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Patient Safety Learning

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  1. Patient Safety Learning
    Left in agonising pain, with staff ignoring his cries for help, Martin Wild called 999 from his hospital bed, desperate for someone to get him the medication he needed.
    This was just the beginning of the 73-year-old’s “nightmare” experience at the hands of Salford Royal Hospital.
    Over nearly five months, the former car salesman says he was subjected to prolonged periods of neglect, including being left to lie in urine-soaked sheets, pleading for medication.
    He lost so much weight that, according to his wife, he became skin and bone. One staff member involved in his care said they’d never seen a hospital patient neglected to such a serious degree.
    Mr Wild told The Independent that his time at Salford Royal Hospital has shattered his belief in the NHS and that he believes it is not fit for purpose.
    “It was a nightmare in that ward. I didn’t feel like there was much caring going on,” he said.
    “I used to lie there at night; I could hear people shouting and screaming for help. It was like being in the third world.”
    Read full story
    Source: The Independent, 24 February 2024
  2. Patient Safety Learning
    The House of Lords is being urged to throw out plans for non-doctor associate roles to be licensed by the same body as doctors.
    Under a planned new law, physician associates (PAs) will be regulated by the General Medical Council (GMC).
    The British Medical Association (BMA) believes this could lead to patients confusing the different roles, which it says could have "tragic consequences".
    There are about 3,200 PAs working in GP surgeries and hospitals in England, with 10,000 more planned in the next decade or so.
    They were introduced to help doctors with their work - examining and diagnosing patients and discussing treatments with them - although PAs are currently unregulated.
    Unlike doctors, they do not have to hold a medical degree, but they usually have a degree in a life science and have to undertake a two-year training course.
    The BMA, the union representing doctors in the UK, believes that regulation by the GMC could lead to a "blurring of the lines" between PAs and doctors.
    In an open letter to the House of Lords ahead of a debate on Monday, the BMA's chairman Prof Phil Banfield said: "PAs are not doctors. They do not hold a medical degree and are not medically trained, despite misleading statements made by some.
    "We know that patients are already confused about telling the difference between PAs and doctors, and this legislation will make this problem worse.
    "Keeping the GMC as the regulator exclusively of doctors would mean we retain the clear distinction between doctors and PAs."
    Read full story
    Source: BBC News, 25 February 2024
  3. Patient Safety Learning
    Seeing the same GP improves patients’ health, reduces doctors’ workloads and could free up millions of appointments, according to the largest study of its kind.
    Research has previously suggested there may be benefits to seeing the same family doctor. But studies have mostly been small or covered a short period of time. Now University of Cambridge and Insead business school researchers have analysed data from 10m consultations over more than a decade in the most authoritative study on the issue yet.
    They found that if all GP practices moved to a model where patients saw the same doctor at each visit, it would significantly reduce doctors’ workloads while improving patient health. Multiple benefits emerged when patients had a long-term relationship with their doctor, researchers found.
    Seeing the same GP – known as continuity of care – meant people waited on average 18% longer between visits, compared with patients who saw different doctors.
    People did not take up more GP time in each consultation and the findings were particularly strong for older patients, those with multiple chronic illnesses, and people with mental health conditions.
    Although it will not always be possible for people to see their regular GP, researchers said the findings would translate to an estimated 5% reduction in consultations if all practices provided the level of continuity of care of the best 10% of practices. That suggests millions of appointments could be freed up.
    The researchers added: “Importantly, if patients receiving care from their regular doctors have longer intervals between consultations without requiring longer consultations, then continuity of care can potentially allow physicians to expand their patient list without increasing their time commitment.”
    Read full story
    Source: The Guardian, 23 February 2024
  4. Patient Safety Learning
    Black children in the UK are four times more likely to experience complications after appendicitis surgery than their white counterparts, a study has found.
    The study, funded by the Association of Paediatric Anaesthetists of Great Britain and Ireland, looked at 2,799 children from 80 hospitals across the UK aged under 16 who had surgery for suspected appendicitis between November 2019 and January 2022.
    Of these, 185 children (7%) developed postoperative complications within 30 days of the surgery. Three-quarters of these complications were related to the wound, while a quarter were respiratory, urinary or catheter-related or of unknown origin.
