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About Sam

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    United Kingdom

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    Lead Editor for the hub
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    Patient Safety Learning
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  1. News Article
    Hospitals have been warned hundreds of ventilators used to keep sedated patients alive are at risk of suddenly shutting down because of a fault, in some cases without warning. The Medicines and Healthcare products Regulatory Agency, which said there were approximately 303 Philips Respironics V60 ventilators used in the UK, has warned hospitals over a delay in replacement parts arriving in the UK to fix the problem. It has issued a safety alert to hospitals to make them aware of the increased risk. The regulator said it had received one report of a ventilator suddenly shutting down but said there was no report of any injury to patients. Read full story Source: The Independent, 23 September 2020
  2. News Article
    A hospital trust has been fined for failing to be open and transparent with the bereaved family of a 91-year-old woman in the first prosecution of its kind. Elsie Woodfield died at Derriford hospital in Plymouth after suffering a perforated oesophagus during an endoscopy. The Care Quality Commission (CQC) took University Hospitals Plymouth NHS trust to court under duty of candour regulations, accusing it of not being open with Woodfield’s family about her death and not apologising in a timely way. Judge Joanna Matson was told Woodfield’s daughter Anna Davidson eventually received a letter apologising over her mother’s death, which happened in December 2017, but she felt it lacked remorse. Davidson said she still had many unanswered questions and found it “impossible to grieve”. The judge said: “This offence is a very good example of why these regulatory offences are very important. Not only have [the family] had to come to terms with their tragic death, but their loss has been compounded by the trust’s lack of candour.” Speaking afterwards, Nigel Acheson, the CQC’s deputy chief inspector of hospitals, said: “All care providers have a duty to be open and transparent with patients and their loved ones, particularly when something goes wrong, and this case sends a clear message that we will not hesitate to take action when that does not happen." Lenny Byrne, the trust’s chief nurse, issued a “wholehearted apology” to Woodfield’s family. “We pleaded guilty to failure to comply with the duty of candour and fully accept the court’s decision. We have made significant changes in our processes.” Read full story Source: The Guardian, 23 September 2020
  3. News Article
    Ten workers at a mental health unit have been suspended amid claims patients were "dragged, slapped and kicked". Inspectors said CCTV footage recorded at the Yew Trees hospital in Kirby-le-Soken, Essex, appeared to show episodes of "physical and emotional abuse". The details emerged in a Care Quality Commission (CQC) report after the unit was inspected in July and August. A spokeswoman for the care provider said footage had been passed to police. The unannounced inspections were prompted by managers at Cygnet Health Care, who monitored CCTV footage of an incident on 18 July. At the time, the 10-bed hospital held eight adult female patients with autism or learning difficulties. The CQC reviewed 21 separate pieces of footage, concluding that 40% "included examples of inappropriate staff behaviour". "People who lived there were subjected not only to poor care, but to abuse," a CQC spokesman said. Workers were captured "physically and emotionally abusing a patient", and failing to use "appropriate restraint techniques", the report said. It identified "negative interactions where staff visibly became angry with patients" and two cases where staff "dragged patients across the floor". "We witnessed abusive, disrespectful, intimidating, aggressive and inappropriate behaviour," the inspectors said. Read full story Source: BBC News, 23 September 2020
  4. News Article
    Sweeping bans on visiting at thousands of care homes risk residents dying prematurely this winter as they give up hope in the absence of loved ones, experts in elderly care have warned. More than 2,700 care homes in England are either already shut or will be told to do so imminently by local public health officials, according to a Guardian analysis of new government rules announced to protect the most vulnerable from COVID-19. Care groups are calling for the government to make limited visiting possible, including by designating selected family members as key workers. Since Friday any care homes in local authority areas named by Public Health England for wider anti-Covid interventions must immediately move to stop visiting, except in exceptional circumstances such as end of life. It also halts visits to windows and gardens and follows seven months of restrictions in many care homes that closed their doors to routine visits in March. The blanket bans will result in the “raw reality of residents going downhill fast, giving up hope and ultimately dying sooner than would otherwise be the case”, warned the charity Age UK and the National Care Forum (NCF), which represents charitable care providers. Read full story Source: The Guardian, 23 September 2020
  5. News Article
