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Content Article
Top picks: Six resources about sepsis
Patient Safety Learning posted an article in Deterioration and sepsis
According to the UK Sepsis Trust, sepsis affects 245,000 people every year in the UK alone, and 48,000 people die of sepsis-related illnesses. Sepsis arises when the body’s response to an infection injures its own tissues and organs. It may lead to shock, multi-organ failure, and death – especially if not recognised early and treated promptly. At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; to provide a space for people to come together and share their experiences, resources and good practice examples. We have pulled together six useful resources about sepsis that have been shared on the hub. They include advice on recognising and managing sepsis along with educational materials. -
Content Article
Health Education England: THINK SEPSIS
Patient Safety Learning posted an article in Deterioration and sepsis
“THINK SEPSIS” is a Health Education England programme aimed at improving the diagnosis and management of those with sepsis. A number of sepsis cases result in death every year. Some of the deaths are preventable. Prompt recognition of sepsis and rapid intervention will help reduce the number of deaths occurring annually. The learning materials that are available on this website support the early identification and management of sepsis. It includes a film and a wide range of learning materials for primary care, secondary care and paediatrics. -
News Article
Blackpool death: Abortion sepsis risk training inadequate
Patient Safety Learning posted a news article in News
Doctors are receiving "inadequate" training about the risk of sepsis after a mother-of-five died following an abortion, a coroner has warned. Sarah Dunn, 31, died of "natural causes contributed to by neglect" in hospital on 11 April 2020, an inquest found. Assistant coroner for Blackpool and Fylde, Louise Rae, said Ms Dunn had been treated as a Covid patient even though the "signs of sepsis were apparent". Her cause of death was recorded as "streptococcus sepsis following medical termination of pregnancy". In her record of inquest, the coroner noted Ms Dunn was admitted to Blackpool Victoria Hospital in Lancashire on 10 April 2020. She was suffering from a streptococcus infection caused by an early medical abortion on 23 March, which had produced sepsis and toxic shock by the time she was admitted to hospital. The coroner said "signs of sepsis were apparent" before and at the time of Ms Dunn's hospital admission but she was instead treated as a Covid-19 patient. "Sepsis was not recognised or treated by the GP surgery, emergency department or acute medical unit and upon Sarah's arrival at hospital, the sepsis pathway was not followed," she added. Read full story Source: BBC News, 19 May 2022 -
News Article
Patient care and safety put at risk in A&E at brand new £350m hospital
Patient Safety Learning posted a news article in News
Patients visiting Wales' newest emergency department were likely to have been put at risk of harm due to the lack of processes and systems in place, inspectors found. Healthcare Inspectorate Wales (HIW) carried out an unannounced inspection of The Grange University Hospital in Cwmbran between 1 and 3 November last year and published its findings on 29 March. On the day of their arrival inspectors said The Grange was at full capacity with no empty beds in A&E or in the hospital in general. Despite the best efforts of staff who were "working hard under pressure" the report stated the emergency department had several issues which could have compromised the privacy and dignity of patients. This included problems with the physical environment of the waiting room, which was described as a "major cause of anxiety" for visitors, as well as with the flow of patients through the hospital in general. It found that patients were not triaged and medically managed in A&E in a timely fashion with many being placed on uncomfortable chairs or in corridors for hours on end. Between 1 April 2021 and 1 November 2021, the average waiting time in the department was six hours and seven minutes. The report said some issues required immediate action including the fact patients in the waiting area were often left to "deteriorate without being overseen". There were also infection control failures which could have led to the cross-contamination of Covid-19. "We were not assured that all the processes and systems in place were sufficient to ensure that patients consistently received an acceptable standard of safe and effective care," the report stated. Read full story Source: Wales Online, 1 April 2022 -
News Article
'Overworked staff' impacting patient safety at Torbay Hospital
Patient Safety Learning posted a news article in News
