A woman was subjected to an unnecessary invasive procedure in an NHS outpatient clinic after she was confused for another patient, a safety watchdog has found.
The Healthcare Safety Investigation Branch has called for a review of how the NHS can avoid the mishap happening again after investigating the case of a 39-year-old woman who was subjected to an unnecessary cervical examination.
HSIB said a better system was needed as the number of outpatient appointments has increased from 54 million to 94 million during the last 10 years with many clinics carrying out more invasive procedures.
According to its latest investigation, the female patient was attending a gynaecological outpatient clinic for a fertility treatment assessment.
The error happened when she was called through from the waiting room as another patient had a similar sounding name.
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Source: The Independent, 2 June 2021
Self-harm among the over-65s must receive greater focus because of the increased risks associated with the pandemic, a leading expert has said.
Loneliness, bereavement and reluctance to access GPs can all be causes in older adults, said Prof Nav Kapur, who has produced guidelines on the subject.
He warned that in over-65s, without the right help, self-harm can also be a predictor of later suicide attempts.
The NHS's mental health director said it had expanded its community support.
Claire Murdoch added that its services, including face-to-face appointments, had "continued for all who needed them", and 24/7 crisis lines had been established.
Over-65s are hospitalised more than 5,000 times a year in England because of self-harm and self-poisoning, figures obtained from NHS Digital show.
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Source: BBC News, 3 June 2021
Oversight failures, a fearful workplace culture and lax quality standards for years at a Veterans Affairs hospital in Arkansas, USA, allowed a pathologist who was routinely drunk on the job to misdiagnose thousands of veterans — sometimes with dire or deadly consequences, a new investigation has found.
Hospital leaders “failed to promote a culture of accountability” that would have led more of the doctor’s colleagues to come forward with accounts that his behavior was putting patients at risk, according to the report released Wednesday by VA’s Office of Inspector General. But the staff members at the Veterans Health Care System of the Ozarks in Fayetteville feared that reporting their concerns would lead to retaliation from their bosses.
“Any one of these breakdowns could cause harmful results,” Inspector General Michael Missal’s staff wrote in an 86-page report about the failures to stop the pathologist, Robert Morris Levy. “Together and over an extended period of time, the consequences were devastating, tragic, and deadly.”
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Source: The Washington Post, 2 June 2021
More than 20 healthcare organisations, including those representing nurses, doctors, surgeons and therapists, are calling for stricter UK guidelines to be introduced on face masks and other personal protective equipment (PPE).
In a virtual meeting with officials, they will say existing rules leave them vulnerable to infection through the air, especially by new Covid variants.
The unprecedented appeal will see them argue that other countries, such as the United States, protect their health workers with higher-grade equipment.
It is thought to be the first time health and care organisations have united on a single issue in this way - a sign of the desperation many feel about the need for staff to be kept safe.
The delegation will include representatives of the British Medical Association, the Royal College of Nursing and many other professional organisations and unions.
On the government side will be about 20 of the most senior officials from all four UK nations, many involved in setting the guidelines on personal protective equipment (PPE).
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Source: BBC News, 3 June 2021
The Care Quality Commission may in future be notified when ‘secretive’ external reviews have looked at patient safety issues within trusts.
Last summer, HSJ revealed guidance for trusts to publish summaries of royal colleges’ reviews was being widely ignored, with some even failing to inform the CQC.
A recent BBC Panorama programme has again raised the issue, with Academy of Medical Royal Colleges chair Helen Stokes-Lampard saying she was “dismayed” the body’s guidance was not being followed.
But she has now told HSJ of “advanced discussions” with the CQC about changes which would see the royal colleges routinely inform the regulator when reviews raise patient safety issues.
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Source: HSJ, 3 June 2021
A second “mutilated” patient left with life-changing injuries after botched hospital surgery has described how she was left in urine-soaked bed sheets for days by nurses who called her lazy when she was unable to get out of bed.
Lucy Wilson told The Independent she believes she would have been better looked after at a veterinary practice compared to the level of care she received from nurses at Norfolk and Norwich Hospital Trust in January last year.
She was one of three patients harmed by surgeon Camilo Valero in the same week and almost died after Dr Valero and other staff failed to recognise her life-threatening injuries following the operation to remove her gall bladder.
Dr Valero is under investigation by the General Medical Council but is still practising under supervision at the trust, which has refused to say whether the third patient survived their ordeal.
