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Patient-Safety-Learning

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News posted by Patient-Safety-Learning

  1. Patient-Safety-Learning
    Giving teenagers the HPV vaccine is cutting cases of cervical cancer by 90%, figures for England show.
    Scientists say it works so well that this type of cancer could be eradicated in the near future. The study shows the vaccine is most effective when offered to Year 8 students - those aged 12 to 13. The vaccine also provides protection against genital warts by preventing human papillomavirus (HPV) infections.
    The study, funded by Cancer Research UK and led by experts at Queen Mary University of London, shows the HPV vaccine combined with cervical screening can dramatically reduce cervical cancer incidence to the point where almost no-one develops it. More cases were prevented in the most deprived socio-economic groups in society - those often hit hardest by the disease.
    Prof Peter Sasieni, lead author of the work that is published in the British Medical Journal,, external said: "Our research highlights the power of HPV vaccination to benefit people across all social groups. Historically, cervical cancer has had greater health inequalities than almost any other cancer and there was concern that HPV vaccination may not reach those at greatest risk. This study captures the huge success of the school-based vaccination programme in helping to close these gaps and reach people from even the most deprived communities."
    Read full story
    Source: BBC News, 16 May 2024
  2. Patient-Safety-Learning
    More than 50 NHS whistleblowers claim to have lost their jobs—with some driven to the brink of suicide—after standing up to protect patients’ lives as bosses bury their concerns.
    The group of doctors and nurses said that they had been targeted after raising concerns about more than 170 patient deaths and nearly 700 cases of poor care.
    One consultant said that it was the “biggest scandal within our country” and claimed the true number of avoidable deaths was “astronomical”. Instead of addressing the problems, the whistleblowers claim that NHS bosses are spending millions of pounds of taxpayers’ money on hiring law firms and private investigators to investigate them instead.
    Last year Rob Behrens, the health ombudsman, warned The Times Health Commission that patient safety was at risk due to “toxic” and hierarchical behaviour among NHS doctors. Professor Phil Banfield, the chairman of the council of the British Medical Association, which represents doctors, wrote in The Daily Telegraph that whistleblowing “is not welcomed by NHS management… NHS trusts and senior managers are more concerned with protecting personal and organisational reputations than they are with protecting patients.”
    In one case, the NHS spent more than £4 million on legal action against a single whistleblower, which included £3.2 million in compensation. Among the clinicians interviewed, 40 said that their employer took “no positive action” to address patient safety concerns; 36 said that patients remained at risk at their place of work; 19 said that NHS trusts covered up the problems, and ten said that their employers had denied there was a problem.
    Whistleblowers’ representatives are urging the government to require independent medical assessments for claims and to ban the suspension or exclusion of doctors for speaking out about patient safety.
    Dr Naru Narayanan, president of the hospital doctors’ union, has called for an independent national whistleblowing body outside of the NHS to register protected disclosures and protect individuals against recriminations. The Times Health Commission recommended that a no-blame compensation scheme should be introduced for medical errors, with settlements determined according to need. Backed by Jeremy Hunt, the chancellor, the scheme would help end the deadly cycle of NHS scandals and cover-ups and ensure families receive timely support.
    Read full story (paywalled)
    Source: The Times, 15 May 2024
  3. Patient-Safety-Learning
    A trust is experiencing severe problems with its electronic patient record system two years after it was installed, HSJ research has revealed.
    A “preliminary review” into the Oracle Cerner electronic patient record – called Surrey Safe Care – at Ashford and St Peter’s Hospitals (ASPH) Foundation Trust in Surrey found the emergency department was still spending “significant time” using the system, an electronic bed board was not updated in real-time, and there were booking and workflow errors in clinics.
    The review, which was released to HSJ after a Freedom of Information Act request and carried out in recent months, found problems stemming from limited system training, configuration issues and insufficient technology available on wards and in clinics. The EPR went live in May 2022.