The Care Quality Commission (CQC) has raised concerns about Torbay Hospital being understaffed and the impact that has had on patient safety. It carried out an unannounced focused inspection of medical care services at Torbay Hospital in December, after receiving information of concern about the service. Cath Campbell, CQC’s head of hospital inspection, said: “When we inspected medical care services at Torbay Hospital, we were mindful of the pressures that the COVID-19 pandemic had had on the trust, and aware that staff were working extremely hard during this time. However, we were concerned to find some of the wards didn’t have enough staff to meet the needs of patients, especially those on a dedicated COVID-19 ward, and the trust wasn’t able to provide us with evidence that there were enough staff on the ward to monitor patients to keep them safe.! “In addition, staff didn’t always complete risk assessments for each patient to remove or minimise risks to people’s safety. Staff also did not always identify patients at risk of deterioration and act quickly to keep them safe." The Torbay and South Devon NHS Foundation Trust says it has taken the CQC’s findings very seriously and made immediate improvements, which the CQC have recognised. Read full story Source: Torbay Weekly, 4 March 2022 -
News Article
Girl, 13, likely to have survived if moved to intensive care, coroner rules
Patient Safety Learning posted a news article in News
A 13-year-old girl who died after contracting sepsis in an NHS hospital probably would have survived if doctors had identified the warning signs and transferred her to intensive care earlier, a coroner has ruled. Martha Mills was the first ever child to die at King’s College hospital (KCH) with a pancreatic injury of the type she sustained in a fall from her bike on an off-road family trail in Wales while on holiday last year. She was transferred to the south London hospital because it is one of three national centres for the care of children with pancreatic trauma. An inquest at St Pancras coroner’s court, north London, heard that several opportunities were missed to refer Martha to intensive care, which probably would have saved her life. In an emotional witness statement, Martha’s mother, Merope, said that after their daughter contracted an infection on 21 August last year, she and her husband, Paul Laity, raised concerns about Martha’s deteriorating health a number of times but doctors sought to reassure them rather than escalate her care. Mills said in her statement that she explicitly raised her fears about Martha going into septic shock over the bank holiday weekend. On 29 August, Martha had high fever, low blood pressure, a racing heart and a rash, which was misdiagnosed by a junior doctor despite Mills voicing her concern that it was caused by sepsis. It was only the next day that Martha was admitted to paediatric intensive care. “I felt that my anxieties about all of Martha’s symptoms, and especially what they might mean when put together and considered in the round, weren’t given proper acknowledgement,” Mills told the court. Prof William Bernal, who produced a serious incident report on Martha’s death for KCH, said there were at least five occasions when she should have had a critical care review. He wrote that Martha’s chances of survival “would have been greatly increased” if she had been admitted to critical care earlier. The inquest heard that KCH was making changes in the wake of Martha’s death, including improving diagnostics and taking account of parents’ views. Read full story Source: The Guardian, 3 March 2022 -
News Article
Failure to act on sepsis led to man’s death
Patient Safety Learning posted a news article in News
A man died after an NHS trust failed to diagnose and treat sepsis quickly enough, a Parliamentary and Health Service Ombudsman investigation has found. Stephen Durkin died after suffering organ failure from sepsis. Stephen’s wife Michelle made a complaint to the Ombudsman after she was left floored by his sudden death which she believed was avoidable. Stephen was an otherwise healthy 56-year-old when he attended Wye Valley Trust A&E in July 2017 with chest pain. Hospital staff suspected he had a major blood vessel blockage and admitted him to a ward overnight. The next morning his overall condition had worsened but staff did not monitor him more closely, as national guidance advises, and he continued to deteriorate throughout the day. The next day Stephen was admitted to intensive care and treated for sepsis but tragically died later that evening. In the space of 48-hours his condition deteriorated rapidly but staff did not act quickly enough and the critical care team attended Stephen ten hours too late. His wife Michelle arrived at the hospital to visit Stephen, only to find that he was critically ill and unresponsive. She was left devastated by his death and turned to the Ombudsman to look into what had happened with his care. Ombudsman Rob Behrens said: "Stephen’s tragic death could so easily have been avoided. His case shows why early detection of sepsis, as set out in national guidelines, is crucial." "Sadly, this is not the first time we have had to highlight this issue. There is clearly more the NHS needs to do. It is vital that NHS trusts ensure their staff are sepsis-aware to reduce the number of avoidable deaths from this life-threatening condition." Read full story Source: PHSO, 3 March 2022 -