    The study found that black children had a four times greater risk of experiencing complications after the operation, and that this risk was independent of the child’s socioeconomic status and health history.
    Appendicitis is one of the most common paediatric surgical emergency with 10,000 performed every year. The authors said that this was the first study to look at the demographic differences of postoperative complication rates in regards to appendicitis.
    The researchers said they could not draw firm conclusions regarding why black children had worse outcomes after this type of emergency surgery, and that this apparent health inequality “requires urgent further investigation and development of interventions aimed at resolution”.
    Read full story
    Source: The Guardian, 22 February 2024
  5. Patient Safety Learning
    Bereaved parents who lose a baby before 24 weeks of pregnancy in England can now receive a certificate in recognition of their loss.
    Ministers say they have listened to bereaved parents who have gone through the painful experience of miscarriage.
    Campaigners said they were "thrilled" that millions of families would finally get the formal acknowledgement that their baby existed.
    All parents who have experienced baby loss since September 2018 can apply.
    They should visit the gov.uk website - applicants must be at least 16 years old, have been living in England at the time of the loss and be one of the baby's parents or surrogate.
    In Wales, there are plans to deliver a similar scheme. 
    Babies who are born dead after 24 completed weeks of pregnancy are called stillbirths, and their deaths are officially registered. But this does not happen for babies who die before that stage.
    Pregnancy loss or miscarriage before 24 weeks is the most common complication of pregnancy, experienced by an estimated one in five women in the UK.
    Read full story
    Source: BBC News, 21 February 2024
  6. Patient Safety Learning
    Health secretary Victoria Atkins has said mental health patients and staff must report the “horrific” sexual abuse allegations uncovered by The Independent to the police.
    Ms Atkins said victims would have her full support if they reported their claims to the police.
    Her intervention comes following a joint investigation by The Independent and Sky News, which revealed almost 20,000 reports of sexual harassment and abuse on NHS mental health wards in England.
    The allegations uncovered include patients claiming to have been raped by staff and other patients while being treated on mental health wards.
    In response to the initial investigation, Ms Atkins said a review launched last year into mental health services would now also look into sexual assault within the sector.
    Speaking on Sky News, she said: “These are horrific allegations that should not and must not happen in our care. Very, very vulnerable people have to stay in mental health inpatient facilities, and they do so because they need care, support, and treatment.
    “Some of the behaviours that have come to light are criminal offences, and so I would encourage anyone who feels able to – and I appreciate it is a difficult step – to go to the police and please report them, because they are crimes and we must drive them out.”
    Read full story
    Source: The Independent, 21 February 2024
  7. Patient Safety Learning
    From forgetfulness to difficulties concentrating, many people who have Long Covid experience “brain fog”. Now researchers say the symptom could be down to the blood-brain barrier becoming leaky.
    The barrier controls which substances or materials enter and exit the brain. “It’s all about regulating a balance of material in blood compared to brain,” said Prof Matthew Campbell, co-author of the research at Trinity College Dublin.
    “If that is off balance then it can drive changes in neural function and if this happens in brain regions that allow for memory consolidation/storage then it can wreak havoc.”
    Writing in the journal Nature Neuroscience, Campbell and colleagues report how they analysed serum and plasma samples from 76 patients who were hospitalised with Covid in March or April 2020, as well 25 people before the pandemic.
    Among other findings, the team discovered that samples from the 14 Covid patients who self-reported brain fog contained higher levels of a protein called S100β than those from Covid patients without this symptom, or people who had not had Covid.
    This protein is produced by cells within the brain, and is not normally found in the blood, suggesting these patients had a breakdown of the blood-brain barrier.
    Read full story
    Source: The Guardian, 22 February 2024
  8. Patient Safety Learning
    Scotland's NHS is unable to meet the growing demand for health services, a spending watchdog has warned.
    A review by Audit Scotland said the increased pressure on the NHS was now having a direct impact on patient safety and experience.
    The watchdog also claimed there was no "overall vision" for the future of the health service.
    The annual report on the state of Scotland's health service highlighted that the NHS was facing soaring costs, patients were waiting longer to be seen and there were not enough staff.
    Stephen Boyle, Auditor General for Scotland, said this had "added to the financial pressures on the NHS and, without reform, its longer-term affordability".