    The trust also had “insufficient analysts” to provide comprehensive management information. Also, performance, utilisation and management information were described as still being “under construction.”
    In a statement, ASPH said, “Annual reviews will be carried out to monitor the continual progress of this project. A new working group of clinical, operational, and digital staff will agree how we use existing resources to improve staff training, add extra functionality to the EPR, invest in appropriate technology and additional analysts.”
    Read full story (paywalled)
    Source: HSJ, 15 May 2024
  4. Patient-Safety-Learning
    A mother of five died of endometrial cancer hours after being admitted to A&E following preventable delays in her diagnosis.
    An inquest was told that a private clinic identified the cancer by ultrasound but the report was never sent to her GP.
    Kerri Mothersole, 44, from Swale in Kent, had a complex medical history including decades of depression and chronic back pain.
    Her 21-year-old son, Jordan Dighton, said: “My mum should have been taken more seriously—if she were, maybe she’d still be alive.”
    In May 2020 Mothersole presented with symptoms of early menopause. Blood tests showed that she had low iron levels and her symptoms persisted. In March 2021 she told her GP at Green Porch Medical Centre that she had had vaginal bleeding for six weeks.
    She could not attend her ultrasound appointments because she was the family’s only driver, and was removed from the waiting list despite rescheduling two appointments.
    In June of that year her GP referred her for an NHS scan at HEM Clinical Ultrasound Service in Sittingbourne. A radiographer, who was new to the private clinic, found a suspected ovarian mass. However, the clinical lead deemed the scan results inaccurate so they were never returned to the GP. Instead Mothersole was asked to attend a second pelvic and abdominal scan. She was losing weight and in persistent pain. Despite her symptoms being gynaecological, she underwent what turned out to be a clear colonoscopy. According to the coroner, had the first scan report been seen this would have led to an urgent referral to gynaecology.
    Mothersole was eventually admitted to A&E, where she remained under the care of oncology until she was discharged home to the care of hospice nurses.
    Dighton told The Times, “The system was so siloed and her case was passed around from department to department. It’s only after her death that we’ve started to make sense of what pathways she should have been on.”
    Read full story (paywalled)
    Read the Prevention of Future Deaths Report for Kerri Mothersole
    Source: The Times, 15 May 2024
  5. Patient-Safety-Learning
    A trust has announced it is scrapping a major suicides review, prompting concerns about the “devastating” impact the surprise move could have on some grieving families.
    The concerns from a whistleblower—and a family member who has reportedly expressed their “upset and shock”—come despite the provider’s insistence they had taken relatives’ views into account when reaching their decision.
    Cambridgeshire and Peterborough Foundation Trust originally announced plans for the review of over 60 cases in July last year—a move which followed allegations that a patient’s record was tampered with after they had died by suicide in the trust’s care. A chair was appointed to lead the review just last month.
    But in a short statement on its website, the trust said it had now taken the decision “not to proceed with [the review] as originally intended [after] speaking with several families and loved ones with lived experience” of the suicide cases, which date back to 2017.
    The review had been “planned with the best of intentions [but] it has become clear… that the review would not answer the individual and highly personal questions some families might have,” the trust said.
    Read full story (paywalled)
    Source: HSJ, 13 May 2024
  6. Patient-Safety-Learning
    Hospital surgical teams that include more female doctors improve patient outcomes, lower the risk of serious complications and could in turn reduce healthcare costs, according to the world’s largest study of its kind.
    Studies show diversity is important in business, finance, tech, education and the law not only for equity but for output. However, evidence supporting the value of sex diversity in healthcare teams has been limited.
    Now researchers who examined more than 700,000 operations spanning a decade report that hospitals with more women in their surgical teams provide better outcomes for patients. The findings were published in the British Journal of Surgery.
    “Care in hospitals with greater anaesthesia-surgery team sex diversity was associated with better postoperative outcomes,” the researchers concluded. “The main takeaway for clinical practice and health policy is that increasing operating room teams’ sex diversity is not a question of representation or social justice, but an important part of optimising performance."