News ArticleAt least 12,000 people were treated for sepsis in hospitals in Ireland last year, with one in five of those dying from the life-threatening condition. However, the HSE said the total number of cases is likely to be much higher. Marking World Sepsis Day, it said the condition kills more people each year than heart attacks, stroke or almost any cancer. The illness usually starts as a simple infection which leads to an “abnormal immune response” that can “overwhelm the patient and impair or destroy the function of any of the organs in the body”. Dr Michael O’Dwyer, the HSE’s sepsis clinical lead, said: “The most effective way to reduce deaths from sepsis is by prevention. “A healthy lifestyle with moderate exercise, good personal hygiene, good sanitation, breastfeeding when possible, avoiding unnecessary antibiotics and being vaccinated for preventable infections all play a role in preventing sepsis. “Early recognition and then seeking prompt treatment is key to survival. Recognising sepsis is notoriously difficult and the condition can progress rapidly over hours or sometimes evolve slowly over days.” Read full story Source: Independent Ireland, 13 September 2022 hub resources on sepsis RCNi: Sepsis resource collection NSW Clinical Excellence Commission - Sepsis toolkit Dr Ron Daniels video: Recognising sepsis Introducing the Suspicion of Sepsis Insights Dashboard
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News Article
Man with diabetes died after GPs ‘failed to spot deteriorating health’
Patient Safety Learning posted a news article in News
A 27-year-old man died from complications linked to diabetes after GPs failed to properly investigate his rapidly deteriorating health. Lugano Mwakosya died on 3 October 2020 from diabetic ketoacidosis, a build-up of toxic acids in the blood arising from low insulin levels, two days before he could see a GP in person. His mother, Petronella Mwasandube, believes his death could have been avoided if doctors at Strensham Road Surgery, in Birmingham, had given “adequate consideration” to Lugano’s diabetic history and offered face-to-face appointments following phone consultations on 31 July and 16 and 30 September. An independent review commissioned by NHS England found two doctors who spoke to Lugano did not take into account his diabetes or “enquire in detail and substantiate the actual cause of the patient’s symptoms”. The review raised concern over the “quality and brevity” of the phone assessments and said the surgery should have offered Lugano an in-person appointment sooner. Read full story Source: The Independent, 7 August 2022 -
News Article
Trust chief calls for six-hour A&E target
Patient Safety Learning posted a news article in News
The chief executive of a trust trialling the new emergency care standards being considered by the government has called for a new six-hour target to either move patients out of accident and emergency, or for them to receive treatment. North Tees and Hartlepool Foundation Trust chief executive Julie Gillon told HSJ a new target should be set as a “body of evidence” indicates patients are at risk of deterioration following A&E waits of six hours or more. The proposal is likely to be broadly welcomed by many clinicians, but could prove controversial in some quarters. NHS England did not include a six-hour target in the bundle of new A&E metrics being piloted, and the proposal could be interpreted by some as a watered-down version of the existing four-hour standard. However, Ms Gillon cited analysis by the Royal College of Emergency Medicine last year which revealed thousands of excess deaths resulting from overcrowding and long stays in A&Es. Read full story (paywalled) Source: HSJ, 4 August 2022 -
News Article
Dementia patients not allowed to use toilet
Patient Safety Learning posted a news article in News
Heather Lawrence was shocked at the state she found her 90-year-old mother, Violet, in when she visited her in hospital. "The bed was soaked in urine. The continence pad between her legs was also soaked in urine, the door wide open, no underwear on. It was a mixed ward as well," Heather says. "I mean there were other people in there that could have been walking up and down seeing her, with the door wide open as well. My mum, she was a very proud woman, she wouldn't have been wanted to be seen like that at all." Violet, who had dementia, was taken to Tameside General Hospital, in Greater Manchester, in May 2021, after a fall. Her health deteriorated in hospital and she developed an inflamed groin with a nasty rash stretching to her stomach - due to prolonged exposure to urine. She died a few weeks later. Heather tells BBC News: "I don't really know how to put it into words about the dignity of care. I just feel like she wasn't allowed to be given that dignity. And that's with a lot of dementia patients. I think they just fade away and appear to be insignificant, when they're not." New research, shown exclusively to BBC Radio 4's File on 4 programme, has found other dementia patients have had to endure similar indignity. Dr Katie Featherstone, from the Geller Institute of Ageing and Memory, at the University of West London, observed the continence care of dementia patients in three hospitals in England and Wales over the course a year for a study funded by the National Institute for Health and Care Research. She found patients who were not helped to go to the toilet and instead left to wet and soil themselves. "We identified what we call pad cultures - the everyday use of continence pads in the care of all people with dementia, regardless of their continence but also regardless of their independence, as a standard practice," Dr Featherstone says. Read full story Source: BBC News, 21 June 2022 -
