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Sam

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  1. News Article
    Senior doctors say female medics have felt pressured into sexual activity with colleagues. Four women who head up medical royal colleges in Wales have written an open letter describing misogyny, bullying and sexual harassment in the workplace. They told BBC Wales that female staff had been asked for sex by male colleagues while on shift. The Welsh government said: "Harassment and sexual violence is abhorrent and has no place in our NHS." Chairwoman of the Royal College of Psychiatrists in Wales, Dr Maria Atkins, said: "I've heard from multiple women over the years that during night-time shifts, they've been propositioned by male colleagues and felt pressured to engage in sexual acts. "When they've refused they are penalised. "It can be very damaging to some less experienced or younger women, because they will be discouraged from engaging with a team, which might have been the specialty of medicine that they wanted to progress their career in." Read full story Source: BBC News, 22 September 2023
  2. News Article
    The national director for patient safety in England has cautioned against the ‘false hope’ of trying to achieve ‘zero harm’ from healthcare, describing it as unachievable. Speaking at HSJ’s Patient Safety Congress earlier this week Aidan Fowler told delegates: “The dream of zero harm is appealing. It’s what we all want. But it’s unachievable in reality, it’s unmeasurable [and] it carries risk.” Mr Fowler said what is really meant is eliminating “avoidable harm”, but also described this as “problematic”. He said: “I challenge any one of you to define ‘avoidable’. We start to define a complex system in simplistic terms. We hear, ‘we’ve had no avoidable harm for six hears in our hospital’. And you think, ‘is that real?’” Mr Fowler stressed the ambition should be to reduce harm to minimal levels, but said the notion that any provider could claim they had no harm for period of years was “hard to credit”. He said by pursuing the “zero harm” ambition, the NHS was also “setting unattainable goals to our staff”. “[We are] creating unrealistic expectations and burning them [staff] out and potentially creating moral distress when they’re not achieving something they’re told they should achieve,” he said. Read full story (paywalled) Source: HSJ, 21 September 2023
  3. News Article
    A cancer patient with months to live has spoken of her fear and anger after chemotherapy was delayed by this week’s strikes. Flora White, 51, began chemotherapy last month, which is required fortnightly to shrink a tumour so it can be surgically removed. But it has now been set back, after the appointment she was due to have with her oncologist the day before was cancelled as a result of strikes. Ms White said that until she got the devastating news about her own delays she had thought cancer patients would be protected from the impact of industrial action. “It’s hard to deal with as it is, let alone the extra worry and stress,” she said. “Your treatment being cancelled and delayed, they don’t understand how they’re affecting some people.” Earlier this week, Prof Karol Sikora, a leading consultant oncologist, said it was “against the ethics of medicine” for doctors to strike, as he urged medics to think again. “If you miss cancer and someone goes for another two years without a diagnosis, it’s as good as leaving someone in the gutter bleeding ... people will die,” he said. Read full story (paywalled) Source: The Telegraph, 21 September 2023
  4. News Article
    It is still unclear how unauthorised metal parts came to be implanted in a number of the 19 children with spina bifida who suffered significant complications after spinal surgery. But it has emerged that one child died and 18 others suffered a range of complications after surgery at Temple Street Children’s Hospital – with several needing further surgery, including the removal of metal parts which were not authorised for use. Parents of the children undergoing complex surgery were left distraught by the disclosures that emerged yesterday, after campaigning for years while the young patients in need of operations deteriorated on waiting lists. Gerry Maguire, of Spina Bifida Hydrocephalus Ireland, said “absolute horror is being visited on parents and their advocates”. He condemned as disturbing the information which is “being drip-fed to his group and “more alarmingly the families concerned”. One mother expressed concern about further delays in surgery and said children are too complex to be taken for care abroad. Read full story Source: Irish Independent, 19 September 2023
  5. News Article