    Dr Julie Hallet, the lead author of the study at the University of Toronto, said, “These results are the start of an important shift in understanding the way in which diversity contributes to quality in perioperative care.”
    Read full story
    Source: Guardian, 15 May 2024
  7. Patient-Safety-Learning
    The last acute trust deemed “inadequate” by the Care Quality Commission has had its rating improved to “requires improvement”, the regulator has announced today.
    Shrewsbury and Telford Hospitals Trust has been rated “inadequate” since November 2021. Until today, it was the only acute trust in England to have the lowest possible combined CQC rating.
    Inspectors said leaders were visible and approachable, but kept the trust’s leadership rating as “requires improvement.” This was unchanged from the previous inspection.
    Meanwhile, maternity services at Princess Royal Hospital in Telford, which for years have been under intense scrutiny over multiple instances of poor care and scores of baby deaths, have also been upgraded, this time from “requires improvement” to “good”.
    Inspectors visiting in October and November 2023 said there had been a “positive shift” in culture with staff saying they felt safer to speak up.
    The CQC’s report said that overall, people were receiving a higher standard of care with “staff now proud to work for the trust” and SaTH was “working hard to help rebuild people’s confidence” in its services.
    Read full story (paywalled)
    Source: HSJ, 15 May 2024
  8. Patient-Safety-Learning
    The Patient-Centered Outcomes Research Institute (PCORI) awarded Patients for Patient Safety US (PFPS US) a $100,000 Eugene Washington PCORI Engagement Award for a new project called “Patients Involved in deVeloping Outcomes Together” or “Project PIVOT.”  Project PIVOT is a novel patient-led initiative to advance the integration of patient-centred patient-reported outcomes (PROs) and patient-reported experiences (PREs) into Patient-Centered Outcome Research (PCOR), Comparative Clinical Effectiveness Research (CER) and quality assessment measurement tools to improve patient safety, diagnostic quality, and equity. 
    “This award will allow us to identify opportunities to capture—directly from patients and families—their care experiences and challenges, filling key gaps in the traditional data sources used to evaluate healthcare quality and safety,” stated Sue Sheridan, co-founder of PFPS US. In contrast to traditional tools, such as clinical outcome measures and hospital readmission rates, Project PIVOT’s long-term goal is to make healthcare safer and more equitable by capturing and learning from patients’ experiences related to patient safety, diagnostic quality and bias.
    Project PIVOT will have a special focus on historically underserved communities to help define which questions and outcomes are most important to capture. Priority areas of focus include maternal/newborn health in communities of colour, the physical, intellectual and developmental disability communities and older adults.
    Read full story
    Source: Newswire, 13 May 2024
  9. Patient-Safety-Learning
    The changes will allow pharmacists to spend more time with patients, levelling the playing field between smaller pharmacies and larger chains.
    The government has confirmed plans to make ‘hub and spoke’ dispensing models available to all local pharmacies. The change aims to make local pharmacies more efficient and free up time for more complex elements of dispensing and clinical care. The move is part of government’s drive to make patient access to medicines and treatment more efficient across the NHS. Patients stand to benefit thanks to an efficiency drive that will allow all local pharmacies to dispense medicines more efficiently.
    Currently, larger pharmacy chains can take advantage of the efficiencies and cost-savings that come with centralising the dispensing of medicines at a larger ‘hub’. But smaller independent pharmacies are unable to operate the same model due to legal restrictions on dispensing for pharmacies under different ownership, meaning they can face additional costs and workload. 
    Under the changes announced today, the government will progress in making the ‘hub and spoke’ model universally available, allowing pharmacies belonging to different legal entities to use hubs belonging to other companies. This will level the playing field between smaller pharmacies and larger chains.  The changes will enable pharmacists to dispense medicines more efficiently and spend more time dealing face to face with patients.
