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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    The Women and Equalities Committee in a recent report has challenged the government over failures to address inequalities in maternity care which have led to Black women dying at four times the rate of white women. Tinuke Awe, 31, was left ‘traumatised’ and forced to go without pain relief after midwives didn’t believe she was in labour. Ms Awe, was induced after experiencing late pre-eclampsia while pregnant with her first child in 2017. She said: “Pre-eclampsia can be life-threatening for mum and baby, and it could’ve been fatal if I wasn’t treated. I was told I couldn’t leave the hospital and had to be induced". “They said the hormones could take 24 hours to work, but my labour happened really quickly and when I told the midwife she didn’t even believe I was in labour.” “I felt so overlooked and it was horrible how nobody listened to me,” she added. “I ended up having to have an assisted delivery which isn’t what I wanted, but it could’ve been avoided if someone had acknowledged I was in labour rather than ignore me. I just felt so unimportant.” Ms Aew alongside Clotilde Abe set up the charity Five X More. The organisation helps give advice and empower Black women to make informed choices during pregnancy and after childbirth. Five X More hope that the testimonials of the women they support can be used to show that better outcomes are possible with their ‘five steps for self-advocacy‘ being used to encourage women to ask for things like a second opinion. Read full story Source: The Independent, 18 April 2023 Read our interview with Tinuke Awe on the hub: Five X More campaign: Improving maternal mortality rates and health outcomes for black women
  2. News Article
    Anew model of care which the Public Health Agency (PHA) say will 'improve maternity services for women and babies in Northern Ireland' is being launched. The new model, which will see women receive support from the same midwifery team during pregnancy, birth and in the early days after birth, is being rolled out across all Health and Social Care (HSC) Trusts in the coming months. ‘Continuity of Midwifery Carer’ (CoMC) is a new model of care for women throughout their childbirth journey "that will provide positive clinical outcomes and higher care satisfaction", the PHA said. Chief Nursing Officer for Northern Ireland, Maria McIlgorm said: “This is a very positive development for maternity services in Northern Ireland. There is a clear evidence base behind the Continuity of Midwifery Carer model which shows that when a woman knows their midwife it can make a significant difference to their experience and outcome. “This woman and family-centred model of care will mean that women across Northern Ireland using our maternity services will receive support from the same dedicated midwifery team throughout their pregnancy, birth and postnatal period.” Read full story Source: Belfast Live, 12 April 2023
  3. News Article
    The NHS has been criticised for sending vulnerable patients to a children’s hospital despite receiving reports of more than 1,600 “sexual safety incidents” at the 59-bed unit. A series of investigations by The Independent have exposed allegations of systemic abuse across a group of children’s hospitals run by the former Huntercombe Group. The latest revealed that a total of 1,643 “sexual safety incidents” had been reported in four years at its hospital in Maidenhead – accounting for more than half of all sex-related investigations reported in the 209 children’s mental health units across the country since 2019. Despite the majority of these reports being made prior to 2022-23, the NHS did not take any action and only stopped using the hospital, also known as Taplow Manor, this year. Gemma Byrne, head of health policy and campaigns at Mind, said in response to The Independent report on sexual incidents: “These horrific reports reveal the systemic scale of abuse and neglect in inpatient mental health settings. Even when patients bravely came forward to share their stories, some of which took place more than 10 years ago, young people continued to be sent to a unit which was known to have catastrophic failings in physical and sexual safety.” Read full story Source: The Independent, 18 April 2023
  4. News Article