    National leaders are looking to greatly reduce the number of direct hospital referrals made by GPs, by insisting that they first discuss cases with hospital consultants. The approach – known as “advice and guidance” or “A&G” – involves GPs sending a patient’s details to a consultant who specialises in their condition before making a referral. The consultant then advises on the best course of action. “A&G’ has been voluntarily adopted by many health systems, but HSJ has now learnt that a move to significantly increase its use of it is being discussed as part of a new national strategy for outpatient services, due to be published by December. Theresa Barnes, outpatients lead at the Royal College of Physicians, is part of a group of clinicians helping to develop the strategy in partnership with NHS England, and said there is a case for A&G to be used “in preference” to direct referrals in a vast number of cases where it is clinically appropriate. She told HSJ: “I think there should be a push to use advice and guidance in preference to direct referrals, so we can maximise that pre-referral interaction and deliver as much care as close to patients’ homes as they can get it and without the delay of potentially waiting for a secondary care appointment.” Read full story (paywalled) Source: HSJ, 20 September 2023
  6. Event
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    CORESS invites you to join their free educational webinar and hear from four speakers as they talk about their area of expertise in relation to patient safety. Programme overview: 14:00 - Introduction to CORESS and Welcome - Professor Frank Smith, Professor of Vascular Surgery & Surgical Education, University of Bristol and North Bristol NHS Trust and CORESS Past-Programme Director 14:03 - Symposium Programme Overview - Miss Harriet Corbett FRCS Paed Consultant Paediatric Urologist, Alder Hey Children’s Foundation NHS Trust, British Association of Paediatric Urologists and CORESS Programme Director 14:05 - SPOT Programme: The National inpatient PEWS Chart - Professor Damien Roland, Consultant in Paediatric Emergency Medicine, Head of Service Children's Emergency Department, University Hospitals of Leicester NHS Trust 14:30 - Championing Patient Safety with Evidence Based Medicine - Robotically Assisted Surgery - Dr John Burke, Chief Medical Officer, AXA Health 14:55 - What’s new at HSIB - Saskia Fursland, National Investigator, HSIB 15:20 - Patient Safety in a Medico-legal Context - Dr Michael Devlin, LLM, MBA, FRCP, FRCGP, FFFLM , Head of Professional Standards and Liaison, MDU 15:45 - Symposium Summary and Close - Harriet Corbett, CORESS Programme Director Intended Audience: This session is for Consultant Surgeons, medics, students with a surgical healthcare background and those in healthcare and insurance sectors with an interest in surgical improvement and patient safety. Register
  7. News Article
    Regulation of managers must not lead to a disbarring process without also introducing ”developmental” and supportive measures, NHS England’s national patient safety director has said. Speaking at HSJ’s Patient Safety Congress, Aidan Fowler was asked whether NHS board members and managers should be regulated, amid calls for this in the wake of the Lucy Letby scandal. He said: “I think there are pros and cons to regulation… What I would say is that you just have to be cautious that you do not lead to a disbarring process without the developmental side of regulation, and the support side of regulation. For staff, to support them to do a good job. “We have seen that there is a gap in patient safety training for boards, which we need to work on, for them to understand and to encourage them to talk about it more. “I think there is a developmental part of regulation, which is really important… in any discussion. I know because we are already having discussions around it. That is a key part to pay attention to.” Read full story (paywalled) Source: HSJ,18 September 2023
  8. News Article
    Dozens more children than initially thought have come to “severe” harm following failings in audiology care, HSJ can reveal. Two more trusts have confirmed that, between them, 30 children suffered severe harm – which is defined as ”permanent or long-term harm” – after the failings. Northern Lincolnshire and Goole Foundation Trust said an external investigation had revealed 14 such cases, while Worcestershire Acute Hospitals Trust found 16 more after going through the same process. A total of 36 confirmed or suspected severe harm cases from paediatric audiology failings across six English trusts are now known about. I NHS England wrote to all 42 integrated care boards at the end of August, asking them to ensure the “approximately” 130 paediatric hearing services in England were running safely. Sir David Sloman, then-chief operating officer, and Dame Sue Hill, chief science officer, said the NHSE “review of these trusts has identified root causes that have led to poor service delivery and outcomes… [which include] lack of clinical governance and oversight, poor reporting of data, poor interpretation of results, poor retention of diagnostic data, and lack of accreditation.” The National Deaf Children’s Society called the speed of the NHS’s response “a scandal”. Read full story (paywalled) Source: HSJ, 19 September 2023
  9. News Article
