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Patient-Safety-Learning

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News posted by Patient-Safety-Learning

  1. Patient-Safety-Learning
    Adult transgender clinics in England are facing a Cass-style inquiry into how they treat patients after whistleblowers raised concerns about the care they provide.
    NHS England has announced that it is setting up a review of how the seven specialist services operate and deliver care after past and present staff shared misgivings privately during a previous investigation.
    As a first step, NHS England will send “external quality improvement experts” into each of the clinics to gather evidence about how they care for patients, to help guide the inquiry’s direction.
    The move follows the publication on Wednesday of a landmark review by Dr Hilary Cass, a former president of the Royal College of Paediatrics and Child Health, which recommended sweeping changes in the way that the health service treats under-18s who are unsure about their gender identity.
    In a letter responding to Cass’s report, which NHS England sent on Tuesday to the seven trusts that host adult gender dysphoria clinics (GDCs), it told them: “We will be launching a review into the operation and delivery of the adult GDCs, alongside the planned review of the adult gender dysphoria service specification.”
    Robbie de Santos, director of campaigns and human rights at Stonewall, an LGBT rights charity, said: “Gender healthcare for adults in the UK is, simply put, not fit for purpose. Many trans adults are being forced to go private at great personal expense to avoid waiting lists in excess of half a decade. We would welcome a review aimed at tackling this unacceptable state of affairs and building capacity into the system.”
    Read full story
    Source: Guardian, 10 April 2024
  2. Patient-Safety-Learning
    A statutory inquiry into deaths of mental health patients will now cover fatalities that took place as late as December 2023.
    The inquiry’s investigations are focused “on the trusts which provide NHS mental health inpatient care in Essex”. This includes: “Essex Partnership University Foundation Trust, and the North East London Foundation Trust and their predecessor organisations, where relevant.”
    NELFT was not specifically mentioned in the original terms of reference although the inquiry told HSJ it had been within the original scope. The inquiry will also now cover deaths of NHS patients from Essex who died when under the care of private sector providers.
    The inquiry’s previous terms of reference covered a period ending in 2020. However, the inquiry’s chair, Baroness Kate Lampard, proposed extending the inquiry’s scope last year due to “ongoing concerns” over services at EPUFT. 
    Read full story (paywalled)
    Lampard Inquiry: Terms of reference
    Source: HSJ, 11 April 2024
  3. Patient-Safety-Learning
    The ambition to diagnose cancer in its earliest stages in England is “seriously off target”, according to a new report by QualityWatch, a research programme by the Nuffield Trust and The Health Foundation
    A rise in urgent referrals in recent years has contributed to delays, along with patients finding it difficult to raise concerns about cancer with GPs. Inequalities in diagnosis, particularly among young people, those in deprived areas, and patients from ethnic minorities, was also highlighted by researchers.
    Experts said that while family doctors are “highly trained” to identify cancers, the issue remains a challenge in primary care because some symptoms can be vague.
    The NHS Long Term Plan said the health service is aiming to diagnose 75% of cancer patients when the disease is in its early stages by 2028.
    However, analysis of NHS data by QualityWatch said “our current course shows we are seriously off target”.
    More than 320,000 people in England were diagnosed with cancer in 2021 – the equivalent of some 900 a day – the report said, with the number of urgent cancer referrals rising since 2009 to more than two million in 2020/21.
    Read full story
    Source: Medscape, 24 April 2024
  4. Patient-Safety-Learning
    The European Commission is recommending measures EU countries should adopt to increase the uptake of two vaccines that prevent viral infections that can cause cancer, it said on Wednesday.
    The two vaccines are against the human papillomaviruses (HPV) that can cause many cancers, including cervical cancer, and against hepatitis B (HBV), which can lead to liver cancer.
    As part of Europe's Beating Cancer Plan, the European Union wants member countries to reach HPV vaccination of 90% for girls by 2030 and significantly increase the rate for boys.
    "Many Member States are well below 50% HPV vaccination coverage for girls with limited data available for boys and young adults, and there is a significant lack of data on HBV vaccination rate," the Commission statement said, adding it was as low as 1% in some countries.
