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Sam

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  1. Sam
    Hundreds of thousands who survived the virus still have side-effects that range from loss of smell to chronic fatigue.
    "It started with a mild sore throat. I was in Devon at the beginning of the lockdown, and because I hadn’t been on a cruise ship, gone skiing in Italy or partying with the crowds at Cheltenham races, I didn’t think it could be COVID-19. Then I developed sinusitis. My GP was practical: “This is not a symptom of the virus,” he emailed me. But my sense of smell had disappeared. At first this wasn’t a sign but six months later, I still can’t tell the difference between the smell of an overripe banana or lavender. I can distinguish petrol but not gas, dog mess but not roses, bacon but not freshly cut grass. Everything else smells of burnt condensed milk."
    Read full story (paywalled)
    Source: The Times, 23 September 2020
  2. Sam
    An external review has been launched at a leading children’s hospital after a series of “never events”.
    According to local commissioners, a review by the Association for Perioperative Practitioners will look into seven incidents at Alder Hey Children’s Foundation Trust over the last two years. The probe had been delayed by the pandemic and began this month.  
    Great Ormond Street Hospital for Children FT and Sheffield Children’s FT, the two other dedicated children’s trusts in England, reported one and four never events respectively, between April 2018 and July 2020, according to national data.
    In a statement, Alder Hey claimed it could not provide further details of the incidents. But most have been described in its board papers over the past year. They include a 15-year-old who had the wrong tooth removed by the surgical division, a patient who had the wrong eye operated on, a swab that was left inside a patient having their adenoids and tonsils removed, and an incorrect implant being inserted into an orthopaedics patient.
    Liverpool Clinical Commissioning’s group’s board papers for September said: “The trust has had a series of seven never events and there is a plan to undertake an external review that has been delayed due to the pandemic response. The trust has approached the Association for Perioperative Practitioners and have agreed the process."
    “The trust also plans to work with Imperial College London on a peer review and bespoke human factors training to include simulation training and coaching. The trust also plans to produce an overarching action plan to bring together the themes and learning from the seven never events. This work is still underway and NHSE/I and CCG had requested a copy of this plan.”
    Read full story (paywalled)
    Source: HSJ, 24 September 2020
  3. Sam
    Delays at the Great Ormond Street Hospital led to a boy dying an agonising death, a health watchdog has found.
    Arvind Jain, 13, who had Duchenne Muscular Dystrophy, died in August 2009 after waiting months for an operation. The ombudsman's report found he had "suffered considerable distress" and criticised referral procedures as "chaotic and substandard".
    The Great Ormond Street Hospital said there were "failings in clinical care".
    Arvind's sister Shushma said: "To read that he was suffering all the time, that was disgusting. He had been asking us repeatedly if he would get the operation and we would be constantly reassuring him that he would not die."
    The degenerative disease Arvind, who lived in Cricklewood, north London, suffered from was not immediately life threatening but in January 2009 his condition had become acute enough for him to struggle with swallowing and feeding. He had a temporary medical solution where a tube was inserted through his nose to help him get the required nutrition. He also experienced a number of other medical complications although none of these was considered life-threatening.
    The permanent solution recommended by his consultant paediatric neurologist was a gastrostomy insertion which would allow Arvind to feed through his stomach.
    The Great Ormond Street Hospital Trust (GOSH) excels in such procedures, however, a series of communication errors meant despite repeated and urgent requests from his neurological consultant, proper investigations were not carried out into Arvind's suitability for the operation.
    After five months of delays he and his family were reassured that as soon as he got the operation he would be much more comfortable. Another hospital also offered to carry out the operation in the event that the delays continued. But the surgical team that was due to carry out the operation never managed to assess Arvind.
    His condition deteriorated to the point where he was not well enough to be operated on and Arvind died on 9 August 2009.
    The Parliamentary and Health Service Ombudsman's report said he "suffered considerable distress and discomfort". It also describes a series of basic shortcomings in Arvind's care.