    Primary Care Minister, Andrea Leadsom said, “We’re continuing our drive to make access to medicines and care faster, simpler and fairer for all patients, including at local pharmacies. These proposals will level the playing field and enable our hard-working community pharmacies to benefit from centralised dispensing. It will also free up highly skilled pharmacists from back-office duties to deliver patient-facing services, including Pharmacy First and contraception consultations, supply medicines and provide advice.”
    Read full story
    Source: WiredGov, 13 May 2024
  10. Patient-Safety-Learning
    NHS England will begin monitoring and benchmarking systems on the extent to which patients are given the option to be treated by a private provider.
    The move follows the government today endorsing the recommendations of a review by the chair of the newly created Independent Patient Choice and Procurement Panel, which has highlighted how some local areas are restricting patient choice.
    It highlighted significant variation in choice between some systems, which it said was driven by factors including messaging from commissioners to GPs that discourages choice and/or encourages referrals to local NHS trusts, financial incentives for referrals to particular providers and difficulties in securing accreditation from commissioners.
    It cited one example where the operator of an independent sector hospital that is co-located with an NHS hospital was contractually prevented by the NHS trust from accepting certain referrals.
    Health and social care secretary Victoria Atkins said: “Empowering patients to take control of their own healthcare decisions is a key part of my missions to make the NHS faster, simpler and fairer for everyone that uses it.”
    Read full story (paywalled)
    Source: HSJ, 15 May 2024
  11. Patient-Safety-Learning
    A recent analysis found poor survival rates after bone fractures in older adults, with fewer than a third of men and half of women surviving five years after a fracture.
    Published in JBMR Plus, the study looked at a cohort of 98,474 Ontario residents age 66 and older who suffered fractures to parts of the body associated with osteoporosis between January 2011 and March 2015. The patients were grouped into sets based on the fracture site and matched to patients with a similar demographic profile but no bone breaks during the study period.
    The fracture cohort was mostly female (73 percent), and the median age at fracture was 80. In the year before the fracture, up to 45 percent of the women and 14 percent of the men had been treated for osteoporosis.
    The analysis revealed that those within a year of a hip, vertebral or proximal non-hip, non-vertebral fracture were at the highest risk of death. The survival probability was lower for the oldest patients.
    “Survival most dramatically declined within one month after most types of fracture, with a five-year survival being similar to or worse than some common cancers,” the paper’s lead author, Laval University department of medicine professor Jacques Brown, said
    Read full story (paywalled)
    Source: Washington Post, 12 May 2024
  12. Patient-Safety-Learning
    More and more UK hospitals are leaving patients in corridors due to a lack of bed space. NHS bosses say so-called corridor care is freeing up ambulances and saving lives, but BBC Newsnight has spoken to patients who say the growing practice is humiliating and degrading.
    Gregory Knowles counted 13 other patients alongside him on a corridor at the Norfolk and Norwich University Hospital (NNUH) in March. Complications after an operation put him back in hospital and on to a ward but at 04:00 one morning he was moved.
    The 68-year-old was wheeled in his bed to reception. "I was waking up with people around me. It was horrendous," he told the BBC. "I had no screens and no facilities for water or for really getting changed. My possessions were on the bottom of the bed. My daughter and partner were as horrified as I was," he said.
    His partner Alicia Goulty described how staff had been too rushed to attend to him. "One day when we got there his catheter had leaked in the bed when he was on the corridor. He was wet with no covers or any screens and I had to take him to the bathroom to get him cleaned". Ms Goulty said her partner's medication had been missed. "We had to ask for water for him. We had to ask sometimes for his meals because he got forgotten."
    Read full story
    Source: BBC News, 15 May 2024
    You can read a nurse's first-hand account of a corridor care shift in this blog on the hub: A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift
  13. Patient-Safety-Learning
    An NHS trust has lost an employment tribunal case against a nurse who had his shifts cancelled after whistleblowing when a patient was put in seclusion because of staff shortages.
