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Patient_Safety_Learning

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News posted by Patient_Safety_Learning

  1. Patient_Safety_Learning
    A woman died when a major private healthcare provider failed to transfer her to NHS intensive care quickly enough after she became critically ill.
    Sabrina Khan said Spire Healthcare staff "should have known something was wrong" with her mother, Nafisa.
    The BBC also obtained testimony from doctors - contracted by the company to work up to 168 hours a week - who say long hours could put patients at risk.
    Spire Healthcare has apologised for failings in Nafisa Khan's care.
    The death of Mrs Khan from east London is one of several deaths following surgery at Spire Healthcare, looked at by BBC Panorama.
    Read full story
    Source: BBC News, 8 April 2024
  2. Patient_Safety_Learning
    The author of a Parliamentary report into ‘failing’ eating disorder services in 2017 says the number of concerning deaths still being reported five years on is ‘very distressing’.
    In the five years since ombudsman Rob Behrens warned of major shortcomings around adult eating disorder services, HSJ has identified at least 19 women whose deaths sparked concerns from coroners about their care (see list below). At least 15 of these were deemed avoidable, and resulted in formal warnings being issued to mental health chiefs.
    Source: HSJ, 14 February 2023
    Read full story
  3. Patient_Safety_Learning
    A woman who suffered chronic abdominal pain for 18 months after undergoing a caesarean section was found to have a surgical instrument the size of a dinner plate inside her abdomen.
    The Alexis retractor, or AWR, was left inside the New Zealand mother after her baby was delivered at Auckland City Hospital in 2020.
    Following initial investigations into the case, Te Whatu Ora Auckland, formerly Auckland District Health Board, claimed it had not failed to exercise reasonable skill and care towards the patient, who was in her 20s.
    But on Monday, New Zealand’s Health and Disability Commissioner, Morag McDowell, found Te Whatu Ora Auckland in breach of the code of patient rights.
    Read full story
    Source: Guardian, 4 September 2023
  4. Patient_Safety_Learning
    Desperately ill people with eating disorders are being refused NHS treatment for “not being thin enough”, as new figures reveal the health service is in the grips of a growing eating disorder crisis.
    Shocking figures obtained by The Independent show at least 5,385 patients – the overwhelming majority, 3,896, of whom are children – were admitted to general wards for conditions such as anorexia and bulimia in 2021-22, more than double the number in 2017-18.
    It comes as separate analysis of NHS figures suggests the number of children being treated for eating disorders more than doubled from 5,240 in 2016-17 to 11,800 in 2022-23.
    Read full story
    Source: Independent 1 August 2023
  5. Patient_Safety_Learning
    Three patients died after delayed transfers from a private hospital within a nine-month period, coroner’s findings reveal.
    Three prevention of future deaths reports reviewed by HSJ raised concerns about the deaths of patients whose transfer from Spire’s Norwich facility to the NHS hospital in the same city was delayed.
    The sites, which are one mile apart, are run by £1bn-turnover private company Spire Healthcare and Norfolk and Norwich University Hospitals Foundation Trust respectively.
    Read full story
    Source: HSJ, 15 November 2023
    Prevention of Future Deaths reports:
    Geoffrey Hoad (13 September 2023) Prevention of Future Deaths report: Christina Ruse (3 October 2022) Prevention of Future Deaths report: Barbara Hollis (3 October 2022)
  6. Patient_Safety_Learning
    Coroners have raised multiple warnings about the way a commonly-used medication is being prescribed to at-risk patients, HSJ has found.
    HSJ has identified at least nine ‘prevention of future deaths’ reports issued by coroners since 2017 which highlighted the way the deceased’s prescription for sertraline was handled, with two of these issued since the start of 2023.
    It comes as Open Prescribing data suggests sertraline prescriptions have increased by almost 40 per cent since 2019, which has led to concerns that GPs are struggling to meet the growing demand for follow-up checks.
    Read full story
    Source: HSJ, 9 August 2023
  7. Patient_Safety_Learning
    Large numbers of midwives report being left feeling undervalued and afraid to speak up due to bullying and widespread staffing shortages, which some say is putting mothers’ and babies’ lives at risk, according to a new publication shared with HSJ.
    The Say No to Bullying in Midwifery report comprises hundreds of accounts, ranging from students, newly qualified and senior midwives, heads of midwifery, maternity support workers and more. It aims to publicise and share concerns they have raised online.
