flawed” while the nursing watchdog, the Nursing Midwifery Council, has apologised for taking so long to review her complaint and has referred itself to its own regulator over the matter.
    With the case still unresolved, Ms Russell will see her career in the NHS end this week after she was not offered any further contract work.
    Speaking to The Independent she said: “If I’m going to lose my job, I want other nurses to know that this is what happens when you raise a concern. I want the public to know this is what happens to us in the NHS when we are trying to protect the public.
    “I have an unblemished career. They’re crying out for nurses. I’ve dedicated my life to the NHS. I haven’t done anything wrong.”
    Read full story
    Source: The Independent, 6 February 2024
  14. Patient Safety Learning
    A policy ‘at the heart’ of NHS England’s efforts to improve maternity care is under question after being sharply criticised by an independent inquiry, and is the subject of major tensions within NHSE and midwifery, HSJ understands.
    The Ockenden report into major care failings at Shrewsbury and Telford Hospital Trust included 15 “immediate actions” for all maternity services in England, which government has accepted and said it would begin implementation.
    However, one of these relates to the “continuity of carer” model, which NHS England has championed since 2017, when it was described as “at the heart of” its national plans for improving maternity care and outcomes.
    The model intends to give women “dedicated support” from the same midwifery team throughout their pregnancy, with claimed benefits including improved outcomes, with a particular focus on some minority groups.
    However, Ms Ockenden indicated its implementation in recent years had stretched staffing, and therefore harmed quality and safety overall, and also appeared to question whether the model was evidenced.
    Some midwifery leaders are advocates for the model, but others have described how it can result in awful working patterns, with concerns it is causing some staff to leave the profession.
    Royal College of Midwives director for professional midwifery Mary Ross-Davie told HSJ: “With the right resources and the right number of midwives, CoC can have a positive impact on maternity care – but in too many trusts and boards this is simply not the situation. We are really pleased, therefore, to see that the review team has echoed the RCM’s recommendations around the suspension of continuity of carer where too few staff puts safe deployment at risk.”
    She said the model was “something to which many maternity services aspire, particularly for women who need enhanced monitoring throughout their pregnancy to deliver better outcomes for them and their baby”.
    Helen Hughes, chief executive of Patient Safety Learning charity, said that although it had heard positive feedback that the model can improve outcomes, there must also be a “robust assessment of the safety impact of implementing such changes and the sources and staffing in place to deliver this”.
    “Otherwise the core intentions and benefits will be lost,” Ms Hughes said.
    Read full story (paywalled)
    Source: HSJ, 31 March 2022
    Further reading
    Midwifery Continuity of Carer: What does good look like? Midwifery Continuity of Carer: Frontline insights The benefits of Continuity of Carer: a midwife’s personal reflection
  15. Patient Safety Learning
    Sarah Spoor and her two adult sons have spent the past 14 months shielding in a one-bedroom apartment, with no garden, in west London. Her youngest sleeps in the bedroom, his brother has a pull-out bed in the kitchen, while Spoor takes the living room in another fold-out bed.
    All three have complex medical conditions that leave them vulnerable to Covid, and despite the strain of living in such close quarters, they don’t feel safe leaving home any time soon.
    “If we catch it, we die; it’s that simple. In the 14 months, I have probably been out about four times, and that’s usually in some dire emergency,” said Spoor, who provides round-the-clock care for her sons, 20 and 24, after their medical team decided it was too risky for their usual carers to continue visiting.
    The family has yet to be vaccinated as their medical conditions, which include type 1 diabetes, adrenal insufficiency, pernicious anemia and thyroid failure, mean they are likely to experience a severe reaction leading to hospital admission, and they are concerned about the risk of catching Covid in hospital when cases are still prevalent.
    Spoor is not alone in fearing a return to life after lockdown, with disability charity Scope estimating 75% of disabled people plan to continue shielding until after their second vaccine dose, and some for longer.
    “I think there is a potential long-term impact that groups of people become squirrelled away and it’s potentially easy for governments and local authorities to forget about them,” said James Taylor, executive director of strategy and social change at Scope. “We’re really worried that, in the long-term, lots of the rights that disabled people have fought for, the visibility, the recognition of disabled people as equal, that all falling away and going backwards.”
    Read full story
    Source: The Guardian, 19 April 2021
  16. Patient Safety Learning
    The number of patients stuck in hospitals despite being ‘medically fit’ to leave has continued to increase in recent months, leading to warnings from NHS Confederation that trusts are finding it ‘impossible’ to make progress on reducing the numbers.