    He added: "Without change, there is a risk Scotland's NHS will take up an ever-growing chunk of the Scottish budget. And that means less money for other vital public services.
    "To deliver effective reform the Scottish government needs to lead on the development of a clear national strategy for health and social care.
    "It should include investment in measures that address the causes of ill-health, reducing long-term demand on the NHS."
    Read full story
    Source: BBC News, 22 February 2024
  9. Patient Safety Learning
    Doctors tore down posters offering patients a secondary care review if they were worried about their condition in hospital, the mother of a teenager who died of sepsis claimed.
    Merope Mills, who has campaigned for a similar policy called “Martha’s Rule” named after her 13-year-old daughter, claimed a small minority of “bad actors” in hospitals risked slowing down the initiative.
    It comes as NHS England announced 100 hospitals with critical care units will be invited to sign up for the policy, which will be rolled out from April this year.
    Martha died from sepsis in 2021 after staff at King’s College Hospital failed to move her to intensive care despite her family warning them her condition had deteriorated.
    “When something similar to Martha’s Rule was introduced to Royal Berkshire Hospital, doctors actually pulled down the posters advertising the service to patients because they hated the idea of giving patients this kind of power,” Mrs Mills told the Today Programme.
    “A small minority of bad actors whose arrogance, complacency or pride stops them listening and doing the right thing and that is what we are trying to challenge with Martha’s Rule. There are pockets of damaging cultures in hospitals around the country. Sometimes it is not a whole hospital, sometimes it is just a ward in a hospital, sometimes it is just a particular individual on a ward in a hospital.”
    Read full story
    Source: The Independent, 21 February 2024
  10. Patient Safety Learning
    In 2009, Emma Murphy took a phone call from her sister that changed her life. “At first, I couldn’t make out what she was saying; she was crying so much,” Murphy says. “All I could hear was ‘Epilim’.” This was a brand name for sodium valproate, the medication Murphy had been taking since she was 12 to manage her epilepsy.
    Her sister explained that a woman, Janet Williams, on the local news had claimed that taking the drug during her pregnancies had harmed her children. She was appealing for other women who might have experienced this to come forward.
    Murphy found the news segment that evening and watched it. “I was just stunned,” she says. “Watching that, I knew. I knew there and then that my children had been affected.”
    At that point, Murphy was a mother to five children, all under six, and married to Joe, a taxi driver in Manchester. “My kids are fabulous, all of them, but I’d known for years that something was wrong,” she says. “They weren’t meeting milestones. There was delayed speech, slowness to crawl, not walking. There was a lot of drooling – that was really apparent. They were poorly, with constant infections. I was always at the doctors with one of them."
    A call between Murphy and Janet Williams was the start of an incredible partnership. It led to the report published this month by England’s patient safety commissioner, Dr Henrietta Hughes, which recommended a compensation scheme for families of children harmed by valproate taken in pregnancy. Hughes has suggested initial payments of £100,000 and described the damage caused by the drug as “a bigger scandal than thalidomide”. It is estimated that 20,000 British children have been exposed to the drug while in the womb.
    Williams and Murphy have campaigned relentlessly to reach this point. It is by no means the endpoint – even now, an estimated three babies are born each month having been exposed to the drug. Together, the women formed In-Fact (the Independent Fetal Anti Convulsant Trust) to find and support families like theirs. They were instrumental in the creation of an all-party parliamentary group to raise awareness in government. 
    Read full story
    Source: The Guardian, 22 February 2024
  11. Patient Safety Learning
    A patient in north Wales suffered "catastrophic" consequences when staff didn't connect their oxygen supply correctly.
    The Betsi Cadwaladr health board, which was caring for the patient at the time, is investigating and says it was one of a small number of recent similar incidents.
    But it refused to say whether the patient died, or to explain what the “catastrophic” consequences were.
    It says it is working to improve staff training to avoid similar incidents happening again.
    On Tuesday, Wales' health minister Eluned Morgan said the health board still had "a lot to do," before it could be taken out of special measures.
    A report to the committee said: “Further patient safety incidents have occurred in the health board related to the preparation and administration of oxygen using portable cylinders.
    “On review, the cylinder had not been prepared correctly, resulting in no flow of oxygen to the patient.
