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An acute trust has claimed “experienced and dedicated staff” have quit their roles because of “the stress and anxiety caused by the instability” of its imaging IT system as its row with a private provider intensifies. Gloucestershire Hospitals Foundation Trust said the picture archiving and communication system imaging software, provided by Philips, had caused “significant disruption” since its deployment in May 2023. Trust CEO Kevin McNamara wrote in a highly critical report to the trust’s September board meeting that “the improvements we would reasonably expect from [the] supplier have not been delivered”. As well as alleging the system’s failings were having a “serious impact” on care quality, the CEO claimed in the report that the disruption had meant “experienced and dedicated staff leaving the service and the trust due to the stress and anxiety caused by the instability of the system”. He also alleged the trust had incurred “significant costs” due to additional staffing and outsourcing for its radiology service “to mitigate the impact of an unstable PACS system”. Read full story (paywalled) Source: HSJ, 16 September 2024

Music from the Spice Girls is blaring out from speakers as the surgeon Paddy Subramanian grabs a bone saw and gets to work on Jacqueline Carby’s left knee. The 78-year-old is one of four patients being operated on side by side in the same room at an NHS hospital in north London. Each of the four operating zones in the vast “barn theatre” is a hive of activity; with half a dozen staff in scrubs buzzing around the foot of each bed, hovering over trays holding an array of surgical tools required to perform routine knee and hip replacements. The surgeons’ soundtrack of choice — jaunty Nineties pop tunes — is punctuated only by the noise of drills, saws and of metal hammering away at bone. The pioneering barn theatre complex at Chase Farm Hospital, part of the Royal Free London NHS Foundation Trust, has been designed to ensure doctors get through as many operations as possible, as quickly and safely as possible. In a week when a report by Lord Darzi criticised the lack of productivity in crumbling hospitals, it provides an example of the NHS at its most ruthlessly slick and efficient. The large open-plan theatre equipped with cutting-edge air canopies that ensure infection cannot spread between the four beds. Compared with traditional single operating theatres it offers the crucial advantage of allowing consultant surgeons to supervise numerous operations at once. Subramanian, a consultant orthopaedic surgeon at the hospital, said: “It is super efficient. There is no bed wasted, and no time wasted. We can do four hip replacements in the same room. One consultant can supervise two parallel operating tables. Communication and the sharing of expertise is key in surgery. Registrars [trainee surgeons] can stick their hand up and ask for help or a second opinion. It is much safer and better for patients and staff.” Read full story (paywalled) Source: The Times, 16 September 2024

An eight-year-old girl died of sepsis hours after she was sent home by a GP who said that the local hospital was full and advised her mother to give her fluids and ibuprofen. Mia Glynn visited a GP surgery twice in four days but her parents Soron, 39, and Katie, 37, were told to take her home, even though she displayed symptoms of group A strep. Her parents, from Biddulph, Staffordshire, first took Mia to the doctor on 5 December 2022, after she had begun vomiting, had a severe headache and complained of a sore throat. They returned to the surgery on 8 December after Mia, who hadn’t eaten properly for the past three days, had a raised heart rate, reduced urine output and was feeling sleepy. The Glynns were told to take their daughter home because the hospital was full and they would have to wait in a corridor. Mia slept in her parents’ bed that night but woke up in the early hours of 9 December, disorientated, with blue lips and rashes on her arms and legs. She complained of feeling hot but was cold to touch. After being rushed to the hospital by an ambulance, she was given intravenous fluids and antibiotics, but went into suspected septic shock and suffered a cardiac arrest about 15 minutes after arriving. Despite attempts to resuscitate her, she died 20 minutes later. Her cause of death was given as sepsis caused by a group A strep infection. Victoria Zinzan, a specialist medical negligence lawyer at Irwin Mitchell who is representing the couple, said: “Sadly through our work we see too many families affected by sepsis; with Mia’s death vividly highlighting the dangers of the condition. Early diagnosis and treatment is key to beating sepsis, therefore it’s vital people know what signs to look out for when it comes to detecting this incredibly dangerous and life-threatening condition.” Read full story (paywalled) Source: The Times, 15 September 2024 Related to reading on the hub: Top picks: 10 resources about sepsis Improving diagnosis for patient safety: World Patient Safety Day 2024