    Official statistics for April suggest an average of 12,589 patients per day in NHS hospitals in England – 13% of all occupied beds – did not meet the “criteria to reside”. At 31 trusts, the proportion was 20% or more.
    NHS England has since told local leaders to make reducing the numbers of delayed discharges an operational priority. The issue is a key factor behind the long waits in emergency care, as ward beds are taking longer to become available to accident and emergency patients.
    Rory Deighton, acute lead at NHS Confederation, said targets to reduce delayed discharges “will not be met” unless the government “invests in domiciliary care wages,” amid high numbers of vacancies in the social care sector.
    Read full story (paywalled)
    Source: HSJ, 1 June 2022
  17. Patient Safety Learning
    Serious safety concerns have been raised about a children’s mental health hospital where staff lacked respect for patients, as the provider faces a police investigation into another one of its units.
    The Huntercombe Hospital in Stafford has been rated as “inadequate” by watchdog the Care Quality Commission (CQC) after inspectors found the safety of children within the hospital was at risk.
    The concerns about this hospital come as The Independent revealed police have launched an investigation into another mental health unit run by the provider in Maidenhead.
    Following an inspection in October inspectors sent an urgent warning notice to the provider, after it found there were not enough staff to keep patients safe.
    The hospital was described as relaying on agency workers who did not have knowledge of the patients.
    The CQC inspectors found children’s wards were dirty with poor hygiene measures in the hospital and patients at risk of infection.
    According to the report staff were found “sitting with their eyes closed for prolonged periods of time”, and that staff observations of at risk patients were “undermined by a blind spot where people could self-harm unseen.”
    Craig Howarth, CQC head of inspection for mental health and community health services, said: “Further to these issues, we saw that staff sometimes showed a lack of respect to patients and one ward was poorly furnished and maintained and there wasn’t always enough emphasis on some people’s individual requirements.”
    Read full story
    Source: The Independent, 11 March 2022
  18. Patient Safety Learning
    There should be independent reviews of the NHS’ readiness for a potential second major outbreak of coronavirus in the UK, senior doctors are arguing.
    The Royal College of Anaesthetists said a series of reviews should be carried out, overseen by an independent group formed from clinical royal college representatives, independent scientists and academics.
    It would encompass investigation of what happened to care quality during the peak of infection and demand through March, April and May — there are major concerns that harm and death was caused by knock of effects, with some health services closed and people being afraid to use others.
    Hospitals were unable to provide many other services as staff, including most anaesthetists, were redeployed to help with critical care.
    Ravi Mahajan, president of the Royal College of Anaesthetists, told HSJ areas such as capacity, workforce and protective equipment were key issues to be reviewed. He said: “We can’t wait for [the pandemic] to finish and then review. [The reviews] have to be dynamic, ongoing, and the sooner they start the better.
    Read full story
    Source: HSJ, 17 June 2020
  19. 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
  20. Patient Safety Learning
    A world-famous hospital has a culture where some staff may put research interests above patient safety, according to an external investigation.
    A report published yesterday cited some employees at Great Ormond Street Hospital for Children Foundation Trust as saying “they feel that the hospital sometimes put too much emphasis on pushing the boundaries of science” and “are concerned [this] may lead to a culture where some prioritise innovation over safety in their practice”.
    The trust’s medical director Sanjiv Sharma commissioned the report into the effectiveness of its safety procedures, from consultancy Verita, in 2020, after families of several patients who died at the hospital raised concerns in the media about how it responded to safety incidents.
    The report said: “We believe that it is sometimes culturally difficult within Great Ormond Street to accept that things can go wrong and to respond appropriately. We were told that some see the organisation as ‘bullet-proof’ in the face of criticism."
    “There is also a view outside the trust that some clinicians at Great Ormond Street can find it difficult to accept that something had gone wrong. Some believe that this reflex is deeply ingrained. This is potentially indicative of a culture of defensiveness. Acknowledging this trait is the first step on the road to changing it.”
    Dr Sharma said in a statement yesterday that GOSH had already taken steps to improve its culture and systems, appointing patient safety educators and patient safety leads in each directorate.
    Read full story (paywalled)
    Source: HSJ, 7 July 2022
  21. Patient Safety Learning
    Nearly half of NHS patients with a learning disability or autism are still being kept inappropriately in hospitals, several years into a key programme to reduce inpatient care, a national review reveals.
    The newly published review by NHS England suggests 41% of inpatients, assessed over an eight-month period to May 2022, should be receiving care in the community.