    Derby and Burton’s maternity services are now among the “most challenged in England”, requiring national involvement to boost improvements. The University Hospitals of Derby and Burton NHS Foundation Trust joins 31 other NHS trusts across England which are now under closer scrutiny aimed at improving the quality of maternity services. A report from the trust details that it asked to be added to the national NHS England Maternity Safety Support Programme (MSSP) "voluntarily". Midwifery and obstetric improvement advisors have now been allocated to the trust to spend two days a week on the trust’s sites and also to provide “virtual” assistance. A letter to Stephen Posey, the trust’s chief executive, sent by Sascha Wells-Munro, the deputy chief midwifery officer for NHS England, details that the organisation’s addition to the national support programme comes after a number of concerning reports – not just its request. It references the Healthcare Safety Investigation Branch report, published in February, which highlighted the cases of seven women and their babies between January 2021 and May 2022, with three mothers and a baby dying and four mothers suffering extreme consequences. Read full story Source: Derbyshire Live, 13 September 2023
  10. News Article
    A police investigation into allegations of cover-up and medical negligence over dozens of deaths at the Royal Sussex county hospital (RSCH) in Brighton has been expanded to include more recent cases, amid internal claims about dangerous surgery. In June the Guardian revealed that Sussex police were investigating the deaths of about 40 patients in the general surgery and neurosurgery departments at the RSCH. The force initially said the investigation, since named Operation Bramber, related to allegations of medical negligence in these departments between 2015 and 2020. It has now extended the scope of the investigation to more recent cases, amid internal allegations that the departments continue to be unsafe and fail to properly review serious incidents. An insider said the police should review what was considered to be an avoidable death after a procedure in July. The source said some of the surgeons remained a danger to the public. “You would not want your family members touched by these people,” they said. They added: “This is not a historic issue, it is ongoing. The same surgeons that were involved in previous problems remain in place.” They cited a woman who lost the power of speech in April after an alleged mistake in surgery to remove a brain tumour led to a stroke, and a man who was left with a brain abscess in May after being operated on despite a heightened risk of infection. Read full story Source: The Guardian, 13 September 2023
  11. News Article
    More than a quarter of million people dipped into their savings or took a loan to pay for a private hospital operation or appointment last year — a record high. This year could exceed that. And who can blame them? With the NHS waiting list at a staggering 7.6 million and monthly strikes by doctors lengthening waiting times, patients are increasingly prepared to jump the queue and pay hard cash to do so. In an effort to cut waits and expand choice for patients, Rishi Sunak is funnelling thousands more NHS patients into the private sector. Yet private healthcare is not without risks, many of which are not fully understood. There is a difference between the NHS, which — for all its faults — has been a dependable, free at the point of use health service for more than 75 years, and the sometimes murky world of private doctors and hospital companies who use them. Can you trust your private doctor? When you look under the bonnet of private healthcare, beyond the glossy adverts, things can get a little uncertain. Read full story (paywalled) Source: The Times, 10 September 2023
  12. News Article
    A grandfather who went into hospital with stomach problems needed both of his legs and his left hand amputating after contracting a life-threatening infection. Stephen Hughes, from Edmondstown, had been admitted to the Royal Glamorgan Hospital in Llantrisant, in March 2022, with gallstones and aggressive stomach inflammation. This led to pancreatitis corroding a hole in the duodenum which caused a significant bleed into his gut. The 56-year-old's condition deteriorated and he was transferred to the ICU at the University Hospital of Wales as a patient in critical condition. Whilst at UHW, his family said that the NHS staff worked tirelessly to stop the internal bleeding he was suffering. His gallbladder was removed on September 8th, 2022, and stents were placed along his arteries. Although these operations were successful, his family claims that Mr Hughes caught sepsis from the feeding tube in his neck on 11 September 2022 whilst recovering. Stephen’s body prioritised sending blood to his vital organs which resulted in his outer limbs being deprived of blood and oxygen. Stephen then had to have life-altering operations, which resulted in both of his legs being amputated towards the end of September, and his left hand being amputated at the start of October. He was later discharged on 31 October. A spokesperson for Cardiff and Vale University Health Board said: “As a Health Board we are unable to comment on individual patient cases, however we appreciate how life altering operations are particularly distressing for the individual and also their loved ones. Read full story Source: Wales Online, 9 September 2023