An NHS trust has admitted that a highly vulnerable baby died because of contaminated feed that it gave her, after denying that for more than a decade. At an inquest on Tuesday, Guy’s and St Thomas’ trust said it had given Aviva Otte a nutritional product containing deadly bacteria in January 2014. It had previously insisted to her mother, a coroner and the Guardian on multiple occasions that she had died of natural causes. The change in GSTT’s explanation of Aviva’s death came during the second day of an inquest into her death and the deaths of two other babies in a separate outbreak of Bacillus cereus five months later. Giving evidence at Southwark coroner’s court in London, Dr Grenville Fox – a senior consultant neonatologist who worked in the neonatal unit where Aviva was treated – said that it was now his opinion that the parenteral nutrition she received was the main cause of her death. His statement represents a significant U-turn by GSTT. It also raises questions about its conduct and honesty over the first outbreak of Bacillus cereus in late 2013 and early 2014, in which four babies including Aviva were infected, which the Guardian first revealed in June 2022. Read full story Source: The Guardian, 10 September 2024

Up to 11,000 patients may have received incorrect test results – including being misdiagnosed as diabetic – due to an equipment error at a trust, HSJ has learned. Bedfordshire Hospitals Foundation Trust (BHFT) experienced an intermittent issue with a machine used to analyse blood samples at its Luton hospital between April and July this year. This affected blood tests are used to measure glucose levels, to diagnose type 2 diabetes and pre-diabetes, as well as to monitor those with known diabetes. The trust is contacting all patients who may have received an incorrect result and inviting them to take another test. The trust said a review into this was ongoing and the incident had been reported to the Medicines and Healthcare Products Regulatory Agency. BHFT said it could not determine the level of harm until all patients have been retested. However it did not expect the issue to have caused serious harm at this stage, and patients were being advised not to worry. It said patients may have received an incorrect diagnosis of diabetes, or prediabetes or given management advice for known diabetes based on an erroneous result. There were no concerns that a diagnosis of diabetes may have been missed as the issue was causing higher results to be measured, according to the trust. Read full story (paywalled) Source: HSJ, 11 September 2024

The public inquiry into what happened when Lucy Letby murdered seven babies at a hospital starts this week amid a growing debate on the evidence used to convict the nurse. Letby was sentenced to 15 whole life orders after she was convicted of murdering seven babies and attempting to murder seven others at the Countess of Chester Hospital following two trials. On Tuesday, an independent statutory inquiry, called the Thirlwall Inquiry, begins to specifically explore what happened at the time of the crimes. It begins, however, at a time of growing debate around scientific evidence used to convict Letby, 34, which has led to questions over whether the hearings should take place. In a letter to ministers last month, a group of 24 neonatal experts said they feared a narrow scope for the inquiry based on Letby’s convictions could lead to “a failure in understanding and examining alternative, potentially complex causes for the deaths, thus missing important lessons”. The terms of reference for the inquiry are the experience of the hospital for the parents of the babies, the conduct of those working at the hospital over the Letby and the effectiveness of NHS management across the country. However, the concerns raised by some over Letby’s convictions have impacted the families of the babies. Tamlin Bolton, who represents the families of six victims, said: “I can’t stress enough how upsetting that has been for all of the families that I represent. “And they have thought about so many ways in which they can try to address that and deal with it and make sure they put their voice across. But of course they’re restricted by wanting to keep themselves confidential and private.” She said it was important to highlight that this week’s inquiry was focussed on the “duty of candour” between patients and hospitals, rather than the criminal convictions “which are final”. Read full story Source: The Independent, 9 September 2024

Men taking sodium valproate are being warned to use contraception while on the medicine, because of a "potential small increased risk" of autism and other neurodevelopmental problems for any children conceived. They should continue to do so - and cannot donate sperm - until three months after they have stopped taking the drug. Sodium valproate, prescribed under brand names including Epilim, Belvo, Convulex and Depakote, is an effective treatment for epilepsy and bipolar disorder. The Medicines and Healthcare products Regulatory Agency (MHRA), which issued the warning, stressed patients must speak to their doctors before making any changes to their medicines. The guidance follows a similar warning from the European Medicines Agency, after data from national registries in Norway, Denmark and Sweden suggested 5% of children born to men taking the drug were harmed. That study did not prove sodium valproate was the cause, the MHRA said, or compare risks for children whose fathers were not on medication. But it raised an "important safety issue that warrants action on a precautionary basis". Read full story Source: BBC News, 5 September 2024