News ArticleThe mother of a seriously ill boy said she was "very alarmed" when a doctor at an under-fire children's ward admitted they were "out of their depth". In October, Carys's five-year-old son Charlie was discharged from Kettering General, but she returned him the next day in a "sort of lifeless" state. She said it seemed "quite chaotic" on Skylark ward before he was transferred to another hospital for further tests. Since the BBC's report in February that highlighted the concerns of parents with children who died or became seriously ill at the hospital, dozens more have come forward. In April, Care Quality Commission (CQC) inspectors rated the Northamptonshire hospital's children's and young people's services inadequate. Among the findings, inspectors said "staff did not always effectively identify and quickly act upon patients at risk of deterioration". Read full story Source: BBC News, 6 June 2023
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News Article
Kettering hospital ward accused of failing children rated inadequate
Patient Safety Learning posted a news article in News
The safety of a ward accused of failing children has been rated as inadequate by inspectors. The care regulator warned Kettering General Hospital (KGH) in Northamptonshire over its children's and young people's services. Inspectors' worries include sepsis treatment, staff numbers, dirt levels and not having an "open culture" where concerns can be raised without fear. Since the BBC's first report in February highlighting the concerns of parents with children who died or became seriously ill at KGH, dozens more families have come forward, bringing the number to 50 to date. Inspectors found that "staff did not always effectively identify and quickly act upon patients at risk of deterioration". They said there were sometimes "delays in medical reviews being undertaken outside of normal working hours", highlighting one case where a seemingly deteriorating patient was not seen until three hours after being escalated to the on-call team. Read full story Source: BBC News, 20 April 2023 -
Content ArticleGomes et al. report the utilisation and impact of a novel triage-based electronic screening tool (eST) combined with clinical assessment to recognise sepsis in paediatric emergency department. An electronic sepsis screening tool was implemented in the paediatric emergency departments of two large UK secondary care hospitals between June 2018 and January 2019. Patients eligible for screening were children < 16 years of ages excluding those with minor injuries or who were brought directly to resuscitation. Utilisation of a novel triage-based eST allowed sepsis screening in over 99% of eligible patients. The screening tool showed good accuracy to recognise sepsis at triage in the ED, which was augmented further by combining it with clinician assessment. The screening tool requires further refinement through multicentre evaluation to avoid missing sepsis cases.
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Content Article
NSW Government: Between the Flags
Patient Safety Learning posted an article in International patient safety
The Between the Flags (BTF) system is a 'deteriorating patient safety net system' for patients who are cared for in New South Wales (NSW) public health facilities in Australia. It is designed to assist clinicians to recognise when patients are deteriorating and to respond appropriately when they do. -
News Article
Cancer patients in England and Wales facing ‘unacceptable’ wait for support
Patient Safety Learning posted a news article in News
The physical and mental health of tens of thousands of cancer patients in England and Wales is deteriorating because they are having to wait months for financial support from the government, a charity has warned. Macmillan Cancer Support said many are waiting as long as five months to receive their personal independence payment (PIP), which is paid to people with long-term physical and mental health conditions or disability, and who have difficulty doing certain everyday tasks or getting around. Health leaders said the “unacceptable” situation had now become critical, with thousands of cancer patients increasingly desperate for help. Research for the charity found that among people with cancer who receive PIP, more than one in four (29%) have reported a deterioration in physical or mental health while they wait to receive it. This rises to almost half (46%) among those who wait more than 11 weeks to receive their first payment. Macmillan is launching a “Pay PIP Now” campaign, saying it is hearing from patients going into debt, skipping meals and cancelling medical appointments due to travel costs, all because of delays to PIP. It wants ministers to cut the average wait times for PIP from 18 weeks at the moment to 12. Research suggests most people with cancer suffer a financial impact from their diagnosis, including from being unable to work while having treatment, increased heating bills to stay warm and the cost of attending appointments. Read full story Source: The Guardian, 6 October 2022 -