    The report said: “Midwives have described their experiences of toxic cultures within their workplaces, with cliques, preferential treatment, unfounded allegations and poor working conditions leading to a negative impact on their health and wellbeing, including suicide attempts and midwives leaving their job or profession.
    Read full story
    Source: HSJ, 13 November 2023
    Order a copy of the report
  8. Patient_Safety_Learning
    Coroners have warned of increasing numbers of deaths caused by problems in the emergency pathway, with some citing ‘severe’ staffing shortages.
    HSJ has identified that at least 24 “prevention of future death” reports were sent to NHS organisations in England and Wales in the first half of 2023, which noted shortcomings within emergency services.
    In six of the 24 cases, coroners found ambulance, emergency room and other delays caused or contributed to patient deaths.
    Read full story
    Source: HSJ 1 August 2023
  9. Patient_Safety_Learning
    A hospital trust is facing a fine in a criminal prosecution over the death of a baby.
    The Care Quality Commission (CQC) is prosecuting Nottingham University Hospitals (NUH) NHS Trust over the death of Wynter Andrews.
    Wynter died 23 minutes after she was born by Caesarean section in September 2019 at the Queen's Medical Centre. 
    The prosecution is one of only two the CQC has brought against an NHS maternity unit.
    The trust is due to face sentencing at Nottingham Magistrates' Court later.
    Read full story
    Source: BBC News, 25 January 2023
  10. Patient_Safety_Learning
    Portable X-ray machines "can literally be the difference between life and death", says radiographer Sam Pilkington.
    For most of us, if we need to be X-rayed the procedure is done in a hospital. But for acutely unwell patients, or for infection control, Ms Pilkington says that portable machines are very helpful.
    This is because "they remove the excess burden of transportation from the patients", says the final-year student at the University of the West of England in Bristol, who is also a member of the Institute of Physics. Instead the X-ray equipment goes to them.
    There are obvious advantages for remote locations, including battlefields, roadsides and disaster zones.
    Read full story
    Source: BBC News, 8 January 2024
  11. Patient_Safety_Learning
    A heart failure patient has become the first in the UK to be fitted with an early warning sensor the size of a pen lid which gives off an alert if their condition deteriorates.
    Consultant cardiologists Dr Andrew Flett and Dr Peter Cowburn have pioneered the procedure to fit the FIRE1 System during trials at University Hospital Southampton (UHS), Hampshire.
    Dr Flett said: “This innovative new device has the potential to improve patient safety and outcomes in the management of patients with chronic heart failure and we are delighted to be the first site in the UK to implant as part of this ground-breaking study".
    Read full story
    Source: The Independent, 12 February 2023
  12. Patient_Safety_Learning
    Capitalizing on the pandemic explosion in telehealth and therapy apps that collect details of your mental health needs, data brokers are packaging that information for resale, a new study finds. There’s no law stopping them.
    In a study published Monday, a research team at Duke University’s Sanford School of Public Policy outlines how expansive the market for people’s health data has become.
    After contacting data brokers to ask what kinds of mental health information she could buy, researcher Joanne Kim reported that she ultimately found 11 companies willing to sell bundles of data that included information on what antidepressants people were taking, whether they struggled with insomnia or attention issues, and details on other medical ailments, including Alzheimer’s disease or bladder-control difficulties.
    Justin Sherman, a senior fellow at Duke who ran the research team, says that mental health data should be treated especially carefully, given that it could pertain to people in vulnerable situations — and that, if shared publicly or rendered inaccurately, could lead to devastating results.
    Source: Washington Post, 13 February 2023
    Read full story
  13. Patient_Safety_Learning
    An integrated care system has terminated a private provider’s contract to run four urgent treatment centres following performance concerns.
    Two local acute trusts were expected to take over from provider Greenbrook Healthcare this week, following the decision by North West London ICS.
    The impacted sites include Hillingdon UTC, which is co-located with the Hillingdon Hospitals Foundation Trust, as well as the Ealing, Central Middlesex and Northwick Park sites that are near to the respective hospitals run by London North West University Healthcare Trust.
    Read full article (paywalled)
    Source: HSJ, 24 January 2023
  14. Patient_Safety_Learning
    Virtual wards, set up to relieve pressure on A&E departments, could create extra NHS demand as some are only staffed for 12 hours a day, the country’s top emergency doctor has warned.
    The service allows patients to be monitored remotely from their own homes, freeing up hospital beds and capacity in emergency departments.