    The report said: "The standard of care provided for Arvind fell so far below the applicable standards as to amount to service failure."
    Read full story
    Source: BBC News, 23 September 2020
  4. Sam
    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
  5. Sam
    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
  6. Sam
    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
  7. Sam
    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
  8. Sam
    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
  9. Sam
    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
  10. Sam
    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
  11. Sam
    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
  12. Sam
    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
  13. Sam
    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
  14. Sam
    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
     
  15. Sam
    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
     
  16. Sam
    '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
  17. Sam
    More than one in four patients with severe mental health conditions are missing diagnosis when they are admitted to hospital for other reasons, new research suggests.
    According to data analysed by scientists at University College London, those who are missing these mental illness diagnoses are more likely to be from ethnic minority groups or have a previously diagnosed mental illnesses.
    However, the situation has improved – in 2006 it was found that mental health diagnoses were missed in more than 50% of cases.
    "We found encouraging signs that clinicians are more frequently identifying severe mental illnesses in hospital patients than they were a decade ago,” Hassan Mansour, a research assistant at UCL psychiatry, said.
    “But there's a lot more that can be done, particularly to address disparities between ethnic groups, to ensure that everyone gets the best care available.
    Training in culturally-sensitive diagnosis may be needed to reduce inequalities in medical care."
    The researchers have suggested these findings may be due to language barriers or stigma felt by patients. It was also suggested that clinicians may be less able to detect these conditions in people from other ethnic and cultural groups.
    Read full story
    Source: The Independent, 18 September 2020
     
  18. Sam
    NHS hospitals have been banned from launching their own coronavirus testing for staff and patients who have symptoms – despite a nationwide shortage in tests.
    Leaked NHS documents, passed to The Independent, show the Department of Health and Social Care (DHSC) has now capped funding for COVID-19 testing in the health service, even though the lack of tests has left hospital doctors, nurses, teachers and other key workers forced to stay at home.
    The diktat warned hospitals that, if they did choose to go ahead, the six figure costs would have to come from their own budgets.
    The warning was sent just a day after testing tsar Baroness Dido Harding admitted to MPs that demand for coronavirus tests is three to four times the number available.
    One senior NHS director told The Independent that NHS trusts had the ability to buy Covid-19 test capacity in local laboratories but now faced the risk of not getting the money to pay for it.
    They said: “This is just barmy at a time when we have cases rising and we need to get test results for staff and patients who are isolating at home waiting for results.
    Read full story
    Source: The Independent, 18 September 2020
     
  19. Sam
    A decision not to "urgently" refer an anorexic woman whose condition had significantly deteriorated contributed to her death, a coroner said.
    Amanda Bowles, 45, was found at her Cambridge home in September 2017.
    An eating disorder psychiatrist who assessed her on 24 August apologised to Ms Bowles' family for not organising an admission under the Mental Health Act.
    Assistant coroner Sean Horstead said the decision not to arrange an assessment "contributed to her death".
    Mr Horstead told an inquest at Huntingdon Racecourse that also on the balance of probabilities the "decision not to significantly increase the level of in-person monitoring" following 24 August "contributed to the death".
    In his narrative conclusion, Mr Horstead said it was "possible... that had a robust system for monitoring Ms Bowles in the months preceding her death been in place, then the deterioration in her physical and mental health may have been detected earlier" and led to an earlier referral to the Adult Eating Disorder Service.   He said this absence "was the direct consequence of the lack of formally commissioned monitoring in either primary or secondary care for eating disorder patients".   Read full story   Source: BBC News, 17 September 2020  
  20. Sam
    Tens of thousands of people avoided going to hospital for life-threatening illnesses such as heart attacks during Britain's coronavirus crisis, data has revealed. 
    Shocking figures reveal that admissions for seven deadly non-coronavirus conditions between March and June fell by more than 173,000 on the previous year. 