News ArticleTina Hughes, 59, died from sepsis after doctors allegedly delayed treating the condition for 12 hours while they argued over which ward to treat her on. Ms Hughes was rushed to A&E after developing symptoms of the life-threatening illness on September 8 last year. Despite paramedics flagging to staff they suspected sepsis, it was not mentioned on her initial assessment at Sandwell General Hospital, in West Bromwich. A second assessment six hours later also failed to mention sepsis while medics disagreed over whether to treat her on a surgical ward or a high dependency unit. The grandmother-of-five was eventually transferred to the acute medical unit at 3am the next morning where sepsis was finally diagnosed, but she continued to deteriorate and was admitted to intensive care four hours later and put on a ventilator. She died the following morning. A serious incident investigation report by Sandwell and West Birmingham Hospitals NHS Trust has since found there was "a delay in explicit recognition of sepsis". Read full story (paywalled) Source: The Telegraph, 4 October 2022
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News Article
Millions in poor health due to lack of rehab after illness, warns UK report
Patient Safety Learning posted a news article in News
Millions of people in the UK are suffering poor health because they miss out on vital rehabilitation after strokes, heart attacks and cancer, which in turn is also heaping further pressure on the NHS, a damning report warns. Physiotherapists say some groups of patients are particularly badly affected. Without access to these services, many patients desperately trying to recover from illness became “stuck in a downward spiral”, they said, with some developing other health conditions as a result. The new report by the Chartered Society of Physiotherapy (CSP) says millions of people in marginalised communities, including those from ethnic minorities, are not only more likely to live shorter lives, but also spend a greater proportion of their lives struggling with health difficulties. Vital services that could tackle those inequities are either unavailable or poorly equipped to meet their needs, the report warns, adding that “some communities face particular barriers”. Prof Karen Middleton, the chief executive of the CSP, said: “Rehabilitation services have been under-resourced for decades and were not designed coherently in the first place. This has exacerbated poor health outcomes, particularly for people from marginalised groups. “It’s not only the individual who suffers. Without adequate access to rehabilitation, health conditions worsen to the point where more and more pressure is eventually piled on struggling local health systems and other public services. “We desperately need a modernised recovery and rehabilitation service that adequately supports patients following a health crisis and prevents other conditions developing.” Read full story Source: The Guardian, 21 September 2022 -
Content ArticleWound care is rarely considered a strategic objective within health and care, but it has considerable impact on patients and on health service resources. In this blog, Ameneh Saatchi, Senior Partnerships and Policy Manager at Public Policy Projects looks at the growing burden of wound care on the health service and what can be done to tackle the problem.
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Content ArticleMeasures exist to improve early recognition of and response to deteriorating patients in hospital. However, management of critical illness remains a problem globally; in the United Kingdom, 7% of the deaths reported to National Reporting and Learning System from acute hospitals in 2015 related to failure to recognise or respond to deterioration. The current study from Albutt et al. explored whether routinely recording patient-reported wellness is associated with objective measures of physiology to support early recognition of hospitalised deteriorating patients. The preliminary findings suggest that patient-reported wellness may predict subsequent improvement or decline in their condition as indicated by objective measurements of physiology (NEWS). Routinely recording patient-reported wellness during observation shows promise for supporting the early recognition of clinical deterioration in practice, although confirmation in larger-scale studies is required.
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Content ArticlePleural effusions are the accumulation of fluid between the lung and chest wall, which may cause breathlessness, low oxygen saturation and can lead to collapsed lung(s). They are a common medical problem and have over 50 recognised causes and various treatments. Large effusions, such as those caused by pleural malignancy, may require insertion of a chest drain and controlled drainage of fluid to allow the lung to inflate. If large volumes of pleural fluid are drained too quickly, patients can rapidly deteriorate. Their blood pressure drops, and they can become increasingly breathless from the potentially life-threatening complication of re-expansion pulmonary oedema. T A review of the National Reporting and Learning System (NRLS) over a recent three-year period identified 16 incidents where patients experienced acute and significant deterioration after uncontrolled or unmonitored drainage of a pleural effusion; two of these patients died and a cardiac arrest call was made for one patient although the outcome was not reported.