    Read full story
    Source: Medscape UK, 31 January 2024
  5. Patient-Safety-Learning
    A major review into a mental health unit abuse scandal has found a catalogue of failings, including repeated missed opportunities to act on concerns, and a board “disconnected” from the realities faced by patients and staff.
    The independent review into failings at Greater Manchester Mental Health Foundation Trust was published today, commissioned after BBC Panorama revealed a “toxic culture of humiliation, verbal abuse and bullying” at Edenfield Centre in Prestwich in September 2022.
    The trust’s then chair, Rupert Nichols, resigned in November 2022, and CEO Neil Thwaite stepped down in spring last year.
    Review chair Professor Oliver Shanley, a former mental health trust CEO and chief nurse, describes in his report how the trust’s culture and leaders’ “insufficient curiosity” contributed to the “invisibility” of the deterioration in care quality. He says its board was focused on “expansion, reputation and meeting operational targets”.
    Read full story (paywalled)
    Read the report of the Independent Review into Greater Manchester Mental Health NHS Foundation Trust
    Source: HSJ, 31 January 2024
  6. Patient-Safety-Learning
    Mental health services are failing to keep patients safe from suicide and harm after leaving hospital, the Parliamentary and Health Service Ombudsman (PHSO) has warned.
    It also identified failings around planning and communication when patients are discharged, and has urged the Government to strengthen the Mental Health Act.
    The warning comes after the Department for Health and Social Care was forced to announce a Care Quality Commission (CQC) rapid review into mental health services in Nottingham following the killings of students Grace O’Malley-Kumar and Barnaby Webber, both 19, and school caretaker Ian Coates, 65, in June last year, by Valdo Calocane.
    Knifeman Calocane had paranoid schizophrenia and had been a regular patient of Highbury Hospital with mental health problems. In a report last week, The Independent revealed separate investigations into Highbury Hospital which have led to the suspension of more than 30 staff over allegations of falsifying records and harming patients.
    The latest report by the Parliamentary and Health Service Ombudsman (PHSO), following a report in 2018, looked at more than 100 complaints between 2020 and 2023 where it had identified failings in mental health care. 
    Lucy Schonegevel, director of policy and practice at the charity Rethink Mental Illness, said: “Someone being discharged from a mental health service, potentially into unsafe housing, financial insecurity or distanced from family and friends, is likely to face the prospect with anxiety and a sense of dread rather than positivity. Mistakes or oversights during this process can have devastating consequences. This report puts a welcome spotlight on how services can improve the support they offer people going through the transition back into the community, by improving communication and the ways in which different teams work together to provide essential care.”
    Read full story
    Read PHSO report Discharge from mental health care: making it safe and patient-centred (PHSO, 1 February 2024)
    Source: Independent (1 February 2024)
  7. Patient-Safety-Learning
    The NHS is in such a dire state the next government should declare it a national emergency, experts are warning, as it emerged that record numbers of patients are being denied timely cancer treatment.
    It is facing an “existential threat” because of years of underinvestment, serious staff shortages and the demands of the ageing population, according to a group of leading doctors and NHS leaders.
    Whoever wins power after the general election will have to “relaunch” the health service and ask the public to do what they can to help save it and preserve its founding principles, they say.
    The call, by a commission of experts assembled by the BMJ medical journal, comes as new figures show that since 2020 more than 200,000 people in England have not received potentially life-saving surgery, chemotherapy or radiotherapy within the NHS’s supposed maximum 62-day wait. Professor Pat Price, a leading NHS oncologist who helped analyse NHS cancer care data, said that the UK was facing “the deepest cancer crisis” of her 30-year career treating cancer patients. 
    The acute concern about the NHS’s ability to cope with the rising tide of illness deepened last night when A&E doctors claimed that a government plan launched a year ago to relieve the strain on overcrowded emergency departments had made no difference. A&E remains in “permacrisis” while care in units is “as unsafe, or more unsafe, than at this time last year”, despite Rishi Sunak hailing his “ambitious and credible plan to fix it”.
    Although 5,000 more hospital beds have been created, the “half-baked” plan has “made little real difference to the experience of patients and the working conditions of health care professionals”, said Dr Ian Higginson, the vice-president of the Royal College of Emergency Medicine.