    People who survive cancer may be at heightened risk of cardiovascular disease in subsequent years, data suggests. However, heart scans may identify early heart damage, potentially opening the door to more tailored follow-up care for cancer survivors. Although previous studies have suggested that people who have been treated for cancer may be at greater risk of future cardiovascular problems such as stroke or heart failure, these have mainly focused on the first year after a cancer diagnosis. Few have looked at longer term risks or included cardiovascular imaging to pinpoint damage that has not yet resulted in symptoms. To plug these gaps, Dr Zahra Raisi-Estabragh at Queen Mary University of London and her colleagues assessed the cardiovascular health of 18,714 UK Biobank participants with a previous diagnosis of lung, breast, prostate, blood, womb or bowel cancer, and compared them with an equal number of participants with no cancer history, tracking their cardiovascular health for nearly 12 years. Almost a third of cancer survivors developed a cardiovascular problem during the study period, compared with a quarter of people in the control group. “This study adds to existing knowledge about the impact of some cancer treatments on cardiovascular disease in cancer survivors,” said Martin Ledwick, the head information nurse at Cancer Research UK. “It may help to inform strategies for how some cancer survivors need to be monitored long-term, especially in situations where they have been discharged from cancer follow-up to the care of their GPs.” Read full story Source: The Guardian, 18 April 2023
  5. News Article
    Patients were left on trolleys for up to four days at a major NHS hospital where whistleblowers raised concerns over “unsafe” staffing levels, it has emerged. In a scathing report, the NHS safety watchdog said it found patients waiting on trolleys, in corridors and outside nursing bays at Good Hope and Heartlands hospital, run by the scandal-hit University Hospitals Birmingham NHS Foundation Trust. In one incident flagged by the Care Quality Commission (CQC), a patient’s skin ulcers had grown significantly worse while they waited for four days on a trolley without an appropriate mattress. At the time of the inspection, most patients had been waiting for more than two days on trolleys, according to the CQC. The inspection took place in December, after concerns were raised by patients and families over care. The CQC said staff told inspectors they’d been left in “unsafe situations” due to poor staffing. Read full story Source: The Independent, 19 April 2023
  6. News Article
    A senior coroner has warned that more allergy sufferers will die due to a “lack of national leadership” following the death of a 17-year-old aspiring doctor. Heidi Connor said the “tragic” case of Alexandra Briess was “not new territory”, citing three recent cases where people had died from anaphylaxis. She has now written to the Government saying lives are at risk without better funding and research into the condition and calling for the appointment of an allergies tsar. The Berkshire coroner’s warning comes after an inquest into the death of “bright and well loved” Alexandra, who died from a reaction to a common anaesthetic. Read full story (paywalled) Source: The Times, 18 April 2023
  7. Content Article
    On 22 May 2021, 17-year-old Alexandra Briess underwent a tonsillectomy and subsequently experienced post-operative bleeding, requiring second operation carried out at Royal Berkshire Hospital on the 30 May. During anaesthesia, she experienced a sudden deterioration and cardiac arrest. Despite extensive resuscitation efforts, Alexandra died on the 31 May. Subsequent investigations have revealed that the most likely cause of her sudden deterioration was an anaphylactic reaction to Rocuronium. In this report, the Coroner highlights connections between this case and three other Prevention of Future Deaths Report’s and suggests there needs to be greater funding and a role within the NHS to coordinate a national approach to prevent/reduce future deaths.
  8. Content Article Comment
    @Barbara Hercliffe Thanks for spotting this. I've updated the link to the guide.
  9. Content Article Comment
    @ZJR Thanks for spotting this. I've updated the link so it should now go to the correct page on the website.
  10. Content Article
    We often hear the mesh scandal blamed on poor surgeon skill. We also hear the argument that high use mesh implanting surgeons are likely to have fewer patients suffering mesh complications, than a less experienced surgeon. However, this study published in JAMA in October 2018, based on NHS data, shows that high mesh implanting surgeons produce the same or even more mesh complications compared to low volume implanters.
  11. Event
    Conference theme: Times of multiples crisis: reasons and ways to keep Patient Safety on the agenda. Key topics: Patient involvement. Safety culture. Leadership, teamwork and organisational performance. Well-being and safety of healthcare workers. Challenge of implementation. Register
  12. Content Article
    Ministers, high-level representatives and distinguished experts from all over the world gathered in Montreux on 23 and 24 February 2023 for the 5th Global Ministerial Summit on Patient Safety. They discussed achievements, challenges, priorities and necessary points of action. The summit marked another key milestone for global developments in patient safety. The Ministers and other participants reaffirmed that patient harm in health care is an urgent public health issue, pertinent to countries of all income settings and geographies and therefore a shared global challenge. Patient safety is essential for the achievement of universal health coverage and global health security. Read the Montreux Charter on Patient Safety launched at the Summit.