    Patients are given devices to track their vital signs, such as blood pressure and oxygen levels, with readings sent back to doctors via smartphone apps.
    Dr Boyle, President of the Royal College of Emergency Medicine, said that virtual wards “must not be seen as a silver bullet for all the problems in urgent and emergency care”.
    “We’re very wary of virtual ward beds being used to say that there are increased beds within hospitals because that’s simply not true,” he said. “The plan for 7,000 or 5,000 extra beds need to be actual beds, with pillows, sheets and staff looking after them.”
    Source: Telegraph, 11 February 2023
    Read full story
  15. Patient_Safety_Learning
    A&E waiting times have deteriorated so much this winter that at some hospitals in England more than half of patients have had to wait more than four hours.
    BBC analysis of data for December and January shows Hull University Hospitals, Wye Valley and Shrewsbury and Telford were worst for A&E waits.
    The best trust out of the 107 providing data, Northumbria Healthcare, had fewer than 10% waiting more than four hours.
    NHS England said plans were being put in place to support struggling trusts.
    Source: BBC, 13 February 2023
    Read full story
  16. Patient_Safety_Learning
    Almost three-quarters of babies born with a rare muscle-wasting disease are living longer thanks to advances in NHS treatment.
    Spinal muscular atrophy (SMA) is a genetic condition that causes muscle weakness, along with progressive loss of movement and paralysis.
    There are three types of this disease that impact children. SMA1 manifests in babies under the age of six months and is the most severe, while SMA2 and SMA3 are less severe. They develop between the ages of seven and 18 months, and after 18 months of age, respectively. According to the NHS, about 70 babies are born in the UK with SMA each year.
    The NHS began rolling out new treatments in 2019, starting with injectable drug nurinersen – marketed as Spinraza – which targets the SMN2 gene in patients. Before 2019 there were no effective drugs for this condition.
    A study by SMA Reach UK claims patients with untreated SMA1 historically had a 50% survival probability at eight to 10 months, reducing to 8% at 20 months of age. However, data from the SMA Reach UK database analysed by NHS England found 73% of babies with SMA1 are now living beyond two years and without permanent ventilatory support.
    Read full story
    Source: Independent, 7 August 2023
  17. Patient_Safety_Learning
    About one in seven people in the UK now take medication to treat depression but some say they are not being given appropriate advice about the potential side-effects of the drugs they have been prescribed.
    Seonaid Stallan's son Dylan was a teenager when he began receiving treatment for body dysmorphia and depression.
    "He was struggling with the way he felt about himself, the way he looked," Seonaid said.
    "He was extremely anxious. He would be physically sick. He would be unable to leave the house."
    Dylan, from Glasgow, was treated with the antidepressant Fluoxetine from the age of 16.
    But when he turned 18, his medication was changed to Sertraline.
    Within two months of his prescription change he had taken his own life.
    Read full story
    Source: BBC, 9 August 2023
  18. Patient_Safety_Learning
    A third of those with a women’s health condition have been made to wait three years or longer for a diagnosis, damning new research has revealed.
    The same study found half of those women took a year or more to be given their diagnosis.
    Srdjan Saso, a consultant gynaecologist and surgeon who works with King Edward VII’s Hospital, told The Independent: “A delayed diagnosis can mean a severe impact on quality of life both professionally and personally.
    “It can have a significant impact on a woman’s day-to-day life and hence needs to be addressed properly and seriously. From a more sinister perspective, in certain cases, it can be cancer and we are picking it up late.”
    Source: Independent, 14 February 2023
    Read full story 
  19. Patient_Safety_Learning
    The parents of a teenager who died in hospital two years ago are calling for patients to be given the right to an urgent second opinion, if they feel their concerns are not being taken seriously by medical staff.
    Martha Mills, who would have been 16 on Monday, died after failures in treating her sepsis at King's College Hospital. An inquest said she could have survived had her care been better.
    Martha's mother, Merope, has helped the think tank Demos write a report which is calling on NHS England to urgently put in place Martha's rule.
    This would "effectively formalise the idea of asking for a second opinion, from a different team outside the team currently looking after you if you feel you are not being listened to", she said.
    She added that asking for a second opinion when there is a deterioration "shouldn't be a problem and it shouldn't involve confrontation".
    It might be that a patient or family could escalate to another team over the phone to get an urgent critical care review.
    Read full story
    Source: BBC News, 4 September 2023
     
  20. Patient_Safety_Learning
    GPs have raised concern about a new colorectal cancer pathway aimed at reducing referrals into one of England’s largest acute hospital trusts.