After requests by The Independent, bosses at the NHS trust have now committed to publishing details of a secret review carried out by the Royal College of Surgeons into Dr Valero’s work and the wider surgical services at the trust.
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Source: The Independent, 31 May 2021
A new national service has been established to improve the quality and management of healthcare construction and refurbishment projects across NHS Scotland.
NHS Scotland Assure brings together experts to improve quality and support the design, construction and maintenance of major healthcare developments. This world first interdisciplinary team will include microbiologists, infection prevention and control nurses, architects, planners, and engineers.
Commissioned by the Scottish Government and established by NHS National Services Scotland, the service will work with Health Boards to ensure healthcare buildings are designed with infection prevention and control practice in mind, protecting patients and improving safety.
Cabinet Secretary for Health and Social Care Humza Yousaf said:
“NHS Scotland Assure will support a culture of collaboration and transparency to provide the reassurance patients and their families deserve to feel safe in our hospitals. This service is unique to Scotland and is leading the way in risk and quality management across healthcare facilities.
“With services designed with patients in mind, we can make a real, positive difference to people’s lives.”
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Source: Scottish Government, 1 June 2021
Thousands of hospital patients were allowed to return to their care homes without a Covid test despite a direct plea to the government from major care providers not to allow the practice, the Observer has been told.
As the crisis began to unfold in early March 2020, providers held an emergency meeting with department of health officials in which they urged the government not to force them to accept untested residents. However, weeks later, official advice remained that tests were not mandatory and thousands of residents are thought to have returned to their homes without a negative Covid result.
The revelation will heap further pressure on the health secretary, Matt Hancock, who has admitted some care residents returned from hospital without a test. It comes after Dominic Cummings, the prime minister’s former senior adviser, last week accused Hancock of misleading the prime minister over the policy, during his unprecedented evidence in parliament.
Some 25,000 people were discharged to care homes between 17 March and 15 April, and there is widespread belief among social care workers and leaders that this allowed the virus to get into the homes.
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Source: The Guardian, 29 May 2021
An online trend that involves using tiny magnets as fake tongue piercings has led the NHS to call for them to be banned amid people swallowing them.
Ingesting more than one of them can be life-threatening and cause significant damage within hours.
In England, 65 children have required urgent surgery after swallowing magnets in the last three years.
The NHS issued a patient safety alert earlier this month and is now calling for the small metal balls to be banned.
It said the "neodymium or 'super strong' rare-earth magnets are sold as toys, decorative items and fake piercings, and are becoming increasingly popular". It added that unlike traditional ones, "these 'super strong' magnets are small in volume but powerful in magnetism and easily swallowed".
The online trend sees people placing two such magnets on either side of their tongue to create the illusion that the supposed piercing is real.
But when accidentally swallowed, the small magnetic ball bearings are forced together in the intestines or bowels, squeezing the tissue so that the blood supply is cut off.
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Source: BBC News, 30 May 2021
People who remain chronically ill after Covid infections in England have had to wait months for appointments and treatment at specialist clinics set up to handle the surge in patients with long Covid.
MPs called on Matt Hancock, the health secretary, to explain the lengthy waiting times and what they described as a “shameful postcode lottery” which left some patients facing delays of more than four months before being assessed at a specialist centre while others were seen within days.
NHS England announced in December that people with long Covid, or post-Covid syndrome, could seek help at more than 60 specialist clinics. But despite government assertions in January that the network of 69 centres was already operating, the all-party parliamentary group on coronavirus found that some clinics were still not up and running three months later.
Freedom of information requests submitted to NHS trusts revealed that while some clinics had opened and were seeing patients, others had been delayed by the second wave of infections in January.
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Source: The Guardian, 30 May 2021
Research has found that people who go to A&E following self-harm receive varying quality of care and this has a significant impact on what they experience subsequently.
The study in BMJ Open, which was codesigned and co-authored with people who have lived experience of self-harm and mental health services, found negative experiences were common, and revealed stigmatising comments about injuries from some hospital staff. Some participants reported being refused medical care or an anaesthetic because they had harmed themselves. This had a direct impact on their risk of repeat self-harm and suicide risk, as well as their general mental health.
According to the research, the participants who received supportive assessments with healthcare staff reported feeling better, less suicidal and were less likely to repeat self- harm.