    Gruelling 12-hour shifts, exhaustion and burnout are leading growing numbers of nurses to quit the NHS within three years of joining, new research reveals. Stress, lack of access to food and drink while at work, and the relentless demands of caring for patients are also key factors in the exodus, the King’s Fund thinktank found. The NHS must make it an urgent priority to tackle the worryingly poor working conditions nurses and midwives face in many hospitals or face worsening workforce shortages, it said. “Staff stress, absenteeism and turnover in the professions have reached alarmingly high levels,” the thinktank said after investigating the working conditions faced by NHS nurses and midwives. “This has been compounded by the Covid-19 pandemic, which has laid bare and exacerbated longer-term issues including chronic excessive workload, inadequate working conditions, staff burnout and inequalities, particularly among minority ethnic groups.” Read full story Source: 23 September 2020
  6. News Article
    NHS England has been asked for a “clear plan and timescale” for development during covid of its controversial scheme which aims to provide extra support for care homes. In its adult social care winter plan the government has advised NHS England to push forward with the rollout of the “enhanced health in care homes” programme, ensuring that all care homes are assigned to primary care networks by 1 October. The scheme requires GP practices to provide extra clinical support and advice to homes. PCNs should also nominate a clinical lead for the care homes and work with other providers, such as social prescribing link workers, health and wellbeing coaches and care co-ordinators, to provide personalised care. The winter plan responds to a number of recommendations published by the COVID-19 support taskforce, after reviewing the management of the virus in the sector. It asks NHSE to provide a clear plan and timetable for its “enhanced health in care homes” programme. Read full story (paywalled) Source: HSJ, 23 September 2020
  7. News Article
    An NHS trust is to appear in court today charged with breaking the law on being open and transparent after a woman’s death in the first ever court case of its kind. The Care Quality Commission (CQC) has brought a criminal prosecution against University Hospitals Plymouth Trust which will appear at Plymouth Magistrates Court tomorrow morning. The trust is charged with breaching the duty of candour regulations under the Health and Social Care Act 2008 which require hospitals to be honest with families and patients after a safety incident or error in their care. Hospitals are legally required to notify patients or families and investigate what has happened and communicate the findings to families and offer an apology. The case relates to how the Plymouth trust communicated with a woman’s family after her death which happened after she underwent an endoscopy procedure at Derriford Hospital in December 2017. The trust was required by law to communicate in an open and transparent way. The CQC has accused the trust of failing to do this. Read full story Source: The Independent, 22 September 2020
  8. News Article
    NHS leaders are being encouraged to have ‘difficult discussions’ about inequalities, after a trust found its BAME staff reported being ‘systematically… bullied and harassed’, along with other signs of discrimination. A report published by Newcastle Hospitals Foundation Trust found the trust’s black, Asian and minority ethnic staff are more likely than white staff to be bullied or harassed by colleagues, less likely to reach top jobs, and experience higher rates of discrimination from managers. It claims to be the first in-depth review into pay gaps and career progression among BAME workforce at a single trust. The new report revealed that, in a trust survey carried out last year, some BAME staff described being subjected to verbal abuse and racial slurs by colleagues; had left departments after being given no chance of progression; and been “systematically… bullied and harassed”. Read full story (paywalled) Source: HSJ, 22 September 2020
  9. Event
    Virimask is a full face mask designed to offer the ultimate protection and maximum comfort against 99.99% of micron-sized particles. Commonly used masks, such as the N95 are limited in continuous use and are not particularly comfortable, or hygienic in longer-term wear. Virimask is designed to last each user a lifetime and uses replaceable HEPA14 filters which block out viral transmission. Unique advantages include the exceptional ventilation and speech clarity, integrated eye protection and varied size range. In this live webinar, the inventor of Virimask, Professor Noam Gavriely, will give a background on Virimask and the challenges faced during the initial phase along with plans for future development. We will highlight the problems with the lack of PPE available during the COVID-19 outbreak and discuss how Virimask can assist our front line workers during the COVID-19 outbreak and any possible future pandemics. The webinar will include customer testimonials and insight to how the world has reacted to the PPE crisis. We will have live discussion and an opportunity for the audience to ask questions in our live Q&A. Registration
  10. News Article
    Covid has brought many hidden tragedies: elderly residents in care homes bereft of family visits, families in quarantine missing loved one’s funerals, and mums forced to go through labour alone. Much of this has been necessary, however painful, but Jeremy Hunt fears we’re getting the balance badly wrong in maternity care. That’s why he is backing The Mail on Sunday’s campaign to end lone births, which has been championed in Parliament by Alicia Kearns. Infection control in hospitals is critically important, but mothers’ mental health can’t be pushed down the priority list. Imagine the agony of a new mum sent for a scan on her own, only to be told that her much longed-for baby has no heartbeat. Or the woman labouring in agony for hours who is told she is not yet sufficiently dilated to merit her partner joining her for moral support. "I have heard some truly heartbreaking stories, which quite frankly should have no place in a modern, compassionate health service. One woman who gave birth to a stillborn baby alone at 41 weeks; another woman who was left alone after surgery due to a miscarriage at 12 weeks," says Jeremy. Perhaps most concerningly of all, there are reports of partners being asked to leave their new babies and often traumatised mothers almost immediately after birth. That means they miss out on vital bonding time and mums lose crucial support to help them recover mentally and physically, in some cases with partners not allowed back to meet their new child properly for several days. "This is a question of basic compassion and decency – the very values that the NHS embodies and the reason we’re all so proud of our universal health service – so we need every hospital to commit to urgent action without delay." Read full story Source: MailOnline, 19 September 2020