A hospital in the US had introduced a lifesize hologram device to replace in-person visits and reduce patient wait times. Patients at a Texas hospital who expect to see doctors in person now encounter doctors via 3D holograms. The Holobox is a two-metre-plus device that projects a hologram of a doctor to conduct real-time consultations. It was designed by Netherlands-based next-gen hologram company Holoconnects. It is set to revolutionise patient care while reducing wait times and accommodating non-hands-on visits, such as consults or pre- and post-operative appointments. Crescent Regional Hospital’s CEO Raji Kumar reports it is ‘much more engaging, interactive, and realistic than a Zoom or telehealth call’. Collaborating with Holoconnects, the hospital sees itself as pioneering the future of healthcare with this innovation. ‘Now, you’re seeing the person as a whole. I’m able to see you as a whole. I can see you walk and talk; I can make you do certain tests, which I cannot do with a smaller screen,’ Kumar said. Kumar reported that about 10 doctors have tested the device with around 15 patients, and despite its early stages, it has received positive feedback. Read full story Source: Surgery, 21 August 2024

Press release 12th August 2024 Public Policy Projects, in partnership with charity Patient Safety Learning, is today announcing a patient safety policy and conference programme. The programme, chaired by Patient Safety Learning Chief Executive Helen Hughes, will consist of three roundtable events and a conference in early 2025. The new programme is designed to embed patient safety as a core priority across national and local health systems. PPP and Patient Safety Learning will develop the programme with a focus on how technology can enable patient centred patient safety. A new editorial board will be established, chaired by Helen Hughes, where key stakeholders, including industry partners and patient leaders, will set editorial direction. Global enterprise software company, RLDatix, is the first programme partner and will join the editorial board. As Patient Safety Learning has recently highlighted, we are not getting safer. Prioritisation of patient safety remains inconsistent across health and care and there is a need for a fresh forum through which stakeholders can engage in collaborative, challenging and meaningful debates that lead to action. PPP’s new programme, Harnessing technology to enable a system wide approach to patient safety, is the product of a unique collaboration between Public Policy Projects and Patient Safety Learning. Both organisations have established track records of engaging with system leaders and key stakeholders and will leverage their networks to convene a unique and influential audience. PPP and Patient Safety Learning argue that patient safety needs to be a core purpose of health and care, not just one priority of many. There is a need for a new system-wide forum and network, for insight and analysis to position patient safety at the core of integrated care systems, NHS and independent health organisations, and care providers. PPP and Patient Safety Learning, along with a range of strategically selected partners, will develop a unique programme of engagement and policy to deliver actionable insights that support systems to drive improvement and reduce avoidable harm. The programme will centre on patient safety across UK health and care, and discuss it through the lens of technology, digital innovation, and data-driven transformation. As the new Secretary of State for Health and Social Care has recognised that industry collaboration will be essential to getting the NHS back on its feet, this programme aims to unite industry experts with sector leaders in strategic partnership. This will ensure the insights and policy delivered reflect all pertinent stakeholders and their ability to drive forward the improvement of patient safety in UK health and care. The programme will also include the establishment of an editorial board, which will bring together some of the country’s foremost leaders in patient safety, along with industry experts, system and patient leaders to set the programme’s editorial direction, ensuring the outputs of the programme are practical and credible. Commenting on the programme, Helen Hughes, Chief Executive of Patient Safety Learning and programme chair, said: “Patient safety needs to be core to health and care. Despite the efforts of many, globally and nationally, the challenges of delivering safe and effective care are as great as ever. “To make the transformational change needed, we need to collaborate system-wide to address often complex systemic issues, using the opportunity of technology innovation and user engagement to drive improvement. Bringing multi-disciplinary leaders together across the health and care system with a focus and drive on patient safety technology is an exciting and much needed innovation. We are delighted to partner with PPP on this exciting impact-focused programme with the support of RLDatix as our first programme partner. Policy for impact The first series of roundtables within this programme, Harnessing technology to enable a system wide approach to patient safety, will both highlight the essential role of technology and digital innovation in ensuring standards for patient safety are met, as well as stressing the importance of ensuring technology and innovations are developed and implemented with the patient front and centre. Each roundtable will focus on a distinct area of technological advancement in health and care, and will host collaborative discussion between sector leaders, industry experts, as well as patient and end-user representatives. Topics: Session one: Uniting system partners and integrating approaches to patient safety. Session two: Data, insight and safety performance: harnessing patient safety information. Session three: Safety design and user engagement: the power of digitally enabled people. Conference PPP has a rich, vibrant and varied portfolio of conference events convening hundreds of carefully selected stakeholders for vital debate and networking. Following the completion of the roundtable series, PPP and Patient Safety Learning will collaborate to produce an annual Patient Safety conference. These events will be used to present findings from the roundtable series as well as engaging a broader audience. The conference will convene the patient safety community and drive strategic prioritisation of patient safety across the health system. Programme contacts: [email protected] [email protected] About Public Policy Projects Public Policy Projects (PPP) is an organisation operating at the heart of health and life sciences policy delivery. We bring together senior leaders and practitioners in the public and private health and life sciences sectors to find realistic solutions to the most pressing issues relating to health and care delivery. We facilitate effective collaboration between public and private sector organisations. We help businesses to grow their profile within the NHS and wider public sector. In turn, we support public sector leaders and organisations with practical recommendations on implementing policy to improve health and wellbeing outcomes for local population. About Patient Safety Learning Patient Safety Learning is a charity and independent voice for improving patient safety. We harness the knowledge, enthusiasm and commitment of healthcare organisations, professionals and patients for system-wide change and the reduction of harm. We support safety improvement through policy, influencing and campaigning and the development of ‘how to’ resources such as the hub, our free award-winning platform to share learning for patient safety, and our unique Patient Safety Standards and support tools.