    “One incident had a catastrophic outcome and is under investigation.”
    Read full story
    Source: BBC News, 20 February 2024
  12. Patient Safety Learning
    Medicine shortages have increased and are “around double what they were a year ago”, it has been claimed.
    Speaking to the Health and Social Care Committee on Monday, Mark Samuels, chief executive of the British Generic Manufacturers Association (BGMA), said they have been highlighting the medicine shortage risk to ministers since July 2021 and the BGMA is “very concerned about it”.
    He said: “We’ve been monitoring it for several years now, and as you saw in the written evidence, shortages have increased.
    “They’re around double what they were a year ago. We have them at 101 shortages in February this year.”
    We've just been hearing devastating stories from people about the emotional toll it's sort of taking on them not being able to access vital medications.
    The shortage of certain medications “continues to be challenging”, Dr Rick Greville, director of distribution and supply at the Association of the British Pharmaceutical Industry (ABPI), told the committee.
    But when asked if the shortage is getting better or worse, he said it is “difficult to know as to whether it is increasing significantly, but certainly it’s a long-standing issue”.
    Meanwhile, there is “serious concern” about the potential harm to people with diabetes due to a shortage of medication, the committee was told.
    Read full story
    Source: Evening Standard, 20 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 thread on the topic: 
    Medication supply issues: have you been affected?
    You'll need to register with the hub first, its free and easy to do. 
    We would also like to hear from pharmacists working in community or hospital settings, and others who have insights to share on this issue. What barriers and challenges have you seen around medication availability? Is there anything that can be done to improve wider systems or processes?
  13. Patient Safety Learning
    Ambulance chiefs have warned that patients are coming to harm, paramedics are being assaulted and control room staff reporting a “high stakes game of chicken” with police during the implementation of a controversial new national care model.
    The Association of Ambulance Chief Executives say in a newly published letter they believe the “spirit” of national agreement on how to implement the Right Care, Right Person model is not being followed by police, raising “significant safety concerns”.
    The membership body set out multiple concerns about the rollout of the model, under which the police refuse to attend mental health calls unless there is a risk to life or of serious harm.
    In the letter to Commons health and social care committee chair Steve Brine, AACE chair Daren Mochrie says timescales for introducing it were often “set by the police rather than “agreed” following meaningful engagement with partners”, meaning demand was shifting before health systems had built capacity. They also flag a lack of NHS funding to meet the new asks. 
    Mr Mochrie, also CEO of North West Ambulance Service Trust, described a “grey area” relating to what he called “concern for welfare” calls, which meet neither the police nor attendance services’ threshold for attendance.
    “To date this is the single biggest feedback theme we have heard from ambulance services, with some control room staff describing feeling like they’re in a ‘high-stakes game of chicken’ where the police have refused to attend and told the caller to hang up, redial 999 and ask for an ambulance,” he wrote.
    Read full story (paywalled)
    Source: HSJ, 20 February 2024
  14. Patient Safety Learning
    Codeine linctus, an oral solution or syrup licensed to treat dry cough in adults, is to be reclassified to a prescription-only medicine due to the risk of abuse, dependency and overdose, the Medicines and Healthcare products Regulatory Agency (MHRA) has announced.
    Codeine linctus is an opioid medicine which has previously been available to buy in pharmacies under the supervision of a pharmacist but will now only be available on prescription following an assessment by a healthcare professional.
    Since 2019, there have been increasing reports in the media of codeine linctus being misused as an ingredient in a recreational drink, commonly referred to as ‘Purple Drank’.
    The decision to reclassify the medicine has been made following a consultation with independent experts, healthcare professionals and patients. 992 responses were received.
    The consultation was launched by the MHRA after Yellow Card reports indicated instances of the medicine being abused, rather than for its intended use as a cough suppressant.
    Dr Alison Cave, MHRA Chief Safety Officer, said: "Patient safety is our top priority. Codeine linctus is an effective medicine for long term dry cough, but as it is an opioid, its misuse and abuse can have major health consequences."
    Alternative non-prescription cough medicines are available for short-term coughs to sooth an irritated throat, including honey and lemon mixtures and cough suppressants.
    Patients are urged to speak to a pharmacist for advice and not to buy codeine linctus from an unregistered website as it could be dangerous.