  11. News Article
    A third of coronavirus patients in intensive care are from black, Asian and minority ethnic backgrounds, prompting the head of the British Medical Association to warn that government inaction will be responsible for further disproportionate deaths. Chaand Nagpaul, the BMA Council chair, was the first public figure to call for an inquiry into whether and why there was a disparity between BAME and white people in Britain in terms of how they were being affected by the pandemic, in April. Subsequent studies, including a Public Health England (PHE) analysis in early June, confirmed people of certain ethnicities were at greater risk but Nagpaul said no remedial action had been taken by the government. Nagpaul told the Guardian: “We are continuing to see BAME people suffering disproportionately in terms of intensive care admissions so not acting means that we’re not protecting our vulnerable communities. Action was needed back in July and it’s certainly needed now more than ever. “As the infection rate rises, there’s no reason to believe that the BAME population will not suffer again because no action has been taken to protect them. They are still at higher risk of serious ill health and dying.” Read full story Source: The Guardian, 20 September 2020
  12. News Article
    Watchdog chief says increasing patient feedback will be the fuel to drive improvements in patient safety Some hospitals and care homes are failing to take action to protect patients from coronavirus as cases rise across the country, the head of the care watchdog has warned. In an interview with The Independent, Ian Trenholm, the chief executive of the Care Quality Commission (CQC), said a series of inspections had revealed a minority of homes and hospitals were not doing enough to prevent infection. He said in one case a care home appeared to have made a “conscious decision” not to follow the rules on wearing masks and gloves and was now in the process of being closed down by the watchdog due to safety fears. Mr Trenholm also revealed the CQC would be looking closely at patients struggling to access services because of the impact of COVID-19 and he warned it would act if some groups were disproportionately affected. The CQC is being forced to move away from its regular inspections of hospitals, care homes and GPs due to the pandemic but Mr Trenholm said it would be redoubling efforts to encourage patients to give feedback on the care they received, adding the watchdog would be more explicit in future about the action it takes. Read full story Source: The Independent, 21 September 2020
  13. News Article
    A series of hospitals will be designated as coronavirus-free zones during the second wave of the outbreak in a significant policy shift designed to ensure the NHS continues treatment for cancer and other conditions, the Guardian has learned. NHS England is determined not to repeat the widespread suspension of normal service that occurred in the first wave, which doctors and charities have criticised for damaging patients’ health, leading to more deaths and creating a backlog of millions of treatments. In a tacit admission that the March shutdown denied patients vital care, NHS bosses have drawn up plans for certain hospitals – mainly small district generals – to treat no COVID-19 patients and focus instead on common planned operations such as cancer surgery, hip and knee replacements, and cataract removals. Under NHS plans, such “clean” hospitals will as far as possible be kept free of coronavirus patients in a reversal of the approach taken in spring. That should reduce the risk of patients admitted for normal care becoming infected with COVID-19 while on wards. Read full story Source: The Guardian, 21 September 2020
  14. News Article
    'Long Covid' is leaving people with so-called ‘brain fog’ for months after their initial recovery, NHS experts have revealed. Dr Michael Beckles, consultant respiratory and general physician at The Wellington Hospital, and the Royal Free NHS Foundation, said he has seen a number of patients suffering from ongoing effects of the disease. He said the main symptom being reported is breathlessness, with patients also describing a brain fog. Dr Beckles said: "I'm seeing more and more patients who have had Covid-19 infection confirmed in the laboratory and on X-ray, who have cleared the infection, and are now still presenting with persistent symptoms. "Some of those symptoms are respiratory, such as breathlessness, chronic cough. "And some have other symptoms such as what the patients describe as brain fog, and I understand that to be a difficulty in concentration." "Some still have loss of sense of taste or smell." He added that it can be frustrating for patients because investigations after the infection can be normal, yet the symptoms persist. Dr Beckles is part of a team of specialists at the new post-COVID-19 rehabilitation unit at The Wellington Hospital. Read full story Source: The Telegraph, 21 September 2020