    Read full story
    Source: Guardian, 31 January 2024
  8. Patient-Safety-Learning
    One of the biggest challenges facing clinicians who treat Long Covid is a lack of consensus when it comes to recognising and diagnosing the condition. But a new study suggests testing for certain biomarkers may identify Long Covid with accuracy approaching 80%. 
    Effective diagnostic testing would be a game-changer in the Long Covid fight, for it’s not just the fatigue, brain fog, heart palpitations, and other persistent symptoms that affect patients. Two out of three people with Long Covid also suffer mental health challenges like depression and anxiety. Some patients say their symptoms are not taken seriously by their doctors. And as many as 12% of Long Covid patients are unemployed because of the severity of their illness and their employers may be sceptical of their condition.
    Researchers at Cardiff University School of Medicine in Cardiff, Wales, United Kingdom, tracked 166 patients, 79 of whom had been diagnosed with Long Covid and 87 who had not. All participants had recovered from a severe bout of acute Covid-19.
    In an analysis of the blood plasma of the study participants, researchers found elevated levels of certain components. Four proteins in particular—Ba, iC3b, C5a, and TCC—predicted the presence of Long Covid with 78.5% accuracy.
    "I was gobsmacked by the results. We’re seeing a massive dysregulation in those four biomarkers," says study author Wioleta Zelek, PhD, a research fellow at Cardiff University. "It’s a combination that we showed was predictive of Long Covid.." 
    Read full story
    Source: Medscape, 29 November 2023
  9. Patient-Safety-Learning
    A 45-year-old mother who almost died after injecting herself with a life-threatening amount of insulin she thought was Ozempic is calling on the Government and social media companies to crack down on the online counterfeit weight-loss jab trade.
    Michelle Sword, a receptionist from Carterton, Oxfordshire, first took Ozempic without any issues after she was prescribed it by a legitimate online pharmacy in early 2021. Ms Sword said she completed an online questionnaire and gave a false BMI that she knew would qualify her the drug. “I just told them what they wanted to hear,” she said.
    Ms Sword said she takes responsibility for her actions, but criticised rogue sellers for taking advantage of people with insecurities and selling a product that “can kill you”.
    She also wants the Government and social media companies to step in to tackle the trend. “I think the drug was in such infancy in what we knew about it that they weren’t able to “police” who got it, who took it, who sourced it. I think they [the Government] need to look at that.”
    Read full story (paywalled)
    Source: inews, 26 November 2023
  10. Patient-Safety-Learning
    A 10-year-old boy with severe asthma died as a result of multiple failings by healthcare professionals amounting to neglect, a coroner has concluded.
    William Gray, from Southend, died on 29 May 2021 from a cardiac arrest caused by respiratory arrest, resulting from acute and severe asthma that was “chronically very under controlled”. His death has led to calls to improve asthma treatment for children nationwide.
    The court heard that William’s death was a “tragedy foretold” having previously suffered a nearly fatal asthma attack on 27 October, 2020, which he survived.
    The coroner said that William’s death was avoidable, his symptoms were treatable, and he should not have needed to use 16 reliever inhalers over 17 months, but instead his condition should have been treated with preventer medications and should have been controlled.
    Julie Struthers, a solicitor at Leigh Day who represented the family, said, “In an inquest involving concerns with medical treatment it is rare for a coroner to find neglect, and even rarer for a coroner to find Article 2, a person’s right to life, to be engaged. This reflects the real tragedy of what happened to William, the substantial number of failures by multiple healthcare professionals in his care, and the importance of improving asthma treatment for children nationwide.”
    Read full story (paywalled)
    Source: inews, 22 November 2023
  11. Patient-Safety-Learning
    Pregnant women are being forced to wait days longer than expected for “urgent” inductions of labour as NHS staff shortages and a lack of beds lead to severe delays.
    New mothers told i the delays, which the health watchdog has found can last up to five days, increased the anxiety they felt during labour.