"This research highlights the importance of learning from the experiences of individuals to help improve care for people who have harmed themselves. We involved patients and carers throughout the entire process and this enabled us to gain a greater insight into what patients want after they present to hospital having harmed themselves", said Dr Leah Quinlivan.
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Source: University of Manchester, 25 May 2021
Almost as soon as the pandemic struck early last year, NHS England recognised that patients catching Covid-19 while they were in hospital for non-Covid care was a real risk and could lead to even more deaths than were already occurring. Unfortunately their fears have been borne out by events since – every acute hospital in England has been hit by this problem to some extent.
Over the last 15 months various NHS and medical bodies have looked into hospital-acquired Covid and published reports and detailed guidance to help hospitals stem its spread. They include the Healthcare Safety Investigation Branch (HSIB) and Public Health England (PHE). Last May, for example, PHE estimated that 20% of coronavirus infections in hospitalised patients and almost 90% of infections among healthcare staff may have been nosocomial, meaning they were caught in a hospital setting.
Before the pandemic the NHS was over-stretched and resources were limited. The crisis distorted it further out of shape and despite NHS staff making huge efforts to contain the virus in extremely challenging circumstances, too often they were overwhelmed.
There are many other reasons, including inadequate ventilation, the sharing of equipment, and nurses and doctors having to gather at nurses’ stations and in doctors’ messes. Some bereaved relatives also cite hospitals deciding – inexplicably – to put their Covid-free loved ones in a bay or ward with one or more people who had the disease, sometimes resulting in tragedy.
While some of these inherent weaknesses have been addressed, others remain, leaving further infections and even more deaths in this way a distinct possibility if the NHS is hit by another Covid surge.
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Source: The Guardian, 24 May 2021
Serious patient safety concerns have been raised about a third major specialty at a struggling acute trust, with inspectors also flagging wider leadership issues.
The Care Quality Commission (CQC) has issued an immediate warning notice in relation to the stroke service at University Hospitals of Morecambe Bay Foundation Trust, following an inspection earlier this month.
A full report will be published later this year, but the immediate issues have been outlined within various documents published ahead of the trust’s board meeting on 26 May.
According to a summary within the papers, the CQC warning notice has flagged “a range of incidents… identifying poor care that requires investigation”, governance concerns around the grading of incidents, poor levels of training and competencies, and worrying delays around administering thrombolysis.
The problems were predominantly found at Royal Lancaster Infirmary.
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Source: HSJ, 25 May 2021
Hospitals have been accused of “unnecessary secrecy” for refusing to disclose how many of their patients died after catching Covid on their wards.
The Patients Association, doctors’ leaders and the campaign group Transparency International have criticised the 42 NHS acute trusts in England that did not comply fully with freedom of information request for hospital-acquired Covid infections and deaths.
The Guardian revealed on Monday that up to 8,700 patients lost their lives after probably or definitely becoming infected during the pandemic while in hospital for surgery or other treatment. That was based on responses from 81 of the 126 trusts from which it sought figures.
The British Medical Association, the main doctors’ trade union, said the 42 trusts that did not reveal how many such deaths had occurred in their hospitals were denying the bereaved crucial information.
“No one should come into hospital with one condition, only to be made incredibly ill with, or even die from, a dangerous infectious disease,” Dr Rob Harwood, chair of the BMA’s hospital consultants committee, said.
“Families, including those of our own colleagues who died fighting this virus on the frontline, deserve answers. We will only get that if there is full transparency."
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Source: The Guardian, 25 May 2021
Safety and quality, as well as integration and leadership, will be a “core focus” for the Care Quality Commission’s (CQC) ratings of integrated care systems (ICS), health secretary Matt Hancock has indicated.
In a letter to health and social care committee chair Jeremy Hunt, Mr Hancock said the Department of Health and Social Care is working with the CQC and NHS England to develop “detailed proposals” on how ICSs will be regulated. The CQC is due to be given “new powers” to rate ICSs under the government’s proposed health and social care bill.
The confirmation that the CQC’s ratings of ICSs will include a focus on safety and quality comes days after former health secretary Mr Hunt warned the NHS could take a “big step back” if ICSs are not rated on these domains.
In the letter published today, Mr Hancock said: “I see these new powers for the CQC as an excellent opportunity not only to inform the public about the quality of health and care in their area, but also as a way to review progress against our aspirations for delivering better, more joined up care across integrated care systems.
“I note your recommendation that quality and safety of care should be a core domain of the CQC reviews and would like to assure you that, alongside integration and leadership, quality and safety will be a core focus when rating integrated care systems."