  13. News Article
    The mother of Martha Mills, whose preventable death in hospital has led to calls for extra patients' rights, has said she is to meet the health secretary to discuss "Martha's Rule". If introduced, it would give families a statutory right to get a second opinion if they have concerns about care. Merope Mills said patients needed more clarity and to feel empowered. Her daughter, Martha, died two years ago after failures in treating her sepsis at King's College Hospital. She had entered hospital with an injury to her pancreas after falling off her bike. The injury was serious but should never have been fatal. Within days she had died of sepsis. In an interview on Radio 4's Today programme, Mrs Mills said she had raised concerns but doctors told her the extensive bleeding was "a normal side-effect of the infection, that her clotting abilities were slightly off". The King's College Hospital Trust said it remained "deeply sorry that we failed Martha when she needed us most" and her parents should have been listened to. Read full story Source: BBC News, 12 September 2023
  14. Content Article
    Report from HSJ, in association with Allocate Software, on why patient safety should be the core business of healthcare.
  15. News Article
    A hospital review of mesh operations by a surgeon who left dozens of patients in agony is now looking into another type of procedure he carried out. Tony Dixon, who used mesh surgery to treat bowel problems, has always maintained he did the operations in good faith. Now it has emerged that other patients who had their rectum stapled are also being written to. Spire Hospital Bristol said its "comprehensive" review remains ongoing. Mr Dixon pioneered the use of artificial mesh to lift prolapsed bowels and a review of the care he gave patients receiving Laparoscopic ventral mesh rectopexy has already concluded. Now the Spire has contacted patients who underwent a Stapled Transanal Rectal Resection (STARR operation) with Mr Dixon. Many of the affected patients have told the BBC they did not give informed consent for the procedure and are in chronic pain. Read full story Source: 11 September 2023
  16. News Article
    The family of a student who died after hospital staff missed that she had developed sepsis despite a string of warning signs have claimed she was the victim of a “lack of care”, as a coroner ruled there were “gross” failures in her treatment. Staff at Southmead hospital in Bristol failed to carry out the sepsis screening and observations needed to keep 20-year-old Maddy Lawrence safe after she was taken to hospital with a dislocated hip sustained in a rugby tackle. Outside court, the student’s mother, Karen Lawrence, said: “It has been a constant struggle to understand how a healthy, strong and fit 20-year-old could lose her life to sepsis which was allowed to develop under the care of professionals. “Her screams of pain and our pleas for help were merely managed, temporarily quietened with painkillers while the infection progressed unnoticed by hospital staff. “Our daughter was failed by a number of nurses and medical staff; symptoms were ignored, observations were not taken, on one occasion for 16 hours. There was no curiosity, basic tests were not completed even when hospital policy required them. “Maddy herself expressed concern on multiple occasions but her pain was not being taken seriously. As well as failing to fulfil their duty, those nurses and medical staff offered no sympathy, no compassion and little attention. “This failure meant Maddy was not given the chance to beat sepsis. Significant delays in its discovery meant the crucial window for treatment was missed. Maddy did not die due to under-staffing or a lack of money. Her death was the result of a lack of care.” Read full story Source: The Independent, 8 September 2023
  17. News Article