    One first-time mother, who wanted to remain anonymous, said that her ordeal has put her off having any more children. The woman, who gave birth to a son in August, said she was “pushed” to book an induction when her waters broke and her baby was almost two weeks overdue. Despite being told by multiple healthcare professionals she needed to “give birth within 24 hours” due to a risk of infection, she did not end up delivering her baby for another 49 hours – without being induced.
    A birthing expert told i she has “never seen a crisis in maternity” like it during her almost 10 years working in the sector.
    It comes after it was revealed that the Care Quality Commission (CQC) watchdog has issued warnings to seven hospitals due to delays to the induction of labour since last year.
    Read full story (paywalled)
    Source: inews, 5 November 2023
  12. Patient-Safety-Learning
    The leadership of a specialist trust in Liverpool is set to be taken over by the chief executive of the city’s main acute provider.
    A message to staff seen by HSJ said James Sumner, who leads Liverpool University Hospitals Foundation Trust, will also become interim CEO of Liverpool Women’s FT at the end of the year when Kathryn Thomson steps down.  Ms Thomson announced her retirement in May.
    There have been long-standing ambitions to move Liverpool Women’s standalone hospital to the new Royal Liverpool Hospital site in the city centre, run by LUHFT, with a possible merger of the organisations.
    The relocation remains the ambition, although the trusts are focusing on service integration in the short term.
    The message to staff, sent this afternoon by chair Robert Clarke, said: “We have been clear for some time about our preferred future direction of travel for the trust, namely a closer collaboration with the large acute provider of services in the city as we believe this will support the long term clinical and financial sustainability of services for the benefit of women, babies and others who access our services.
    “Liverpool Women’s has secured agreement with NHS Cheshire & Merseyside on our ambition to move to a shared CEO model…This is a positive step in providing ongoing stability for Liverpool Women’s.”
    Read full story (paywalled)
    Source: HSJ, 30 August 2023
  13. Patient-Safety-Learning
    In the most deprived areas of England and Scotland, the nearest 24/7 accessible defibrillator is on average a round trip of 1.8 km away—over a mile—according to a pioneering study supported by the British Heart Foundation (BHF).
    The researchers, led by Dr Chris Wilkinson, senior lecturer in cardiology at Hull York Medical School, used data from national defibrillator network The Circuit to calculate the median road distance to a defibrillator with unrestricted public access across Great Britain's 1.7 million postcodes.
    Among the 78,425 defibrillator locations included, the median distance from the centre of a postcode to a 24/7 public access defibrillator was 726.1 metres – 0.45 miles. In England and Scotland, the more deprived an area was, the farther its average distance from a 24/7-accessible defibrillator – on average 99 metres more in England, and 317 metres farther in Scotland for people living in the most compared with the least deprived areas. There was no link between defibrillator location and deprivation in Wales.
    The researchers said they hoped the findings, presented at the European Society of Cardiology (ESC) Congress in Amsterdam and published in the journal Heart, would lead to more equal access to defibrillators. They noted that there were over 30,000 out-of-hospital cardiac arrests (OHCA) annually in the UK; in England nearly 30% happened at weekends, and 40% between 6pm and 6am. 
    Read full story
    Read research study: Automated external defibrillator location and socioeconomic deprivation in Great Britain (28 August 2023)
    Source: Medscape, 29 August 2023
  14. Patient-Safety-Learning
    The NHS workforce plan will cost £50 billion and result in the health service employing half the public sector by the 2030s, analysis concludes today.
    Jeremy Hunt, the chancellor, has in effect “stolen more than a decade’s worth of budgets” from his successors by setting out plans to hire almost a million extra NHS staff without a clear way to pay for them, the Institute for Fiscal Studies (IFS) says.
    Hunt has been urged to use his autumn statement to start setting out whether tax rises, borrowing or cuts elsewhere will be used to fund the “massive spending commitment”.
    Read full story (paywalled)
    Source: The Times, 30 August 2023
  15. Patient-Safety-Learning
    Targeted screening of patients with type 2 diabetes could more than double new diagnoses of heart conditions, a study suggests.
    When applied at a larger scale, such an approach could translate into tens of thousands of new diagnoses, researchers believe.