    Read full story
    Source: MHRA, 20 February 2024
  15. Patient Safety Learning
    A suicidal man died hours after being discharged from a scandal-hit hospital which is at the centre of a probe into the care of Nottingham triple killer Valdo Calocane.
    Daniel Tucker was released from a mental health ward at Highbury Hospital in Nottingham last year and died shortly afterwards, having taken a toxic substance he had purchased online.
    An inquest into his death last week found there were multiple failings by Nottinghamshire Healthcare Foundation Trust in the lead-up to Tucker’s death, with no appropriate care plan or risk assessment in place for him before or after his discharge.
    The 10-day hearing heard he had been discharged from the hospital on 22 April, despite having shared suicidal intentions with staff just days before. The jury concluded that failures by staff to ensure an appropriate plan for him contributed to his death.
    It comes after health secretary Victoria Atkins ordered the Care Quality Commission to carry out an inquiry into Nottinghamshire Healthcare. The probe will look at the handling of Calocane, who had been discharged from Highbury Hospital and was a patient under the trust’s community crisis services when he stabbed three people to death in a brutal knife rampage.
    Read full story
    Source: The Independent, 18 February 2024
  16. Patient Safety Learning
    Michelle Nolan takes morphine daily for the pain she has lived with for 14 years after botched surgery at the hands of a once renowned surgeon.
    She suffered irreversible nerve damage in July 2010 when John Bradley Williamson, a former president of the British Scoliosis Society, inserted a screw that was too long into her spine at Spire Manchester Hospital.
    The 49-year-old from Chadderton, near Oldham, needs crutches and lost her job as a legal secretary and later her house and marriage. “I lost everything because of him,” she said. “I thought I was the only one he had harmed.”
    She was not. Families and patients operated on by Williamson over two decades at the Salford Royal Hospital, Spire Manchester Hospital and the Royal Manchester Children’s Hospital, have formed a support group and want a full recall of all of his patients.
    They fear some could be suffering without realising they are victims of poor care.
    Williamson told the coroner investigating Catherine’s death that her surgery “progressed uneventfully” and “the blood loss was perhaps a little higher than one would usually anticipate but was certainly not extreme”.
    Yet days after her death, Williamson sent an internal letter to the hospital’s haematology department head Simon Jowitt describing the surgery as “difficult” and involving “a catastrophic haemorrhage”.
    Read full story (paywalled)
    Source: The Times, 18 February 2024
  17. Patient Safety Learning
    The government is considering plans to allow dentists from abroad to work without taking an exam to check their education and skills.
    The proposal, which is subject to a three-month consultation, aims to address the severe shortage of NHS dentists.
    It is hoped a quicker process would attract more dentists.
    The British Dental Association has accused the government of avoiding the issues "forcing" dentists to quit.
    The proposal forms part of the government's £200 million NHS Dental Recovery Plan for England, announced earlier this month.
    Under the plan, dentists could also be paid more for NHS work, while so-called "dental vans" would be rolled out to areas with low coverage, alongside an advice programme for new parents.
    There is also a proposal of £20,000 bonuses for dentists working in under-served communities, as part of an effort to increase appointment capacity by 2.5 million next year.
    At present, overseas dentists are required to pass an exam before they can start work in the UK - the new idea would see the General Dental Council (GDC) granted powers to provisionally register them without a test.
    Stefan Czerniawski, executive director of strategy at the GDC said: "We need to move at pace, but we need to take the time to get this right - and we will work with stakeholders across the dental sector and four nations to do so."
    Read full story
    Source: BBC News, 17 February 2024
  18. Patient Safety Learning
    A woman said she has been unable to get her ADHD medication for months.
    Hannah Huxford, 49, from Grimsby is one of thousands of patients unable to get hold of medicine to manage their symptoms due to a national shortage.
    Mrs Huxford, who was diagnosed with the condition two years ago, described the situation as a "huge worry".
    The Department of Health and Social Care (DHSC) said it had taken action to improve the supply of medicines but added that "some challenges remain".
    Mrs Huxford said the medicine made a "huge difference" and got her life back on track.
    "It enables me to function and concentrate so I can be more proactive, I can be more productive," she explained.