    A 33-year-old New Zealand woman who was accused of faking debilitating symptoms has died of Ehlers-Danlos Syndrome (EDS). Stephanie Aston became an advocate for patients' rights after doctors refused to take her EDS symptoms seriously and blamed them on mental illness. She was just 25 when those symptoms began in October 2015. At the time, she did not know she had inherited the health condition. EDS refers to a group of inherited disorders caused by gene mutations that weaken the connective tissues. There are at least 13 different types of EDS, and the conditions range from mild to life-threatening. EDS is extremely rare. Aston sought medical help after her symptoms—which included severe migraines, abdominal pain, joint dislocations, easy bruising, iron deficiency, fainting, tachycardia, and multiple injuries—began in 2015, per the New Zealand Herald. She was referred to Auckland Hospital, where a doctor accused her of causing her own illness. Because of his accusations, Aston was placed on psychiatric watch. She had to undergo rectal examinations and was accused of practising self-harming behaviours. She was suspected of faking fainting spells, fevers, and coughing fits, and there were also suggestions that her mother was physically harming her. There was no basis for the doctor’s accusations that her illness was caused by psychiatric issues, Aston told the New Zealand Herald. “There was no evaluation prior to this, no psych consultation, nothing,” she said. She eventually complained to the Auckland District Health Board and the Health and Disability Commissioner of New Zealand. “I feel like I have had my dignity stripped and my rights seriously breached,” she said. Read full story Source: The Independent, 6 September 2023
  18. Event
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    The theme for this event from Learning from Excellence is “Hope”, and the intention is to inspire optimism through focusing on positivity whilst facing the many challenges in the NHS. Our speakers have been chosen from a range of disciplines and backgrounds, offering a diversity of thought-provoking and inspirational stories and messages. The content will be presented in a range of formats, from in person lectures, extensive panel Q&A and pre-recorded podcast conversation highlights. Register
  19. News Article
    A not-for-profit health system in Maine has threatened legal action against a 15-year-old boy for shedding light on alleged patient safety issues in the paediatric ward of one of its hospitals. Samson Cournane, a student at the University of Maine, started a petition (Patient Safety in Maine Matters) advocating for an investigation into Northern Light Eastern Maine Medical Center last year, claiming conditions at the hospital were unsafe. Mr Cournane’s mother, Dr Anne Yered, had previously been fired from the hospital after reportedly voicing safety concerns to the hospital’s CEO and president in 2020. In the petition, Mr Cournane said his mother was threatened by hospital staff after raising concerns, with one hospital manager going so far as to show up in her backyard to confront her. Dr Yered subsequently claimed she was wrongfully terminated. Mr Cournane then began pushing for an investigation into the hospital, outlining problems in the petition, which was addressed to US Representative Jared Golden. He alleged that the medical director of the paediatric intensive care unit (ICU) — a former colleague of his mother’s — finished just one year of a three-year critical care fellowship, and implied other hospital employees may be scared to come forward with safety concerns. Read full story Source: The Independent, 4 September 2023
  20. News Article
    Tonjanic Hill was overjoyed in 2017 when she learned she was 14 weeks pregnant. Despite a history of uterine fibroids, she never lost faith that she would someday have a child. But, just five weeks after confirming her pregnancy she seemed unable to stop urinating. She didn’t realize her amniotic fluid was leaking. Then came the excruciating pain. “I ended up going to the emergency room,” said Hill, now 35. “That’s where I had the most traumatic, horrible experience ever.” An ultrasound showed she had lost 90% of her amniotic fluid. Yet, over the angry protestations of her nurse, Hill said, the attending doctor insisted Hill be discharged and see her own OB-GYN the next day. The doctor brushed off her concerns, she said. The next morning, her OB-GYN’s office rushed her back to the hospital. But she lost her baby. Black women are less likely than women from other racial groups to carry a pregnancy to term — and in Harris County, where Houston is located, when they do, their infants are about twice as likely to die before their 1st birthday as those from other racial groups. Black fetal and infant deaths are part of a continuum of systemic failures that contribute to disproportionately high Black maternal mortality rates. “This is a public health crisis as it relates to Black moms and babies that is completely preventable,” said Barbie Robinson, who took over as executive director of Harris County Public Health in March 2021. “When you look at the breakdown demographically — who’s disproportionately impacted by the lack of access — we have a situation where we can expect these horrible outcomes.” Read full story Source: KFF Health News, 24 August 2023
  21. News Article