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Source: HSJ, 25 May 2021
An NHS trust has been urged to publish the full findings of an independent review of its services after it released a heavily redacted report.
University Hospitals Sussex has refused to reveal the recommendations made after a review by the Royal College of Surgeons in 2019.
A patients' group said the findings should be "in the public domain".
The trust said the review of its neurosurgery department "did not highlight any safety concerns".
The review was discovered as part of a BBC Panorama investigation into unpublished patient safety reports. A heavily edited report was released under freedom of information laws.
It showed the trust asked the Royal College of Surgeons to look at "concerns raised in respect of clinical outcomes, allocation of sub-specialties and governance arrangements".
All issues and recommendations were obscured, with only positive feedback disclosed.
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Source: BBC News, 20 May 2021
Nearly half the hospitals targeted in covid-related spot checks were found to be breaching health and safety laws.
An unpublished Health and Safety Executive report found just five out of 17 acute hospitals inspected had high levels of compliance with measures to manage the risks around covid.
Meanwhile, letters were sent to eight hospitals “formally requiring them to take remedial action to remedy contraventions of health and safety law”. The remaining four hospitals were given advice.
The inspections — which involved 13 hospitals in England and two each in Scotland and Wales — focused on seven areas: risk assessment; management arrangements specific to covid; social distancing; cleaning and hygiene; ventilation; dealing with suspected covid cases; and personal protective equipment.
The health and safety watchdog highlighted social distancing in non-clinical areas — which covered areas outside of clinical wards such as offices, rest areas, changing rooms and workshops — as needing improvement in some hospitals.
The inspectors — who visited between November last year and January this year — also found some hospitals needed more robust covid security measures if they were to comply with government guidance.
HSE also noted that, although all the hospitals had adequate supplies of PPE, not all had adequate arrangements in place for ensuring it was used effectively.
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Source: HSJ, 5 May 2021
Patients are finding it increasingly hard to see their GPs, with warnings that pandemic restrictions have too often “closed the door” on NHS treatment, a report warns.
The Patients’ Association survey comes as an investigation reveals that almost 100 GP surgeries closed down or merged with other practices last year.
In total, almost 2.5 million patients were forced to switch to a new surgery because of 788 such closures since 2013, the freedom of information disclosures reveal .
Rachel Power, chief executive of the Patients’ Association, said the findings from its survey were “worrying” and show “clear dissatisfaction” from the public.
The report said: “It is increasingly clear that many patients have found that new methods for arranging appointments do not work for them, or simply that they do not understand how to go about it. GPs are the front door to the NHS, and patients are increasingly perceiving that that door is closed to them.”
Roughly half of those who had telephone consultations said the experience was worse than a traditional appointment, with three times as many saying they were unhappy about their experience, compared with those offering praise.
The report warns: “The data does not show a ringing endorsement of new or remote methods for accessing NHS care; indeed, in most cases patients rated these methods worse than traditional contact.”
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Source: The Telegraph, 30 April 2021
A concise training programme aimed at informing healthcare staff about diabetes has the potential to significantly improve patient safety, according to researchers.
The programme, which was developed by the North West London Collaboration of Clinical Commissioning Groups, has been linked with a reduction in diabetes-related errors.
The Diabetes 10 Point Training Programme was initially created with the aim of improving inpatient safety by ensuring frontline staff have access to diabetes training.
Researchers from the CCG collaboration noted that the annual National Diabetes Inpatient Audit (NaDIA) had made for “grim reading with errors, harm, increased length of stay and mortality”.
They highlighted that a workforce with knowledge of diabetes was “crucial to inpatient safety”, and said that complex diabetes care could be delivered by non-specialists with adequate training.
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Source: Nursing Times, 29 April. 2021
A private healthcare provider has been ordered to pay £20,000 after failing to disclose errors in the treatment of patients under the care of a surgeon.
Spire Healthcare was prosecuted today in what the Care Quality Commission (CQC) said was “the first prosecution of its kind against an independent provider of healthcare”.
The CQC said concerns around the treatment of four patients were initially raised by Leeds Clinical Commissioning Group, several physiotherapists at the hospital and another surgeon.
The patients had surgical procedures carried out by Michael Walsh, a shoulder surgeon who held practising privileges at Spire Leeds until his suspension in April 2018. The procedures resulted in the patients suffering prolonged pain and requiring further remedial surgery.
