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Content ArticleThe Department of Health and Social Care (DHSC) and Health Services Safety Investigations Body.(HSSIB) share the common objective to improve patient safety. To achieve this, HSSIB and DHSC will work together in recognition of each other’s roles and areas of expertise, providing an effective environment for HSSIB to achieve its objectives through the promotion of partnership and trust, and ensuring that HSSIB also supports the strategic aims and objective of DHSC and wider government as a whole.
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Content ArticleThis document from the Department of Health and Social Care (DHSC) sets out how health and care systems should work together to support discharge from all mental health and learning disability and autism inpatient settings for children, young people and adults. It sets out best practice on: how NHS bodies and local authorities should work closely together to support the discharge process and ensure the right support in the community, and provides clarity in relation to responsibilities patient and carer involvement in discharge planning.
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Content Article
BBC Panorama: Midwives under pressure (29 January 2024)
Patient Safety Learning posted an article in Maternity
Panorama investigates the crisis in maternity care that is putting women and babies at risk. Whistleblowers at a trust in Gloucestershire tell reporter Michael Buchanan about the deaths of mothers and babies, the dangers of understaffing and a culture that they say has failed to learn from mistakes. The regulator, the Care Quality Commission, has said that maternity services at the trust are inadequate, and Panorama has calculated that maternal deaths there are almost double the national average. The trust says that it's deeply sorry for failings in its care and that it's made improvements to its maternity services. -
News Article
Whistleblowers accuse NHS trust of avoidable baby deaths
Patient Safety Learning posted a news article in News
Serious concerns about maternity services at an NHS trust have been revealed by BBC Panorama. Midwives say a poor culture and staff shortages at Gloucestershire Hospitals NHS Trust have led to baby deaths that could have been avoided. A newborn baby died after the trust failed to take action against two staff, the BBC has been told. The trust says it is sorry for its failings and is determined to learn when things go wrong. Concerns about two staff members, both midwives, had been raised by colleagues at the Cheltenham Birth Centre after another baby died 11 months earlier. The birth centre allowed women with low-risk pregnancies the choice of giving birth there under the care of midwives - there were no emergency facilities in the centre. In the event of complications, women should have been transferred to the Gloucestershire Royal Hospital, which is part of the same trust and about a 30-minute drive away. But on both occasions, the two midwives did not get their patients transferred quickly enough. The two midwives on duty for both deaths are now being investigated by their regulator, the Nursing and Midwifery Council. Read full story Source: BBC News, 29 January 2024 -
News Article
NHS trust ‘abandoned’ budding paramedic who took her own life
Patient Safety Learning posted a news article in News
Rebecca McLellan, a trainee paramedic, pursuing the job she had dreamed of as a child, took her own life at the age of 24. Amid the devastation felt by her loved ones, serious questions have now emerged about the standard of care she received at Norfolk and Suffolk NHS Foundation Trust (NSFT). In notes recorded before her death last November, McLellan said that Norfolk and Suffolk NHS Foundation Trust (NSFT) had “abandoned” her in a time of need. An internal investigation has now been launched by the mental health trust, which has been dogged by safety concerns for more than a decade. Relatives of McLellan, who lived in Ipswich, Suffolk, and was being treated for bipolar disorder, are among hundreds of bereaved families who believe their loved ones were failed under the care of the trust. Her mother, Natalie McLellan, 48, said it was clear that some of her daughter’s feelings of helplessness in her final months were “shaped by their inadequacy”. “She was somebody that had it all,” said Natalie. “She had a supportive family, she had a nice flat, she had a nice car, she was doing exactly what she wanted to do in life. She had a voice, she was able to speak and advocate for herself as a medical professional. If she can’t get help, what the hell hope is there for anybody else? Recent months have seen calls for a public inquiry and criminal investigation into NSFT after bosses last year admitted to losing count of the number of patients that had died on its books. Campaigners describe the mismanagement of mortality figures as “the biggest deaths crisis in the history of the NHS”. The Times has spoken to trust staff, bereaved relatives and MPs who say that despite repeated promises of improved care the trust’s overstretched services remain unsafe and require urgent reform. Read full story (paywalled) Source: The Times, 26 January 2024 -