    Previous data for England shows there were nearly 6,000 fewer admissions for heart attacks in March and April compared with last year, and almost 137,000 fewer cancer admissions from March to June.
    Analysis by the Daily Mail found that the trends were alarmingly similar across the board for patients who suffered strokes, diabetes, dementia, mental health conditions and eating disorders. 
    Health experts said the statistics were 'troubling' and warned that many patients may have died or suffered longterm harm as a result.  
    Gbemi Babalola, senior analyst at the King's Fund think-tank said: "People with some of the most serious health concerns are going without the healthcare they desperately need. Compared with the height of the pandemic, the NHS is seeing an increase in the number of patients as services restart, and significant effort is going into new ways to treat and support patients."
    "But the fact remains that fewer people are being treated by NHS services."
    Read full story
    Source: Daily Mail, 13 September 2020
  21. Sam
    Yesterday marked the second World Patient Safety Day, and this year’s theme shined a light on health worker safety – those on the frontline of the pandemic have been selfless in their sacrifices to care for an ailing global population. What has become ever clearer is that a health system is nothing without those who work within it and that we must prioritise the safety and wellbeing of health workers, because without safe health workers we cannot have safe patients.
    Improving maternity safety has been a priority for some time – although rare, when things go wrong the consequences are unthinkable for families and the professionals caring for them. Maternity negligence makes up 50% of the total value of negligence claims across all NHS sectors, according to the latest NHS Resolution annual report and accounts. It states there were claims of around £2.4 billion in 2019/20, which is in the region of £6.5 million a day. This cost says nothing of the suffering families and professionals associated.
    However, without investing in the maternity frontline we cannot hope to make integral systemic changes to improve maternity safety and save mothers’ and babies’ lives, writes Sara Ledger, head of research and development at Baby Lifeline in the Independent.
    "We owe it to every mother and baby to rigorously and transparently scrutinise the safety of maternity services, which will be in no small way linked to the support staff receive."
    Read full story
    Source: The Independent, 17 September 2020
  22. Sam
    Patients who receive good perioperative care can have fewer complications after surgery, shorter hospital stays, and quicker recovery times, shows a large review of research.
    The Centre for Perioperative Care, a partnership between the Royal College of Anaesthetists, other medical and nursing royal colleges, and NHS England, reviewed 27 382 articles published between 2000 and 2020 to understand the evidence about perioperative care, eventually focusing on 348 suitable studies.
    An estimated 10 million or so people have surgery in the NHS in the UK each year, with elective surgery costing £16bn a year.
    A perioperative approach can increase how prepared and empowered people feel before and after surgery. This can reduce complications and the amount of time that people stay in hospital after surgery, meaning that people feel better sooner and are able to resume their day-to-day life.
    Read full story (paywalled)
    Source: BMJ, 17 September 2020
  23. Sam
    More than 1,500 breast cancer patients in UK face long waits to have reconstructive surgery after hospitals could not operate on them during the pandemic because they were tackling COVID-19.
    The women are facing delays of “many months, possibly years” because the NHS has such a big backlog of cases to get through, according to research by the charity Breast Cancer Now.
    When the lockdown began in March the NHS stopped performing breast reconstructions for women seeking one after a mastectomy as part of its wider suspension of care. That was because so many operating theatres were being used as overflow intensive care units and because doctors and hospital bosses feared that patients coming into hospital might catch Covid.
    The NHS started doing them again in July, but not everywhere and not in the same numbers as before.
    “We are deeply concerned by our finding that over 1,500 breast cancer patients may now face lengthy and extremely upsetting delays for reconstructive surgery,” said Delyth Morgan, the chief executive of Breast Cancer Now. “This will leave many women who want to have reconstruction with one breast, no breasts or asymmetric breasts for months, possibly even years.”
    Lady Morgan said: “Reconstructive surgery is an essential part of recovery after breast cancer for those who choose it.