    She said she had been unable to get her usual supply since October 2023 and has to ration what she can get hold of.
    "Christmas time it was just getting beyond a joke. I was going back to the pharmacy, probably two or three times in a month, just to collect the little IOUs and it was getting to the point where that, in itself, was becoming a stress," she said.
    "All of a sudden, if this medication is taken away from me, I'm frightened that I will go back to not being able to cope."
    James Davies, from the Royal Pharmaceutical Society, said the supply shortage has been caused by manufacturing problems and an increase in demand.
    "There are more people who are being diagnosed with ADHD, more people seeking to access ADHD treatments. That's not just related to the UK, this is a global problem," he said.
    Mr Davies said some ADHD medication has come back into stock but added "it's quite a fluid situation at the moment".
    Read full story
    Source: BBC News, 19 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 thread on the topic: 
     
    You'll need to register with the hub first, its free and easy to do. 
    We would also like to hear from pharmacists working in community or hospital settings, and others who have insights to share on this issue. What barriers and challenges have you seen around medication availability? Is there anything that can be done to improve wider systems or processes?
  19. Patient Safety Learning
    Patients are facing delays stuck on hidden waiting lists that do not show up in the official figures in England, a BBC News investigation reveals.
    The published waiting list stands at 7.6 million - but the true scale of the backlog is thought to be much higher.
    This is because patients needing ongoing care are not automatically included in those figures - even if they face major delays.
    NHS England said hospitals should be monitoring and counting such cases.
    But BBC News found evidence suggesting this is not always the case.
    The problem affects patients receiving ongoing care, as well as those removed from waiting lists even before starting treatment.
    BBC News has spoken to patients waiting months and even years for vital treatment, such as cancer care, spinal treatment and others at risk of going blind because of deteriorating eyesight.
    Hospitals are meant to return patients facing unnecessary delays to the waiting list to ensure they are counted in the backlog figures.
    But of 30 NHS trusts asked by BBC News how regularly this was happening, only three could provide figures.
    Karen Hyde, from Insource, a company that helps hospitals manage waiting lists, said the guidance was "commonly ignored".
    "This is a huge issue. The NHS does not incentivise hospitals to keep a close eye on these patients.
    "We know there are long waits for those on the waiting list. For those not on the official waiting list, it is likely to be even worse - but the figures are not published."
    Read full story
    Source: BBC News, 19 February 2024
  20. Patient Safety Learning
    Italy will carry out an inquiry into its handling of the coronavirus pandemic in a move hailed as “a great victory” by the relatives of people killed by the virus but criticised by those who were in power at the time.
    Italy was the first western country to report an outbreak and has the second highest Covid-related death toll to date in Europe, at more than 196,000. Only the UK’s death toll is higher.
    The creation of a commission to examine “the government’s actions and the measures adopted by it to prevent and address the Covid-19 epidemiological emergency” was approved by the lower house of parliament after passing in the senate.
    Consuelo Locati, a lawyer representing hundreds of families who brought legal proceedings against former leaders, said: “The families were the first to ask for a commission and so for us this is a great victory. The commission is important because it has the task, at least on paper, to analyse what went wrong and the errors committed so as not to repeat the massacre we all suffered.”
    Read full story
    Source: The Guardian, 15 February 2024
  21. Patient Safety Learning
    A trust’s main maternity unit has been rated “inadequate” and given a warning notice amid concerns delayed Caesarean sections are causing harm to babies.
    The Care Quality Commission (CQC) told Maidstone and Tunbridge Wells Trust to make significant improvements in how quickly it carries out emergency C-sections, the regulator said in a report today.
    The trust was also told to improve risk management, governance and oversight of services at its Tunbridge Wells Hospital.
    Inspectors found between April and July last year, 42% of “category 1” emergency Caesareans – defined as those posing an immediate threat to the life of the woman or foetus — at the Tunbridge Wells Hospital were delayed. The National Institute for Health and Care Excellence says these should be carried out “as soon as possible and in most situations within 30 minutes of making the decision”.
    The report identified “ongoing recurrent delays” to emergency Caesareans overnight, as the trusts did not have a second theatre available.
    This “meant an increased risk of harm, including cases reported by the service such as babies with ‘acute foetal hypoxia’ had emerged due to delayed births”, the inspection report said.