The CQC said it brought the prosecution after Spire failed to share details of what happened to the patients who were being treated by Mr Walsh, in line with their duty of candour responsibilities to be transparent and provide timely apologies when serious incidents occur.
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Source: HSJ, 29 April 2021
The submissions are in, the guest judges have voted, and the results have been announced for the Leading Healthcare Awards 2021. We are delighted that Patient Safety Learning's hub has won the 2021 Patient Safety category of the Leading Healthcare Awards.
View al the winners here
Maternity services are at risk because demoralised midwives are planning to quit the NHS, healthcare leaders have warned.
A new report, carried out by the Institute for Public Policy Research, suggests 8,000 midwives may depart due to the “unprecedented pressure” of the coronavirus pandemic.
Researchers, who surveyed about 1,000 healthcare professionals from around the country in mid-February, discovered that two-thirds reported being mentally exhausted once a week or more.
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Source: The Independent, 31 March 2021
Campaigners have started legal action against the government over guidance that bans care home residents in England aged 65 and over from taking trips outside the home.
John's Campaign, of residents and their loved ones, says the ban is unlawful. They are also challenging the requirement for residents to self-isolate for 14 days after such visits.
The government said its guidance provides a "range of opportunities" for visitors to spend time with loved ones.
Nearly all residents have now had at least one dose of the vaccine, and care homes have been cautiously reopening, allowing indoor visits with designated family or friends.
But the government guidance, updated on 8 March, says trips to see family or friends "should only be considered" for under-65s while national Covid restrictions apply because they increase the risk of bringing Covid into a home.
Visits out for residents, whatever their age, "should be supported in exceptional circumstances such as a visit to a friend or relative at the end of their life", it adds - but on returning to the home, the resident must self-isolate for two weeks.
The legal letter sent to the Department of Health and Social Care by John's Campaign says the decision whether someone can go on a visit outside a care home should be based on individual risk assessments.
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Source: BBC News, 2 April 2021
Intense pressures on the already overstretched NHS are being exacerbated by the tens of thousands of health staff who are sick with Long Covid, doctors and hospital bosses say.
At least 122,000 NHS personnel have the condition, the Office for National Statistics disclosed in a detailed report that showed 1.1 million people in the UK were affected by the condition. That is more than any other occupational group and ahead of teachers, of whom 114,000 have it.
Patient care is being hit because many of those struggling with Long Covid are only able to work part-time, are too unwell to perform their usual duties, or often need time off because they are in pain, exhausted or have “brain fog”.
“Ongoing illness can have a devastating impact on individual doctors, both physically and by leaving them unable to work. Furthermore, it puts a huge strain on the health service, which was already vastly understaffed before the pandemic hit,” said Dr Helena McKeown, the workforce lead at the British Medical Association, which represents doctors.
“With around 30,000 sickness absences currently linked to Covid in the NHS in England, we cannot afford to let any more staff become ill. Simply put, if they are off sick, they’re unable to provide care and patients will not get the care and treatment they need.
“In the longer term, if more staff face ongoing illness from past COVID-19 infection, the implications for overall workforce numbers will be disastrous.”
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Source: The Guardian, 3 April 2021
An estimated 10% to 30% of people who get COVID-19 suffer from lingering symptoms of the disease, or what's known as "long COVID."
Judy Dodd, who lives in New York City, is one of them. She spent nearly a year plagued by headaches, shortness of breath, extreme fatigue and problems with smell, among other symptoms.
She says she worried that this "slog through life" was going to be her new normal.
Everything changed after she got her COVID-19 vaccine.
"I was like a new person, it was the craziest thing ever," says Dodd, referring to how many of her health problems subsided significantly after her second shot.
And she's not alone. As the U.S. pushes to get people vaccinated, a curious benefit is emerging for those with this post-illness syndrome: Their symptoms are easing and, in some cases, fully resolving after they get vaccinated.
Judy Dodd suffered lingering symptoms of COVID-19 for nearly a year, until she got her vaccine.
It's the latest clue in the immunological puzzle of long COVID, a still poorly understood condition that leaves some who get infected with wide-ranging symptoms months after the initial illness.
The notion that a vaccine aimed at preventing the disease may also be a treatment has sparked optimism among patients, and scientists who study the post-illness syndrome are taking a close look at these stories.
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Source: NPR, 31 March 2021