    A judgment published last week found that Mark Temperton, a mental health nurse, was “subjected to detriment” after having made a “protected disclosure” during his agency shift at Greater Manchester Mental Health Foundation Trust’s (GMMH) Atherleigh Park Hospital.
    Mr Temperton, who is also employed by the Priory Group as a regulatory inspector as well as doing ad-hoc work for the Care Quality Commission, worked as an agency mental health nurse for Blackstone Recruitment and was booked to work a night shift in a psychiatric intensive care unit (Priestners Unit) at Atherleigh Park on 14 October 2022.
    He raised concerns after a patient, brought in by the police, was put “immediately” into seclusion because of staff shortages. Mr Temperton subsequently raised it with the nurse in charge and with a locum consultant psychiatrist but the patient was kept in seclusion.
    According to the Mental Health Act’s Code of Practice, seclusion “should not be used as a punishment or a threat, or because of a shortage of staff”. Serious concerns were also raised about the trust’s Edenfield Centre in September 2022 by BBC Panorama, one of them being use of inappropriate seclusion.
    Paul Lewis-Grundy, associate director of corporate governance at GMMH, said: “It is absolutely vital that staff feel confident and safe to speak up, with no detrimental impact to themselves or their career and prospects. Over the past two years, we have invested significantly, and taken a number of steps, to support this across GMMH.”
    Read full story (paywalled)
    Source: HSJ, 15 May 2024
  14. Patient-Safety-Learning
    A new vaccine could be effective against coronaviruses which have yet to emerge, with hopes it could be used to battle future pandemics, research suggests.
    Scientists at the University of Cambridge, the University of Oxford, and Caltech in the US are developing a novel approach called “proactive vaccinology”, which aims to train the body’s immune system to recognise several different coronaviruses.
    The vaccine used antigens – a substance that triggers an immune response in the body – found in eight different coronaviruses, including those circulating in bats. This trains the immune system to go after the parts of the antigens that are shared across the viruses and other similar ones, including those not included in the vaccine.
    “Our focus is to create a vaccine that will protect us against the next coronavirus pandemic, and have it ready before the pandemic has even started,” said Rory Hills, a graduate researcher in the University of Cambridge’s Department of Pharmacology and first author of the report.
    He added: “We’ve created a vaccine that provides protection against a broad range of different coronaviruses – including ones we don’t even know about yet.”
    Read full story
    Source: Independent, 7 May 2024
  15. Patient-Safety-Learning
    Integrated care boards and local authorities are cutting their voluntary contributions to the better care fund by more than £500m compared to a high point in 2021-22.
    It appears to be caused by the funding squeeze in both the NHS and local government; extra pressure on ICBs to focus on hospital admissions and discharge; a shift away from pooled budgets as a method of integration; and restructure, with ICBs taking over from clinical commissioning groups in 2022.
    Local BCF pooled budgets are made up of mandatory “minimum” funds from ICBs and local government – the largest share, which the government has generally ordered to grow steadily each year – and from the “additional” voluntary contributions.
    In the past government has said it wants the sum pooled across the NHS and councils to grow and to ultimately account for most NHS and adult social care spending, to help join up services and decision making.
    But figures published on Tuesday by NHS England show the voluntary income going backwards. At its high point in 2021-22, ICBs and councils planned a discretionary ”additional” contribution of £3bn, and the actual spend turned out to be £3.2bn – £2bn from the NHS and £1.2bn from councils.
    The newly published figures show the total was planned to fall to £2.8bn in 2023-24 and £2.7bn in 2024-25 – £500m less than the 2021-22 peak spend.
    Read full story (paywalled)
    Source: HSJ, 8 May 2024
  16. Patient-Safety-Learning
    Five babies have died from whooping cough as cases continue to rise in England, health officials have announced.
    The UK Health Security Agency (UKHSA) reported 1,319 cases in England in March, after just over 900 in February, making the 2024 total nearly 2,800.