  13. News Article
    A silent crisis in men’s health is shortening the life spans of fathers, husbands, brothers and sons. For years, the conventional wisdom has been that a lack of sex-specific health research mainly hurts women and gender minorities. While those concerns are real, a closer look at longevity data tells a more complicated story. Across the life span — from infancy to the teen years, midlife and old age — the risk of death at every age is higher for boys and men than for girls and women: Men are at a greater risk of dying from covid-19 than women, a gap that cannot be explained by rates of infection or preexisting conditions. More men die of diabetes than women. The cancer mortality rate is higher among men — 189.5 per 100,000 — compared with 135.7 per 100,000 for women. Men die by suicide nearly four times more often than women, based on 2020 data from the Centers for Disease Control and Prevention. “Some people think health care is a zero sum gain and one dollar to men’s health is taking something away from women,” said Ronald Henry, president and co-founder of the Men’s Health Network, an advocacy group. “That’s wrong. We are fully supportive of women’s health efforts and improving quality of life for women.” "But by viewing men as the privileged default, health experts are ignoring important sex differences that could illuminate health issues across gender and minority groups." Read full story (paywalled) Source: The Washington Post, 17 April 2023
  14. News Article
    A tribunal which allowed a doctor's voluntary removal from the medical register was an "unlawful corner-cutting exercise", a judge has said. Neurologist Michael Watt was at the centre of Northern Ireland's biggest recall of patients. The Medical Practitioners Tribunal Service (MPTS) allowed him to voluntarily remove himself in 2021. It meant he would not face a public hearing about any fitness to practice issues. More 2,500 patients who were in his care had their cases reviewed - with around one in five having their diagnosis changed. Having already quashed the decision to grant removal, Mr Justice McAlinden delivered a scathing assessment of how the application was handled on Monday. In Belfast's High Court, he described the process where Dr Watt's request was heard without the necessary jurisdiction as a "fiasco". The court also heard how Dr Watt appeared to have a "get out of jail free card" where patients were denied public scrutiny of their medical care. Read full story Source: BBC News, 17 April 2023
  15. News Article
    Thousands of women are to be called for smear tests after errors in Scotland's cervical screening programme. In June 2021 it was discovered that several women had died from cervical cancer after being wrongly excluded from NHS Scotland's screening list. Now a further review expects to find 13,000 patients who have had a hysterectomy will need further tests. MSPs were told two years ago that a small number had died from cervical cancer after wrongful exclusion from the programme, and that further incorrect exclusions were possible. The most common reason for exclusion was after a total hysterectomy, where the entire cervix has been removed, meaning there was no need for cervical screening. But some were recorded as having had this procedure where there was only a sub-total or partial hysterectomy, meaning cervical screening was still needed. An urgent audit followed and all affected women were invited for follow-up examination. Now, a wider audit of 150,000 women who have had subtotal hysterectomies has been launched. Read full story Source: BBC News, 17 April 2023
  16. News Article
    Almost 200,000 hospital appointments and procedures in England were cancelled during last week’s junior doctors’ strikes, it has been revealed. There were 20,000 more appointments cancelled in the strikes that ran between 11 and 15 April than in the shorter strike in March, NHS England figures show. A total of 27,361 staff were not at work during the peak of the strikes, though the true figure could be higher as some workforce data was incomplete. The NHS’s national medical director, Prof Sir Stephen Powis, said the figures showed the “colossal impact of industrial action on planned care in the NHS”, with nearly half a million appointments rescheduled over the last five months. He said every postponed appointment had “an impact on the lives of individuals and their families and creates further pressure on services and on a tired workforce – and this is likely to be an underestimate of the impact as some areas provisionally avoided scheduling appointments for these strike days”. Read full story Source: The Guardian, 17 April 2023
  17. News Article
    An MPs' report is calling for faster progress to tackle "appalling" higher death rates for black women and those from poorer areas in childbirth. The Women and Equalities Committee report says racism has played a key role in creating health disparities. But the many complex causes are "still not fully understood" and more funding and maternity staff are also needed. The NHS in England said it was committed to making maternity care safer for all women. The government said it had invested £165m in the maternity workforce and was promoting careers in midwifery, with an extra 3,650 training places a year. Black women are nearly four times more likely than white women to die within six weeks of giving birth, with Asian women 1.8 times more likely, according to UK figures for 2018-20. And women from the poorest areas of the country, where a higher proportion of babies belonging to ethnic minorities are born, the report says, are two and a half times more likely to die than those from the richest. Caroline Nokes, who chairs the committee, said births on the NHS "are among the safest in the world" but black women's raised risk was "shocking" and improvements in disparities between different groups were too slow. "It is frankly shameful that we have known about these disparities for at least 20 years - it cannot take another 20 to resolve," she added.