    “Women with breast cancer have told us these delays are causing them huge anxiety, low self-esteem and damaged body confidence, and all at a time when the Covid-19 pandemic has denied them access to face to face support from healthcare professionals and charities.”
    Read full story
    Source: The Guardian, 18 September 2020
  24. Sam
    Accidents on maternity wards cost the NHS nearly £1 billion last year, Jeremy Hunt, the chairman of the Commons health committee, has revealed.
    The former health secretary said the bill for maternity legal action was nearly twice the amount spent on maternity doctors in England. It was part of the NHS’s £2.4 billion total legal fees and compensation bill, up £137 million on the previous year.
    Mr Hunt has also told the Daily Mail there is evidence that hospitals are failing to provide details of avoidable deaths despite being ordered to do so three years ago as he highlighted “appalling high” figures which showed that up to 150 lives are being lost needlessly every week in public hospitals.
    Responding to the figures, Mr Hunt said: "Something has gone badly wrong."
    In 2017, he told trusts to publish data on the number of avoidable deaths among patients in their care. But freedom of information responses from 59 hospital trusts, about half the total, found less than a quarter gave meaningful data on avoidable deaths.
    Mr Hunt cited “major cultural challenges” which he blamed for preventing doctors and nurses from accepting any blame. He blamed lawyers who get involved “almost immediately” once something goes wrong with a patient’s care.
    “Doctors, nurses and midwives worry they could lose their licence if they are found to have made a mistake. Hospital managers worry about the reputation of their organisation,” he added.
    Mr Hunt said: “We have appallingly high levels of avoidable harm and death in our healthcare system. We seem to just accept it as inevitable.”
    An NHS spokesman said: “Delivering the safest possible health service for patients is a priority, and the national policy on learning from deaths is clear that hospitals must publish this information every three months, as well as an annual summary, so that they are clear about any problems that have been identified and how they are being addressed.
    Read full story
    Source: The Telegraph, 18 September 2020
  25. Sam
    An investigation into the outbreak of a bacterial infection that killed 15 people has found there were several “missed opportunities” in their care.
    Mid Essex Clinical Commissioning Group has released the outcome of a 10-month investigation into a Strep A outbreak in 2019, which killed 15 people and affected a further 24. The final report was critical of Provide, a community interest company based in Colchester, as well as the former Mid Essex Hospital Services Trust (now part of Mid and South Essex Foundation Trust).
    It said: “This investigation has identified that in some cases there were missed opportunities where treatment should have been more proactive, holistic and timely. These do not definitively indicate that their outcomes would have been different.”
    Investigators found that 13 of the 15 people that died had received poor wound care from Provide CIC. They reported that inappropriate wound dressings were used and record keeping was so poor that deterioration of wounds was not recognised.
    Even wounds that had not improved over 22 days were not escalated to senior team members for help or referred to the tissue viability service for specialist advice, with investigators told this was often due to concerns over team capacity.
    The report, commissioned by the CCG and conducted by consultancy firm Facere Melius, said: “[Some] individuals became increasingly unwell over a period of time in the community, yet their deterioration either went unnoticed or was not acted upon promptly. Sometimes their condition had become so serious that they were very ill before acute medical intervention was sought”.
    Other findings included delays in the community in the taking of wound swabs to determine if the wound was infected and by which bacteria. It said in one case nine days elapsed before the requested swab took place. Even after Public Health England asked for all wounds to be swabbed following the initial outbreak, this was only conducted on a single patient.
    In other cases there were delays in patients being given antibiotics and this “could have had an adverse impact on the treatment for infection”.
    It also found that sepsis guidelines were not accurately followed, wounds were not uncovered for inspection in A&E, and some patients were given penicillin-based antibiotics despite penicillin allergies being listed in their health records.
    Read full story (paywalled)
    Source: HSJ, 17 September 2020
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