    Conditions such as coronary artery disease, atrial fibrillation and heart failure affect millions of people worldwide, causing a large number of deaths and increasing healthcare costs.
    Treatments are available that can prevent stroke or acute heart failure, but systematic screening is not currently common practice.
    Those living with conditions such as type 2 diabetes or chronic obstructive pulmonary disease (COPD) – a group of lung conditions that cause breathing difficulties – are at high risk of such conditions.
    A team of researchers led by Dr Amy Groenewegen, from the University Medical Centre Utrecht in the Netherlands, has developed a three-step screening process to detect conditions in high-risk people at an early stage.
    Study author Dr Groenewegen said: “An easy-to-implement strategy more than doubled the number of new diagnoses of heart failure, atrial fibrillation and coronary artery disease in high-risk patients.”
    Read full story
    Source: Independent, 29 August 2023
  16. Patient-Safety-Learning
    All tech support for flu and covid vaccinations will be switched off on Thursday after NHS England decided against extending its contract with its supplier in favour of developing an in-house system, according to HSJ.
    NHSE last week told suppliers System C and Graphnet it would not extend the contract for the National Immunisation Management Service – just one week before the contract ends.
    NIMS, provided by the two British firms in partnership with NHS South Central and West Commissioning Support Unit, has been used for the last three years to manage the vaccination programme.
    Its functionalities include a single data store holding vaccination records for more than 60 million people, a call and recall service that can identify and contact groups of eligible individuals according to age and clinical priority, and reporting and analysing of vaccination activity in “near real time”.
    NHSE informed System C it would not extend the contract last Thursday – five working days before it was due to expire, according to a message from System C to customers, seen by HSJ.
    In its message, System C said: “This means that all functionality, including the NIMS application programming interface links to third party booking systems, all outgoing feeds and extracts, NIMS dashboards and the point of vaccination data capture application will stop working after 31 August.”
    There is currently “significant usage” of the system by GPs and trusts, which means NIMS users “may need to take action to deal with the retirement of the system” – the message stated.
    Read full story (paywalled)
    Source: HSJ, 30 August 2023
  17. Patient-Safety-Learning
    The number of appointments and treatments postponed by strike action in the NHS in England is nearing one million.
    The 48-hour walkout by consultants in England last week saw more than 45,000 appointments being cancelled.
    It brings the total number of postponed hospital appointments since industrial action began in the NHS in December to 885,000.
    Once mental health and community bookings are included, it tops 944,000.
    The true total is likely to be even higher, as services have stopped scheduling appointments on strike days and these will not be included in the figures released by NHS England.
    Alongside consultants, junior doctors, nurses, physios, ambulance workers and radiographers have also walked out at various stages.
    NHS national medical director Professor Sir Stephen Powis said: "Industrial action continues to have a huge impact on the NHS, and on the lives of patients and their families. This strike took place into a bank holiday weekend, when NHS activity is generally lighter, but many services have for some time avoided scheduling any planned appointments for strike days in order to prioritise emergencies. This means the true impact of this action will be even higher, and as we move into September, the extraordinary cumulative effect of more than nine months of disruption poses a huge challenge for the health service, as staff work tirelessly to tackle the backlog."
    Read full story
    Source: BBC News, 29 August 2023
  18. Patient-Safety-Learning
    Delays in patient care and a lack of consultant support have left junior medics fearing for their mental health, an NHS England investigation has discovered.
    Junior doctors described haematology services delivered from University Hospitals Birmingham’s Heartlands Hospital as “chaotic”.
    Their concerns are raised in a report by NHS England Workforce, Training and Education (formerly Health Education England). UHB’s haematology service has been under scrutiny since 2021, when HSJ revealed whistleblower concerns over patient safety, including a series of blood transfusion’ never’ events.
    The WTE team visited UHB in April. As a result, the haematology service is now subject to the General Medical Council’s enhanced monitoring regime. This means intensive support is given to trainees and the trust to improve medical training. UHB’s obstetrics and gynaecology department is also under enhanced monitoring.
    The WTE report warns that consultants working across multiple sites left trainee medics at Heartlands without sufficient support and supervision. Most conversations with consultants were via telephone, leaving juniors feeling “unsupported and insecure”. 