    More than 120,000 died waiting for NHS treatment, as backlog hits all-time high. The number of NHS patients dying while waiting for treatment has doubled in five years, new figures suggest. More than 120,000 people died while on waiting lists last year, according to an analysis of health service data. The total is even higher than it was in lockdown, with health leaders saying the pandemic and NHS strikes have made clearing backlogs more difficult. Matthew Taylor, the chief executive of the NHS Confederation, said: “These figures are a stark reminder about the potential repercussions of long waits for care. They are heartbreaking for the families who will have lost loved ones and deeply dismaying for NHS leaders, who continue to do all they can in extremely difficult circumstances." “Covid will have had an impact on these figures – but we can’t get away from the fact that a decade of under-investment in the NHS has left it with not enough staff, beds and vital equipment, as well as a crumbling estate in urgent need of repair and investment.” Read full story (paywalled) Source: The Telegraph, 31 August 2023
  22. Event
    World Patient Safety Day 2023 will be observed on 17 September under the theme “Engaging patients for patient safety", in recognition of the crucial role patients, families and caregivers play in the safety of health care. Evidence shows that when patients are treated as partners in their care, significant gains are made in safety, patient satisfaction and health outcomes. By becoming active members of the healthcare team, patients can contribute to the safety of their care and that of the health care system as a whole. World Patient Safety Day serves as a reminder that patient safety is a shared responsibility, highlighting the profound impact of patient engagement in forging a safer and more compassionate healthcare landscape worldwide. WPA is organising a webinar on patient engagement. Join the webinar and learn from patient safety champions and leading patient advocates on "Patient Engagement in Patient Safety Around the World". Register
  23. Event
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    AHRQ’s Consumer Assessment of Healthcare Providers and Systems (CAHPS®) program will host a free webcast about how the agency’s CAHPS Consortium is addressing survey stakeholders’ emerging needs for patient experience measurement and improvement. Topics of the webcast include: The value of AHRQ’s CAHPS program and its use of survey results to improve patient experience. Updates in survey content in response to changes in care delivery. Efforts to improve CAHPS survey design and administration methods. The development of new surveys in response to emerging information needs. Register
  24. News Article
    The inquiry into how nurse Lucy Letby was able to murder seven babies will now have greater powers to compel witnesses to give evidence. In a significant move, ministers upgraded the independent inquiry after criticism from families of the victims that it did not go far enough. The inquiry, ordered after Letby was found guilty this month, was not initially given full statutory powers. Health Secretary Steve Barclay said he had listened to the families. He said he had decided a statutory inquiry led by a judge was the best way forward and "respects the wishes" of the families. Mr Barclay said the key advantage was the power of compulsion. "My priority is to ensure the families get the answers they deserve and people are held to account where they need to be," he added. He said an announcement about who would chair the inquiry would be made in the coming days - ministers have already said it will be a judge. Richard Scorer, a lawyer who is representing two of the families, welcomed the government's announcement. "It is essential that the chair has the powers to compel witnesses to give evidence under oath, and to force disclosure of documents. Without these powers, the inquiry would have been ineffectual and our clients would have been deprived of the answers they need and deserve," he said. Read full story Source: BBC News, 30 August 2023
  25. News Article
    Details of allegations against a surgeon who left dozens of patients in agony after undergoing mesh operations have been published. A tribunal will look at whether Tony Dixon failed to provide adequate clinical care to six patients at Southmead Hospital and the private Spire Hospital in Bristol. He had pioneered the use of artificial mesh to lift prolapsed bowels. The surgeon, who was dismissed in 2019, has always maintained the operations were done in good faith, and that any surgery could have complications. The Medical Practitioners Tribunal, which starts in Manchester on 11 September and is due to end on 23 November, will look into allegations that between 2010 and 2016 Mr Dixon failed to provide adequate clinical care in a number of areas, including: ensuring procedures for some of the patients were clinically indicated adequately advising some of the patients regarding options for treatment obtaining informed consent before performing clinical procedures adequately performing a procedure for one patient providing adequate post-operative care for some communicating appropriately with some of the patients and their family members. Read full story Source: BBC News, 24 August 2023

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