Hundreds of doctors and nurses have been left free to practise unchecked despite being accused of serious sexual assault and rape in the last six years, The Independent can reveal. Between 2018 and 2024, some 248 doctors faced allegations of rape, sexual assault or attempted rape without their licences being suspended, according to new figures from the General Medical Council (GMC). The Independent can reveal: Between 2018 and 2024, 11 doctors were accused of possessing indecent images of children but no interim orders were made. Over the same period, 261 doctors faced no restrictions despite allegations of physical assault. In 2018, one doctor accused of murder had no restrictions placed on their ability to practise. A doctor found to have sexually assaulted colleagues was able to practise as long as he informed the GMC of his job movements. The shocking figures, obtained via a freedom of information (FOI) request, call into question the decision-making of the UK’s two biggest health watchdogs after a series of exposés by The Independent. Helen Hughes, chief executive of the charity Patient Safety Learning, said the figures were “deeply troubling” from both patient and staff safety perspectives. She said: “In healthcare, patients are often faced by a significant power imbalance. When serious allegations are made against healthcare professionals, there must be robust processes in place to safeguard both staff and patients while these are being investigated.” Read full story Source: The Independent, 12 August 2024

At least 70 incidents that ‘should never be allowed to happen’ have taken place at hospitals in the north in the last five years. As severe pressure on the health service continues to grow, figures obtained by The Irish News through Freedom of Information requests show that 70 so-called ‘Never Events’ have occured since 2019. The data also shows that two deaths were caused as a result of such incidents in the last five years, one in the Belfast trust area and one in the South Eastern trust area. ‘Never Events’ in the NHS are defined as ‘wholly preventable’ incidents where there are ‘strong systemic protective barriers’ in place to avoid them. Each incident has the potential to cause serious harm or death. The data provided to The Irish News from the five health and social care trusts in the North show that the Belfast Trust alone was responsible for 37 Never Events. SDLP MLA Colin McGrath says the figures are “extremely worrying” and that he has written to Health Minister Mike Nesbitt for an “urgent assessment” of the number of incidents. “’Never Events’ by their very title should never occur but the sheer scale of them is worrying,” the South Down MLA said. “It is most concerning too to hear that people have died as a result of these events - underlying the serious nature of them. “I have written to the Minister on the back of these figures secured by the Irish News and have asked for an urgent assessment of them to ensure learning from the incidents is achieved to reduce their occurrence in the future.” Read full story Source: The Irish News, 5 August 2024

The British Medical Association (BMA) has called for the ban on puberty blockers for under-18s to be lifted. The doctors’ union also wants a pause on the implementation of a landmark review into gender care for children and young people. It said it wanted to undertake an evaluation of the Cass Review after academics expressed concern about its approach. The review, commissioned by NHS England, called for a move away from medical interventions for children struggling with their gender identity and advocated a more holistic model incorporating better mental health support. The review was led by leading paediatrician Dr Hilary Cass and prompted the last government to ban the use of puberty blockers for under-18s questioning their gender – a move which was then supported by Labour when they won the election. These drugs suppress the natural production of hormones and delay the onset of puberty. The ban applied to private clinics, because the NHS had already stopped using them outside of clinical trials, and was challenged in the High Court by campaign group TransActual. The BMA said members of its Council, its top decision-making body, voted in favour of a motion last month that was critical of the Cass Review and called on the union to "publicly critique" it. The BMA said it was concerned about its impact on transgender healthcare provision because of its "unsubstantiated recommendations". Read full story Source: BBC News, 1 August 2024