    It fears it could be a bumper year for the bacterial infection. The last peak year, 2016, saw 5,949 cases in England.
    The infection can be particularly serious for babies and infants.
    Half of cases seen so far this year have been in the under-15s, with the highest rates in babies under three months of age.
    The five babies who died this year were all under three months old.
    Known as pertussis or "100-day cough", the infection is a cyclical disease with peaks seen every three to five years.
    UKHSA has said a steady decline in uptake of the vaccine in pregnant women and children and the very low numbers seen during the pandemic, as happened with other infections because of restrictions and public behaviour, were both factors.
    The agency said a peak year was therefore overdue and urged families to come forward to get vaccinated if they had not already.
    Read full story
    Source: BBC News, 9 May 2024
  17. Patient-Safety-Learning
    NHS England has found that one in five GP surgeries – and more than two-fifths in some regions – were built more than 75 years ago, and is concerned a lack of space will stop it meeting targets to train more GPs, HSJ has learned. 
    An internal NHSE document seen by HSJ reveals a major audit it commissioned in 2019 – but has not made public – found 20 per cent of 8,900 buildings examined were built before 1948. The figure rises to more than 40 per cent of practices in London, HSJ understands.
    These practices are likely to be in converted houses, normally owned by GP partners, with very limited space and little scope for expansion.
    The NHSE slides which include the figure warn the “limited [GP] estate” means there is “strain on existing capacity and meeting current training needs is challenging”.
    HSJ understands officials are concerned poor estates and lack of space will restrict the big expansion of GP training planned under the NHS long-term workforce plan. Other fears relate to poor tech and the shortage of experienced staff to supervise trainees.
    NHSE said in a statement: “NHS England has asked every ICS to review their infrastructure  to assess which buildings they need to expand and reconfigure to manage additional workforce over the next 10 years.”
    Read full story (paywalled)
    Source: HSJ, 9 May 2024
  18. Patient-Safety-Learning
    A piece of equipment known as a vein finder is being used for inpatients at Ysbyty Gwynedd in order to improve the experience for patients with hard-to-find veins.
    Anyone who has difficult veins will know the discomfort when there are failed attempts to locate a vein, such as when having bloods taken.
    Having noticed the need to improve the experience for patients with difficult veins, Junior Doctor Lois Williams secured a £3,000 grant from Health Education and Improvement Wales and around £600 from Menter Môn to purchase the equipment through the Trainees Transforming Training initiative.
    Dr Williams said: “We’ve been very lucky to obtain a grant to purchase a vein finder and we hope this will empower nurses, phlebotomists, medical students and junior doctors to take blood and cannulate from patients who are difficult to obtain access. It works by infrared, which can bounce back and show us visibility of the vein which you cannot do with the naked eye. It also helps to reduce the time we need to attempt cannulating patients and how often we might need to cannulate them because of failed attempts, which can be quite distressing for some patients. Our hope is that this will improve the quality of patient care in the future.”
    Read full story
    Source: NHS Wales, 30 April 2024
  19. Patient-Safety-Learning
    Bereaved families who lost loved ones in the contaminated blood scandal have claimed their relatives were being “used for research” after discovering historic notes in medical records.
    It is claimed that some patients being treated for the blood clotting disorder haemophilia in the 1970s and 1980s were given blood plasma treatment which doctors knew might be contaminated and infect them with hepatitis.
    They wanted to study the links between the haemophilia treatment Factor VIII and the risk of infection, but a number of families have claimed their loved ones were enrolled in these studies without their knowledge or consent.
    The Factor 8 campaign group alleges that instead of stopping treatment, clinicians lobbied to continue trials, even after identifying the association between hepatitis and the treatment.
    Jason Evans, director of the campaign group, found notes alluding to the research in his father’s medical records. He has since found other families who have discovered the same notes in the records of their loved ones. Mr Evans, whose father died in 1993 after being infected with both HIV and hepatitis C during the course of his treatment for haemophilia, said: “It is appalling that hundreds of people with haemophilia across the country were knowingly infected with lethal viruses under the guise of scientific research. These secret experiments, conducted without consent, show individuals were treated as mere test subjects, not human beings."