    The pathway was implemented in December 2022 to tackle long waiting lists at United Lincolnshire Hospitals Trust (ULHT) by reducing the number of referrals from primary care. 
    But the Lincolnshire LMC and Primary Care Network Association both raised concerns about the pathway and its impact on general practice in a letter to their ICB earlier this month.
    Read full story
    Source: Pulse, 13 February 
  21. Patient_Safety_Learning
    GPs are attempting to deal with up to 3,000 patients each, amid worsening staff shortages, according to new analysis.
    The research shows that the number of patients per GP has risen sharply, as rising numbers of doctors reduce their hours, or opt for early retirement.
    Daisy Cooper, spokeswoman for Liberal Democrat Health and Social Care, said:
    “This ever-worsening GP shortage is having a terrible human cost, as people face delayed or missed diagnoses and A&Es fill up with desperate patients looking for treatment."
    Read full story (paywalled)
    Source: Telegraph, 14 February 
  22. Patient_Safety_Learning
    Medical clinics are using fake Google reviews to boost their profiles online, a BBC investigation has found.
    Consumer groups say fake reviews are a "significant and persistent problem" and have called on internet firms to do more to remove them and fine companies.
    Which? has warned it could be a serious issue if someone chooses a treatment clinic based on reading a fake review.
    Read full story
    Source: BBC 2 August 2023
  23. Patient_Safety_Learning
    In the U.S., the prescribing label of Ozempic's sister drug, Wegovy, already warns of possible suicidal ideation because of similar side effects linked to other weight loss drugs.
    Following reports of self-injury and suicidal thoughts among a small number of people who’ve taken Ozempic or Wegovy in Europe and the United Kingdom, health regulators there are investigating whether the drugs carry a risk of these side effects.
    The European Medicines Agency said last month that it was reviewing 150 such reports from people who took drugs in this class, called GLP-1 receptor agonists, which lower blood sugar and suppress appetite by mimicking a hormone in the gut.
    Then last week, the U.K.'s Medicines and Healthcare products Regulatory Agency told Reuters that it was reviewing safety data about the drugs following similar reports.
    Neither Ozempic nor Wegovy, which are both versions of a drug called semaglutide at different dosages, carry warnings about suicidal ideation in Europe or the U.K., since clinical trials have not shown evidence of an increased risk.
    But in the United States, the Food and Drug Administration requires that medications for weight management that work on the central nervous system carry a warning about suicidal thoughts. Because the agency approved Wegovy as a weight loss treatment, its prescribing label asks medical professionals to monitor for these symptoms and to discontinue the medication if people develop them. Ozempic, which is only FDA-approved to treat diabetes, does not come with that warning.
    But some patients think it should.
    Read full story
    Source: NBC 1 August 2023
  24. Patient_Safety_Learning
    Jonathan Medland's voice crackles with anger and emotion when he talks about his beloved son Jon, who tragically took his own life aged just 22.
    'He was the most exuberant, engaging, funny and amazing young man you could ever wish to meet — nobody had a bad word to say about him — he was really going places,' says Jonathan, 66, a retired driving instructor from Barnstaple in Devon. 'But that drug did something terrible to his brain.'
    The drug he's referring to is isotretinoin — brand name Roaccutane — a pill first licensed in the UK for the treatment of severe acne in 1983 and since taken by hundreds of thousands of patients.
    Read full story
    Source: Mail Online 31 July 2023
  25. Patient_Safety_Learning
    Groundbreaking treatments for Alzheimer’s disease that work by removing a toxic protein called beta amyloid from the brain may benefit whites more than Black Americans, whose disease may be driven by other factors, leading Alzheimer’s experts told Reuters.
    The two drugs - Leqembi, from partner biotech firms Eisai (4523.T) and Biogen (BIIB.O), and an experimental treatment developed by Eli Lilly (LLY.N), donanemab — are the first to offer real hope of slowing the fatal disease for the 6.5 million Americans living with Alzheimer’s.
    Although older Black Americans have twice the rate of dementia as their white peers, they were screened out of clinical trials of these drugs at a higher rate, according to interviews with 10 researchers as well as four Eisai and Lilly executives.
    Prospective Black volunteers with early disease symptoms did not have enough amyloid in their brain to qualify for the trials, the 10 researchers explained.
    Read full story
    Source: NBC 31 July 2023
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