    The report stated: “Trainees described the workload … as chaotic and some reported the stress … was affecting their mental health… Some reported they do not feel valued, and the panel heard examples of people crying every day. Most described their roles as 100 per cent service provision… [they] reported very limited learning opportunities overall.”
    Read full story (paywalled)
    Source: HSJ, 24 August 2023
  19. Patient-Safety-Learning
    Just three “slightly unhealthy traits” in mid-life increase the risk of early death by a third, research suggests.
    The study found people carrying extra weight in their 40s and 50s who also had slightly raised blood pressure, cholesterol or blood sugar levels were also 35 per cent more likely to have a heart attack or stroke over the next three decades.
    Researchers warned that middle-aged people with this “cluster of slightly unhealthy traits” – known as metabolic syndrome – typically had a heart attack or stroke two years earlier on average than healthier people the same age.
    Dr Lena Lönnberg, of Västmanland County Hospital, Sweden, who was lead researcher for the study, said: “Many people in their 40s and 50s have a bit of fat around the middle and marginally elevated blood pressure, cholesterol or glucose but feel generally well, are unaware of the risks and do not seek medical advice. “In fact, most people live with slightly raised levels for many years before having symptoms that lead them to seek healthcare.”
    She warned that because the individual “unhealthy traits” did not usually make people feel unwell, most people were unaware of the risks combined with excess weight.
    An estimated one in four UK adults has metabolic syndrome, with rising obesity levels one of the main drivers.
    On their own, diabetes, high blood pressure, and obesity can damage the blood vessels. 
    But even if patients only have mild versions of each condition, experts warn having the three together can be particularly dangerous.
    Read full story (paywalled)
    Source: The Telegraph, 25 August 2023
  20. Patient-Safety-Learning
    A mum suffered a perforated bowel and sepsis after being told she was anxious and should take constipation medication and drink peppermint tea.
    Farrah Moseley-Brown was in "agonising pain" after having her second son, Clay, but the hospital sent her home.
    Because of the delay in treating her, Ms Moseley-Brown, 28, of Barry, Vale of Glamorgan, now has a stoma.
    Cardiff and Vale health board admitted failures in her care and gave its "sincere apologies".
    Since the error, Ms Moseley-Brown has turned to TikTok to inform people about the dangers of sepsis and has had 15 million views one one video alone.
    She was booked into University Hospital Wales, Cardiff, for a Caesarean on 7 May 2020. After Clay was born, Ms Moseley-Brown lost about two-and-a-half pints of blood and needed further surgery to stem the bleeding.
    "I felt really unwell and I said this to the nurses and the staff at the hospital which they didn't listen to. They kept saying it was after-pain but it was just agonising," Ms Moseley-Brown said.
    Read full story
    Source: BBC News, 25 August 2023
  21. Patient-Safety-Learning
    Covid cases in England have almost doubled in a month after the rise of two new variants.
    According to the most recent government statistics available, 875 cases were logged in England on August 11, compared to just 449 a month earlier. Hospital admissions have also risen by a fifth in a week.
    UKHSA statistics show Covid cases in England rose from a seven-day rolling average of 373 on July 8 to 879 as of August 8. Also, 589 out of 6,500 neighbourhoods in England had detected at least three Covid cases in the week to August 12.
    The uptick comes after reports of a new variant called Eris which makes up one in four new cases. Also, another strain nicknamed Pirola is quickly spreading globally. 
    The US is also seeing an increase in hospital admissions with coronavirus, its first significant uptick since December 2022.
    The UK Health Security Agency (UKHSA) said they are unsettled by the variant and suggested the rapid spread could suggest an international transmission.
    Christina Pagel, a member of the Independent Scientific Advisory Group for Emergencies that advises on the virus, said: "Without ramping up surveillance, and in the face of waning immunity, we are travelling into winter more vulnerable and with blinkers on."
    Prof Pagel predicted the new wave could cause extreme pressure on the health service, with a repeat of last winter’s “unprecedented” NHS crisis of Covid, flu and respiratory virus that came all around the same time.