    Read full story
    Source: Independent, 9 May 2024
  20. Patient-Safety-Learning
    Drug shortages in England are now at such critical levels that patients are at risk of immediate harm and even death, pharmacists have warned.
    The situation is so serious that pharmacists increasingly have to issue “owings” to patients – telling someone that only part of their prescription can be dispensed and asking them to come back for the rest of it later, once the pharmacist has sourced the remainder.
    Hundreds of different drugs have become hard or impossible to obtain, according to Community Pharmacy England (CPE), which published the report. Widespread and often long-lasting shortages posed “immediate risks to patient health and wellbeing” and caused distress, it said.
    “The medicine supply challenges being faced by community pharmacies and their patients are beyond critical,” said Janet Morrison, CPE’s chief executive. “Patients with a wide range of clinical and therapeutic needs are being affected on a daily basis and this is going far beyond inconvenience, leading to frustration, anxiety and affecting their health.
    CPE, which represents England’s 10,500 community pharmacies, based its findings on a survey of the views of owners of 6,100 pharmacy premises and 2,000 of their staff. It found:
    79% of pharmacy staff said that medicine shortages were putting patient health at risk. 91% of pharmacy owners had seen a “significant increase” in the problem since last year. 99% of pharmacy workers found a drug was unavailable at least weekly, and 72% encountered that several times a day. Pharmacists are finding themselves on the receiving end of abuse and hostility from patients who are frustrated and angered by not being able to get the drugs they have been prescribed.
    Read full story
    Source: Guardian, 9 May 2024
  21. Patient-Safety-Learning
    An agency providing last-minute freelance nurses to NHS hospitals is routinely charging up to £2,000 a shift, BBC News has discovered.
    Glen Burley, chief executive of an NHS trust, said that Thornbury Nursing Services is targeting areas in England where nurses are in short supply. He says it is "profiteering" from an overstretched NHS, but Thornbury says it offers a valuable, flexible service.
    The government says new measures will end the use of expensive agencies. However, Labour has said the high costs are a result of the "Conservatives' failure to train enough nurses over the past 14 years".
    Under NHS rules, hospital managers are obliged to use staffing agencies that work within an agreed framework, with a limit or cap on how much should be paid. But when last-minute essential cover is needed, trusts may use off-framework agencies, such as Thornbury. These are not legally obliged to abide by pre-agreed pay scales.
    Workload pressures in the NHS and a desire for more flexibility over shifts are thought to be driving more nurses to work for such agencies, which tend to pay the people on their books more while also taking a payment for themselves.
    BBC News has discovered Thornbury charges almost £2,000 for a 12-hour bank holiday shift by a specialist paediatric nurse - an area of expertise where there are known staff shortages. Of that, BBC News calculates the nurse receives about £1,050 - meaning nearly £800 goes to the agency. 
    Read full story
    Source: BBC News, 8 May 2024
  22. Patient-Safety-Learning
    NHS staff do not correctly monitor a baby’s heart rate during labour in almost half of cases where serious failings lead to tragedy, a review of maternity care has found.
    The Care Quality Commission identified that inadequate foetal monitoring occurred in 45 of 92 cases (49%) in which a baby died or suffered serious brain damage while being born in a midwife-led unit in England.
    The findings show that correct monitoring is “critically important” to ensure care is safe in all maternity units, said Sandy Lewis, the director of the CQC’s maternity and newborn safety investigations (MNSI) programme. It analysed four common failings in the 92 births in a report that is intended to help midwives and doctors improve the quality and safety of care.
    In one case the investigation team found that “there were likely to have been abnormalities in the baby’s heart rate which were ongoing for a prolonged period of time, which were not identified during intermittent auscultation [monitoring]”.