    It also criticised the trust for not responding to a high level of post-partum haemorrhages, some of which had caused “moderate” harm.
    Read full story (paywalled)
    Source: HSJ, 16 February 2024
  22. Patient Safety Learning
    Areas across England where the highest proportion of ethnic minorities live have the poorest access to GPs, with experts attributing this disparity to an outdated model being used to determine funding.
    As of October 2023, there were 34 fully qualified full-time-equivalent GPs per 100,000 patients in the areas with the highest proportion of people from ethnic minority backgrounds, according to a Guardian analysis of NHS Digital and census data.
    This is 29% lower than the 48 general practitioners per 100,000 people serving neighbourhoods with the highest proportion of white British people.
    Although ethnic minorities tend to be younger than the white British population, minority ethnic areas still have the lowest number of GPs per person even when factors such as age, sex and health necessities are considered.
    Prof Miqdad Asaria at the London School of Economics department of health policy said it was “very concerning” that ethnic minorities “have systematically poorer access to primary care which is likely to be a key driver of current and future health inequalities”.
    “Primary care plays a crucial role in preventing disease, diagnosing and treating illness, and facilitating access to specialist or hospital treatment for people who need it,” he added.
    Read full story
    Source: The Guardian,15 February 2024
  23. Patient Safety Learning
    Ambulance trusts have often prioritised capacity and response times over dealing with cases of misconduct, a review of culture in the sector for NHS England has found.
    The review says ambulance trusts need to “establish clear standards and procedures to address misconduct”.
    The work was carried out by Siobhan Melia, who is Sussex Community Healthcare Trust CEO, and was seconded to be South East Coast Ambulance Service Foundation Trust interim chief from summer 2022 to spring last year.
    Her report says bullying and harassment – including sexual harassment – are “deeply rooted” in ambulance trusts, and made worse by organisational and psychological barriers, with inconsistencies in holding offenders to account and a failure to tackle repeat offenders.
    She says “cultural assessments” of three trusts by NHSE had found “competing pressures often lead to poor behaviours, with capacity prioritisation overshadowing misconduct management”, adding: “Staff shortages and limited opportunities for development mean that any work beyond direct clinical care is seen as a luxury or is rushed.
    “Despite this, there is a clear link between positive organisational culture and improved patient outcomes. However, trusts often focus on meeting response time standards for urgent calls, whilst sidelining training, professional development, and research.”
    Read full story (paywalled)
    Source: HSJ, 15 February 2024
  24. Patient Safety Learning
    An integrated care board (ICB) has found its handling of whistleblowing “not fit for purpose”, after a complaint about safety incidents not being properly investigated.
    A report by North West London ICB, obtained by HSJ, states: “The whistleblowing policy is not fit for purpose and requires immediate updating. The [Freedom to Speak Up] Guardian has been left blank and the policy does not include key components of best practice.”
    It also found the “whistleblower should have been provided with a substantive response to their concerns within 28 days” but in fact waited 98 working days, “due to delays with starting the whistleblowing component of the grievance”.
    The ICB reviewed its processes after a complaint from a staff member who raised concerns early last year about “a lack of, or poor, response” to reported patient safety incidents in the system, which are meant to be routinely reviewed by ICBs “prior to closure”. 
    Read full story (paywalled)
    Source: HSJ, 15 February 2024
  25. Patient Safety Learning
    The number of patients waiting more than 12 hours for a bed on a ward after being seen in A&E in England was 19 times higher this winter than it was before the pandemic, figures show.
    There were nearly 100,000 12-hour waits in December and January - compared with slightly more than 5,000 in 2019-20.
    A decade ago these waits were virtually unheard of - in the four winters up to 2013-14 there were fewer than 100.
    The King's Fund said long delays were at risk of becoming normalised.
    It said the pressures this winter had received little attention compared with last winter, despite no significant improvement in performance.
    During December 2023 and January 2024, 98,300 patients waited more than 12 hours for a bed on a ward after A&E doctors took the decision to admit them.
    The Northern Ireland branch of the Royal College of Emergency Medicine (RCEM) said the pressures were "unsurmountable" and it was having a detrimental impact on patients.
    Read full story
    Source: BBC News, 15 February 2024
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