News Article
Crumbling hospitals cause over 100 care disruptions a week, NHS figures show
Patient Safety Learning posted a news article in News
Hospitals in England are being hit with disruptions to patients’ care more than 100 times every week because of fires, leaks and problems created by outdated buildings, NHS figures reveal. There have been 27,545 “clinical service incidents” over the past five years – an average of 106 a week – data compiled by the House of Commons library shows. They are incidents the NHS says were “caused by estates and infrastructure failure related to critical infrastructure risk” and are linked to the service’s massive backlog of maintenance, the bill for which has soared to £11.6bn. All the incidents led to “clinical services being delayed, cancelled or otherwise interfered with” for at least five patients for a minimum of 30 minutes. That means the 27,545 incidents between 2018-19 and 2022-23 disrupted the care of at least 137,725 patients, according to an analysis of NHS data by the Commons library commissioned by Ed Davey, the leader of the Liberal Democrats. “These findings are shocking but sadly not surprising, given the dilapidated, and in some cases dangerous, state of so many NHS facilities,” said Saffron Cordery, the deputy chief executive of NHS Providers, which represents health service trusts. The “unacceptable impact on patients” should spur ministers into increasing the NHS’s capital budget so trusts can urgently overhaul their estates, she said. Read full story Source: The Guardian, 26 January 2024 -
News ArticleCampaigners have said that more lives would be lost unless mental health services were reformed. Figures show 120 people each year are killed by people with mental illnesses. Julian Hendy, whose father was killed by a psychotic man with a long history of mental ill health 17 years ago, said health professionals must be “more assertive” and work better with other agencies such as the police. Valdo Calocane, who was sentenced on Thursday to an indefinite hospital order after being convicted of manslaughter of three people in Nottingham, had fallen off the radar of mental health services, which allowed him to avoid taking his medicine. Hendy accused Nottinghamshire Healthcare NHS Foundation Trust, which was responsible for Calocane’s care, of “washing their hands” of him. He said: “It’s not responsible and it’s not safe. It doesn’t look after people properly … That hasn’t helped him at all, or protected his rights at all, because he has now committed this terrible offence.” Read full story (paywalled) Source: The Times, 26 January 2024
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Content Article
House of Lords debate - Maternity Services (26 January 2024)
Patient Safety Learning posted an article in Maternity
This is the video recording of a House of Lords debate on the delivery of maternity services in England, put forward by Baroness Taylor of Bolton. -
Content ArticleThis is a safety critical and complex National Patient Safety Alert. Implementation should be co-ordinated by an executive lead (or equivalent role in organisations without executive boards) and supported by clinical leaders in diabetes, GP practices, pharmacy services in all sectors, weight loss clinics, private healthcare providers and those working in the Health and Justice sector.
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Content ArticleGreat Ormond Street Hospital NHS Foundation Trust is one of the world’s leading children’s hospitals, receiving 242,694 outpatient visits and 42,112 inpatient visits every year (figures from 2021/22). This paper seeks to provide an overview of the safety systems and processes Great Ormond Street Hospital has in place to keep patients, staff, and healthcare environments safe.
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Content ArticleThis study from Jalilian et al., published in the BMJ, evaluated the length of stay difference and its economic implications between hospital patients and virtual ward patients. It found that the use of a 40-bed virtual ward was clinically effective in terms of survival for patients not needing readmission and allowed for the freeing of three hospital beds per day. However, the cost for each day freed from hospital stay was three-quarters larger than the one for a single-day hospital bed. This raises concerns about the deployment of large-scale virtual wards without the existence of policies and plans for their cost-effective management.