    In another, midwives were so busy dealing with a separate emergency on the unit that they failed to monitor the baby at the correct recommended intervals and the woman was left unattended.
    The 92 incidents involved 62 cases in which the newborn suffered a severe brain injury, 19 in which it was alive at the start of labour but was stillborn and 11 when it died within its first six days of life.
    Read full story
    Source: Guardian, 8 May 2024
  23. Patient-Safety-Learning
    Hospitals in the UK are facing shortages of almost 2,000 anaesthetists, leading the NHS to miss 1.4 million operations a year, doctors have warned.
    The government has been urged to increase funding for the number of newly qualified doctors who can train as anaesthetists as more than 2,000 miss out on places each year.
    The Royal College of Anaesthetists has said the NHS will not be able to tackle waiting lists without more of these specialist doctors. Their warning comes amid fears hospitals are substituting doctors for staff without sufficient training, called anaesthesia associates.
    This week the NHS will publish new waiting list figures. They stood at 7.6 million in March.
    Dr Fiona Donald, president of the Royal College of Anaesthetists warned: “The shortage of anaesthetists has reached crisis levels and is preventing patients from getting the operations they so desperately need. During the election campaign, I’m sure we’ll see all parties pledge to reduce NHS waiting lists but unless their policies include plans for more anaesthetists they will have limited impact.”
    According to the college, each year 2,600 doctors apply for anaesthetist training however only 550 places are funded. For more advanced training there are around 650 applicants a year yet only 400 are funded.
    Read full story
    Source: Independent, 8 May 2024
  24. Patient-Safety-Learning
    The government is launching a review of the Care Quality Commission and has appointed a senior NHS figure to lead it, HSJ understands.
    The Department of Health and Social Care has commissioned the work, along with other departments, and selected Penny Dash, current North West London Integrated Care Board chair and formerly a senior McKinsey & Company consultant, to lead it.
    HSJ understands the review will examine how the CQC’s recently updated assessment framework is working, and how it links to NHS England’s national oversight framework.
    It will also consider whether the CQC’s ratings were properly rewarding and incentivising the improvement of care, and how the regulator is taking into account service user and patient voices, sources told HSJ. 
    One source involved said they hoped the work would also respond to providers’ complaints that CQC inspections are making it more difficult for them to redesign services, for example by enforcing minimum staffing requirements, and are skewing their priorities. 
    Read full story (paywalled)
    Source: HSJ, 8 May 2024
  25. Patient-Safety-Learning
    A study cited at the infected blood inquiry as evidence that the devastating consequences of blood products contaminated with hepatitis could not have been foreseen, misrepresented the results of a trial in making its case, according to the Guardian.
    Up to 6,520 people are believed to have been infected with hepatitis C through imported factor VIII blood products in the 1970s and 80s, while a further 26,800 are estimated to have been infected with the virus though blood transfusions. About 2,000 people are estimated to have died as a result.
    The inquiry, which publishes its final report on 20 May, heard that the medical profession considered non-A and non-B hepatitis (later known as hepatitis C) as “relatively benign” at the time, with Pier Mannuccio Mannucci’s 2003 paper, 'Aids, hepatitis and haemophilia in the 1980s: memoirs from an insider', quoted in support of this proposition. 
    Mannucci’s 2003 paper argued that the view held by “the great majority of haemophilia treaters was that the problem of hepatitis was a tolerable one, because the benefits of concentrates seemed to outweigh risks”.
    In making his argument, Mannucci cited his own work, writing: “A prospective biopsy study was undertaken by me … in 10 haemophiliacs with non-A, non-B chronic hepatitis followed up for more than six years. The study, published in 1982, demonstrated no case of progression towards cirrhosis or haepatocellular carcinoma.”
    However, the original 1982 report says that there were actually 11–not 10–people included in the study and “one patient with active cirrhosis died of liver failure during the follow-up period”.
    Who knew what about the risks and when is a key plank of the inquiry.
    Read full story
    Source: Guardian, 2 May 2024

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