    Read full story
    Source: Independent, 24 August 2023
  22. Patient-Safety-Learning
    Top young cancer researchers are leaving the UK in a “brain drain” fuelled by the continuing failure to reach an agreement over the EU’s study programme, scientists warn.
    The two-and-a-half-year delay in joining the £85bn Horizon Europe scheme, the largest collaborative research programme in the world, has “damaged the UK’s reputation” and made it more difficult to attract and retain the brightest researchers into the nation’s labs.
    Cancer Research UK (CRUK) surveyed 84 cancer specialists about Horizon Europe and found that three-quarters of respondents favoured association with the programme compared with only 11% who wanted the UK to go it alone with the government’s plan B, known as Pioneer.
    Prof Julian Downward, head of the Oncogene Biology Lab at the Francis Crick Institute in London, said: “We need Horizon Europe very badly. The current situation is damaging UK science every day. We are losing top junior faculty regularly who decide to move to EU countries so they can take up European Research Council grants.”
    Read full story
    Source: Guardian, 25 August 2023
  23. Patient-Safety-Learning
    Thirty families are starting legal action against the government, care homes and several hospitals in England over the deaths of their relatives in the early days of the Covid pandemic.
    The families argue not enough was done to protect their loved ones from the virus.
    They are claiming damages for loss of life and the distress caused.
    The government says it specifically sought to safeguard care home residents using the best evidence available.
    The legal claims focus on the decision in March 2020 to rapidly discharge hospital patients into care homes without testing or a requirement for them to isolate.
    The cases follow a 2022 High Court judgement that ruled the policy was unlawful - as it failed to take into account the risk to elderly and vulnerable care home residents of asymptomatic transmission of the virus.
    One of the cases is being brought by Liz Weager, whose 95-year-old mother Margaret tested positive for the virus in her care home in May 2020 and died later in hospital. "What was happening in the management of those care homes? What advice were they having?" Liz asks. "It goes back to the government. There was a lack of preparedness, which then translated down to the care home."
    Read full story
    Source: BBC News, 25 August 2023
  24. Patient-Safety-Learning
    The use of surgical mesh to treat a common childbirth injury is now suspended in New Zealand because of safety concerns.
    The extraordinary step, which follows a similar move in the United Kingdom, was announced today by Te Whatu Ora.
    It is being celebrated by a woman who spearheaded a campaign to highlight the harrowing mesh injuries suffered by her and many other Kiwi women. “It is an acknowledgement that their concerns were not just in their heads,” Sally Walker told the Herald. “It will give us some hope.”
    About 100 women around the country who are on waiting lists for urogynaecological surgeries involving mesh are being contacted by doctors to tell them their operations for stress urinary incontinence are on hold.
    The Director-General of Health Dr Diana Sarfati said the Surgical Mesh Roundtable (MRT), an oversight and monitoring group chaired by the Ministry of Health, had been investigating a “pause” since earlier this year.
    The group’s assessment was that the balance of benefit and harm from the procedure would be improved by the series of additional measures already planned, and it recommended a pause until those measures were substantively in place.
    “After considering the MRT’s assessment, I have decided to support a pause to allow the following steps to be put in place to reduce the harms linked to the procedure as much as possible,” said Sarfati.
    Read full story
    Source: NZ Herald, 22 August 2023
  25. Patient-Safety-Learning
    NHS England could have gone further to insist that errors and failures by senior NHS leaders are disclosed to future employers, according to the leading barrister who reviewed the NHS’s fit and proper person test (FPPT).
    Tom Kark KC’s review of the FPPT was delivered to government five years ago and made public the following year, and changes were finally proposed by NHSE earlier this month. 
    In an interview with HSJ, Mr Kark said he broadly welcomed the plans, and that the revised framework should provide greater consistency across NHS boards “if applied correctly”; and could “strengthen the hand” of chairs and chief executives.
    Part of the purpose of the regime is to prevent senior managers and other board members who make big errors in one role, from keeping this secret from a future employer.
    Mr Kark told HSJ he had heard evidence that when “someone leaves under a cloud, they pop up somewhere else, and the information is lost.”
    Read full story (paywalled)
    Source: HSJ, 16 August 2023

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