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News Article
Top doctor ‘desperate’ to keep parents out of ‘lobster trap’ hospitals
Patient Safety Learning posted a news article in News
One of the country’s most senior doctors has said he is “desperate” to keep his elderly parents out of hospital, which he said are like “lobster traps”. Dr Adrian Boyle, president of the Royal College of Emergency Medicine, said hospitals are easy to get into but hard to get out of. His comments come after figures showed the number of patients in hospital beds in England who no longer need to be there has reached a new monthly high. An average of 13,613 beds per day were occupied by people ready to be discharged from hospital in October. That was up from 13,305 in September and the highest monthly figure since comparable data began in December 2021, according to analysis by the PA news agency. In an interview with the Daily Mail, Dr Boyle said: “Hospitals are like lobster traps – they’re easy to get into and hard to get out of. “If social care was able to do its job in the way we want it to, these poor people wouldn’t be stranded in hospital. “I have elderly parents and I’m desperate to keep them out of hospital. “For someone who is frail, hospital is often a bad place for them. They’re being harmed by being in hospital.” Read full story Source: The Independent, 14 November 2022 -
News ArticleA Guardian analysis has found that as many as one in three hospital beds in parts of England are occupied by patients who are well enough to be discharged, with a chronic lack of social care meaning many do not have suitable places to go. Barry Long's 91-year-old mother has Alzheimer’s and was admitted to Worthing hospital on 30 May after a minor fall. She was a bit confused but otherwise unhurt, just a bit shaken. Whilst in hospital, she caught Covid and had to be isolated, which she found distressing, and became increasingly disoriented. She was declared medically fit to be discharged but no residential bed could be found for her. Then, in August, she was left unsupervised and fell over trying to get to the toilet and she fractured her hip, which required surgery. Her hip was just about healed when she caught her shin between the side bars and the frame of the bed, cutting her shin so badly that she is being reviewed by a plastic surgeon to see if it needs a skin graft. "Since the operation, my mum is pretty much bedbound and lives in a state of confusion and anxiety", says Barry. "Her physical health and mental wellbeing have deteriorated considerably in the almost five months she has spent in the care of the NHS. She spends all day practically trapped in bed, staring into space or with her eyes shut, just rocking to and fro. She has little mental stimulation." Read full story Source: The Guardian, 13 November 2022
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News ArticleEarly warning scores are used in the NHS to identify patients in acute care whose health is deteriorating, but medics say it could actually be putting people in danger. The rollout of an early warning system used in hospitals to identify patients at the greatest risk of dying is based on flawed evidence, according to a study published in the BMJ which suggests that much of the research supporting the rollout of NEWS was biased and overly reliant on scores that could put patients at greater risk.. Medical researchers said problems with NHS England's National Early Warning Scores (NEWS) system had emerged "frequently" in reports on avoidable deaths. The system sees each patient given an overall score based on a number of vital signs such as heart rate, oxygen levels, blood pressure and level of consciousness. Doctors and nurses can then prioritise patients with the most urgent NEWS scores. But some professionals have argued that the system has reduced nursing duties to a checklist of tasks rather than a process of providing overall clinical assessment. Professor Alison Leary, a fellow of the Royal College of Nursing and chair of healthcare and workforce modelling at London South Bank University, told The Independent: “In our analysis of prevention of future death reports from coroners, early warning scores and misunderstanding around their use feature frequently". “It's clear that some organisations use scoring systems and a more tick box approach to care as they lack the right amount of appropriately skilled staff, mostly registered nurses.” “Early warning scores might not perform as well as expected and therefore they could have a detrimental effect on patient care,” the authors of the research conclude. “Future work should focus on following recommended approaches for developing and evaluating early warning scores, and investigating the impact and safety of using these scores in clinical practice.” Read full story Source: The Independent, 21 May 2020
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Content ArticleThis article details the case and findings of an investigation by the Parliamentary and Health Service Ombudsman (PHSO) into the death of Stephen Durkin. Stephen died after suffering organ failure from sepsis, while under the care of Wye Valley NHS Trust. His wife, Michelle Durkin, subsequently made a complaint that delays in the diagnosis and treatment of sepsis led to her husband’s death.