  18. Content Article
    In the UK, maternal mortality for Black women is currently almost four times higher than for White women, and significant disparities also exist for women of Asian and mixed ethnicity. In this report the Women’s and Equalities Select Committee reviews what is currently understood about the reasons for disparities in maternal deaths, analyses Government and NHS action to date and existing recommendations for change and consider the ongoing challenges to addressing disparities.
  19. News Article
    Nine in 10 beauty clinics are breaking the law by advertising Botox, new research reveals, sparking fresh concern that Britain’s booming £3.6bn cosmetic treatments industry is like the “wild west”. Academics at University College London (UCL) found 88% clinics in London are flouting regulations intended to protect public health banning the advertising of Botox and other forms of botulinum toxin. The disclosure prompted warnings the illegal advertisements could help persuade vulnerable people to undergo injections that could leave them feeling traumatised. Promotion of the anti-ageing substance is illegal because it is a prescription-only medicine, which cannot be advertised under the Human Medicines Regulations 2012. A group of beauty professionals who are seeking to rid the industry of its reputation for dubious practices said the findings showed consumers were being subjected to “a tsunami of untamed and unrestricted promotional activity that presents a threat to public protection and patient safety”. Read full story Source: The Guardian, 14 April 2023
  20. News Article
    The government is investigating reports that growing numbers of people are developing life-changing allergies to some gel nail products. Dermatologists say they are treating people for allergic reactions to acrylic and gel nails "most weeks". Dr Deirdre Buckley of the British Association of Dermatologists urged people to cut down on gel nail use and stick to "old-fashioned" polishes. Some people have reported nails loosening or falling off, skin rashes or, in rarer cases, breathing difficulties, she said. Although most gel polish manicures are safe and result in no problems, the British Association of Dermatologists is warning that the methacrylate chemicals - found in gel and acrylic nails - can cause allergic reactions in some people. It often occurs when gels and polishes are applied at home, or by untrained technicians. Dr Buckley said: "We're seeing it more and more because more people are buying DIY kits, developing an allergy and then going to a salon, and the allergy gets worse." The allergies can leave sufferers unable to have medical treatments like white dental fillings, joint replacement surgery and some diabetes medications. This is because once a person is sensitised, the body will no longer tolerate anything containing acrylates. Read full story Source: BBC News, 15 April 2023
  21. News Article
    The deaths of 650 patients treated by a breast cancer surgeon who was convicted of maiming hundreds are being investigated, it has been reported. Once one of the country’s leading doctors, Ian Paterson carried out thousands of operations before he was jailed for uneccesarily performing hundreds of life-changing surgeries. The Sunday Times has now revealed medical experts are sifting through the records of women who were cared for by the disgraced surgeon over more than twenty years. He is currently serving a 20-year jail term, having been found guilty of 17 counts of wounding with intent. Many of the procedures, which took place between 1997 and 2011, had “no medically justifiable reason”, a court heard. According to The Sunday Times, 27 inquests have been opened in cases where coroners “believe there is evidence to have reason to suspect that some of those deaths may be unnatural”. Read full story Source: The Independent, 16 April 2023
  22. News Article