    Reasons given for continued hospital care in the NHSE review included lack of suitable accommodation, with 19% having needs which could be delivered by community services; delays in moving individuals into the community with appropriate aftercare; legal barriers, with one region citing “ongoing concerns for public safety” as a barrier for discharge; and no clear care plans.
    In some cases, individuals were placed in psychiatric intensive care units on a long-term basis, because “there was nowhere else to go”, while another instance cited a 20-year stay in hospital.
    Other key themes included concerns about staff culture, particularly “institutionalisation” and suggestions that discharge delays were not being sufficiently addressed.
    The report adds: “While the process around discharge can be time consuming, staff may perpetuate this by accepting such delays as necessary or inevitable.”
    Read full story (paywalled)
    Source: HSJ, 22 February 2023
  22. Patient Safety Learning
    Inspectors raised serious concerns around leadership and safety at Lister Hospital in Stevenage, run by East and North Hertfordshire Trust, when they visited in October. The maternity service was also rated inadequate for leadership.
    The CQC also raised concerns about staffing shortages, infection prevention control, care records, cleanliness, waiting times and training.
    The inspection did, however, find staff worked well together, managers monitored the effectiveness of the service and findings were used to make improvements.
    Carolyn Jenkinson, the CQC’s head of hospital inspection, said: “This drop in quality and safety was down to insufficient management from leaders to ensure staff understood their roles, and to ensure the service was available to people when they needed it.”
    Read full story (paywalled)
    Source: HSJ, 20 January 2023
  23. Patient Safety Learning
    The latest annual report into the deaths of people with learning disabilities has criticised the “insufficient” national response to past recommendations and called for “urgent” policy changes.
    The national learning disabilities mortality review programme has criticised the response from national health bodies to its previous recommendations.
    To date, just over 7,000 deaths have been notified to the programme and reviews have been completed for just 45%.
    There have been four annual reports for programme to date, and in the latest published today, the authors warned: “The response to these recommendations has been insufficient and we have not seen the sea change required to reassure [families] that early deaths are being prevented."
    “It is long over-due that we should now have concerted national-level policy change in response to the issues raised in this report and previous others. A commitment to take forward the recommendations in a meaningful and determined way is urgently required.”
    The latest report also warns that black, Asian and ethnic minority children with learning disabilities die “disproportionately” younger compared to other ethnicities.
    It also found system problems and gaps in service provision were more likely to contribute to deaths in BAME people with learning disabilities. 
    Read full story
    Source: HSJ, 16 July 2020
  24. Patient Safety Learning
    Leaders at a mental health trust tolerated high levels of safety incidents and accepted verbal assurance with ‘insufficient professional curiosity’, a critical report has found.
    An NHS England-commissioned review into governance at Tees, Esk and Wear Valleys Foundation Trust has been published, reviewing the organisation’s response to serious safety concerns flagged at the former West Lane Hospital in Middlesbrough.
    It follows separate reports identifying “systemic failures” over the deaths of inpatients Christie Harnett, Nadia Sharif and Emily Moore.
    The new report, conducted by Niche Consulting, criticises board and service leaders’ handling of concerns about the regular occurrence of restraint and self-harm.
    More than a dozen incidents of inappropriate restraint, some seeing patients dragged along the floor, were identified in November 2018, resulting in multiple staff suspensions and some dismissals. 
    Niche found there was a “lack of accountable leadership at all levels” and lack of evidence for decisions in response to the November 2018 incidents.
    Read full story (paywalled)
    Source: HSJ, 21 March 2023
  25. Patient Safety Learning
    NHS England has issued a ‘tokenistic’ and ‘insulting’ funding settlement for staff mental health and wellbeing hubs this year, which is not enough to provide proper support, HSJ has been told.
    A letter sent by NHSE to its regional directors, and seen by HSJ, confirmed that the hubs have been allocated just £2.3m for 2023-24. NHSE says the funding, which is far below current running costs, must be spent within the financial year.
    It appears to confirm fears that many of the 40 hubs will need to be shut, if they are not funded locally.
    One hub lead said: “Day in, day out, we work with colleagues across the NHS who are struggling with a wide range of mental health issues, from anxiety and depression to burnout and dealing with the impacts of moral injury.
    “Staff are exhausted, overwhelmed by their workload and struggling to give their patients the care they know they deserve.
    “I urge ministers to speak directly to hub leads to find out exactly what the issues are on the ground, and how the hubs are helping staff who are working at their limits, while supporting staff retention.”
    Read full story (paywalled)
    Source: HSJ, 6 July 2023
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