    An all-out nurses’ strike over the May bank holiday will present “serious risks and challenges” to the NHS, a health leader has warned. Sir Julian Hartley, chief executive of NHS Providers, said the “unprecedented” strike action – which will involve staff in emergency departments, intensive care units and cancer care for the first time – was “extremely worrying”. He also said the threat of coordinated industrial action with junior doctors could result in the “most difficult challenge” for the NHS to date. Sir Julian told BBC Breakfast: “If this takes place in the way that it’s been described, then it would be the first time that we’ve seen nurses not working in those key areas, which of course would present serious risks and challenges for trusts to manage and mitigate that.” Nick Hulme, chief executive of Ipswich and Colchester hospitals, told Radio 4 the latest round of nurses’ strikes will “significantly increase the risk to patients”, adding cancer patients will face greater risks as care could be delayed. He said: “If there is a delay to cancer care, some delays won’t cause significant effects, but there are many people who have been waiting far too long for care and this will only exacerbate that risk." Read full story Source: The Independent, 16 April 2023
  23. News Article
    In an enormous leap forward in the understanding of Parkinson’s disease (PD), researchers have discovered a new tool that can reveal a key pathology of the disease: abnormal alpha-synuclein — known as the “Parkinson’s protein” — in brain and body cells. The breakthrough published in the scientific journal The Lancet Neurology, opens a new chapter for research, with the promise of a future where every person living with Parkinson’s can expect improved care and treatments — and newly diagnosed individuals may never advance to full-blown symptoms. The tool, called the α-synuclein seeding amplification assay (αSyn-SAA), can detect pathology in spinal fluid not only of people diagnosed with Parkinson’s, but also in individuals who have not yet been diagnosed or shown clinical symptoms of the disease, but are at a high risk of developing it. By helping to identify people at the earliest stages of PD, “We could then study what happens at different biological stages of the disease,” says Dr. Sherer. Says Ken Marek, MD, PPMI principal investigator, “αSyn-SAA enables us to move to another level in effecting new strategies for prevention of disease.” Read full story Source: The Michael J Fox Foundation for Parkinson' research, 13 April 2023
  24. News Article
    A father whose baby died at six weeks after his vitamin K jab was missed has urged parents not to be taken in by misinformation spreading across social media. Alex Patto, 33, and his wife wanted their newborn son, William, to have the vitamin K jab to protect him against a rare but serious bleeding disorder known as vitamin K deficiency bleeding (VKDB). But the Rosie Hospital in Cambridge missed the jab and their firstborn child tragically passed away at six weeks old after suffering a bleed on his brain. Cambridge University Hospitals NHS Foundation Trust has completed a serious incident report and an inquest is due to take place in the coming months. Having gone through baby loss, Alex said he finds it “hard to understand” why parents would trust unverified information on social media over advice from their healthcare professional to opt into the jab. iNews previously revealed an increase in anti-vaccination misinformation on social media discouraging parents from getting the vitamin K jab for their newborn babies. The jab is a vitamin injection, not a vaccine – which are given to protect against infectious diseases – but doctors have reported videos on social media are incorrectly mislabelling it as such. Read full story Source: iNews, 23 March 2023
  25. News Article
    A company which ran children's homes where residents were systemically abused also failed to prevent adults being harmed, BBC News has learned. An investigation found 99 cases of abuse at a Doncaster home for vulnerable adults in 2010. One worker even ordered a Taser to use there. The care home company - Hesley - said improvements were made at the time. But children at other Hesley homes were later reported to have been punched, kicked and fed chillies. The BBC reported in January how more than 100 reports of appalling abuse and neglect - dating from 2018 to 2021 - were uncovered at sites run by the Hesley Group. They included children being locked outside in freezing temperatures while naked, and having vinegar poured on wounds. Now the BBC has obtained confidential reports from within Hesley and the local authority which reveal wider safeguarding failings spanning more than a decade at both children's homes and placements for vulnerable young adults. Read full story Source: BBC News, 14 April 2023
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