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News Article
Virtual ward costs twice that of inpatient care, study finds
Patient Safety Learning posted a news article in News
Researchers have found the costs of treating patients in a 40-bed virtual ward were double that of traditional inpatient care. The study’s authors said the findings should raise concerns over a flagship NHS England policy, which has driven the establishment of 10,000 virtual ward beds. Virtual wards, sometimes described as “hospital at home”, are cited as a safe way to reduce pressure on hospitals, by reducing length of stay and enabling quicker recovery. The study at Wrightington Wigan and Leigh Teaching Hospitals, in Greater Manchester, found a clear reduction in length of stay but also found higher rates of readmission. The authors said this led to additional costs, with the cost of a bed day in the virtual ward estimated at £1,077, compared to £536 in a general inpatient hospital bed. “This raises concerns [over] the deployment of large-scale virtual wards without the existence of policies and plans for their cost-effective management. This evidence should be taken into consideration by [the] NHS in planning the next large deployment of virtual wards within the UK… “Virtual wards must be cost effective if they are to replace traditional inpatient care, the costs must be comparable or lower than the costs of hospital stay to be economically sustainable in the medium to long terms.” To break even, the paper said the virtual ward would need to double its throughput, but warned this would risk lowering the standard of care. Read full story (paywalled) Source: HSJ, 25 January 2024 -
News ArticleThe medical leaders of the maternity unit of a flagship hospital threatened with closure have written to their chief executive saying the downgrade would not be safe, HSJ has learned. Nineteen obstetric and gynaecological staff, including the clinical director, wrote to the chair and CEO of the Royal Free London Foundation Trust this week saying the proposals to shutter services at the trust’s main site in Hampstead would increase the risk of harm to mothers. Their letter said: “Whilst we accept, and support, the need to review provision of maternity and neonatal services across [north central London], aiming for care excellence and best outcomes, we have significant concerns about the current proposals.” The letter said the Royal Free was the only unit in NCL to offer a “range of supporting specialist services for complex maternity care”, including rheumatology and neurology and is the “only hospital in NCL to provide both 24-hour interventional radiology and on-site acute vascular surgery and urology support”. The medics’ letter said co-morbidities from cardiac, renal, haematological and neurological conditions had driven an increase in maternal mortality over the past decade and that RFH’s services were well-equipped to manage these complex cases. Read full story (paywalled) Source: HSJ, 24 January 2024
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News Article
Department of Education updates National Framework for Children’s Social Care
Patient Safety Learning posted a news article in News
The Department of Education has recently provided an update to the national framework for Children’s Social Care. The key point to be aware of is the increased focus on sharing responsibility and strengthening multi-agency working to safeguard children. This change is likely to impact a wide variety of stakeholders involved in children’s care, including NHS Trusts, ICBs, education partners, local authorities, voluntary, charitable and community sectors and the police. The focus continues to be on a child-centred approach with the intention of keeping children within the care of their families wherever possible; this collaborative working may include working with parents, carers or other family but the wishes and feelings of the child alongside what is in the child’s best interests remain paramount. Joined up working is to be viewed as the norm. For health professionals, you will be expected to have lead roles for children with health needs, such as children who are identified as having special educational needs or disabilities. Read full story Source: Bevan Brittan, 23 January 2024 -
Content ArticleIn this BMJ Leader article, Roger Kline discusses the failings of the Countess of Chester NHS Boards in 2022 following the arrest of Lucy Letby. Roger highlights that this is not unique to the Counter of Chester: Reputation management that avoids timely decisive action is familiar to staff in many NHS organisations. Primacy of finance at a time of gross NHS under-resourcing has roots in Government policy and a national failure to challenge it. The failure of the Countess of Chester Board to be curious and create a culture where staff who raised concerns were seen as “gold dust” not troublemakers, is commonplace not unique. Roger acknowledges that there are no simple solutions but says that the regulation for managers is a performative gesture unless accompanied by other measures. He suggests that we "Make patient safety the prime litmus test for all initiatives and 'stop the line' (from Board to ward) when it is not. Do not allow organisational reputation to ever influence decision making in response to concerns. Be relentlessly 'problem sensing' not “comforting seeking'”.
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News ArticleMore than 30 members of staff at a major NHS mental health hospital have been suspended over claims of serious misconduct including falsifying medical records and mistreating patients, The Independent has learned. The suspensions come after an internal investigation into serious conduct allegations at Highbury Hospital in Nottinghamshire, which employs hundreds of staff members. The suspended employees include registered professionals – such as doctors, nurses and nursing associates – and non-registered professionals, which would cover healthcare assistants and non-clinical staff. It comes just a week after the same trust – Nottinghamshire Healthcare Foundation Trust – was issued with a warning by the safety watchdog over concerns about the safety of patients at Rampton Hospital, a high secure hospital which has housed patients such as Charles Bronson and Ian Huntley. In an email leaked to The Independent, the trust told staff: “We are saddened to report that over recent weeks it has been necessary to suspend over 30 colleagues due to very serious conduct allegations. “These allegations have included falsifying mental health observations, as well as maltreatment of patients in our care. “We hope we have your understanding in taking action when the conduct of colleagues falls so far outside of what patients deserve.” Read full story Source: The Independent, 23 January 2024
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Content ArticleOn the 9 December 2022, Dennis John William King suffered sudden chest pain which extended down his arm. His wife called 999 and spoke with an ambulance service call handler. Following triage of the call, the response to Mr King's call was graded as a Category 3 (a potentially urgent condition which is not life threatening with a target response of 120 minutes). This call was subsequently re-graded following review in the call centre to a Category 2 (a potentially serious condition requiring rapid assessment, urgent on scene intervention or transport to hospital, with a response within 40 minutes and a target of 18 minutes). Upon hearing that the waiting time for an ambulance could be as long as six hour, Mr and Mrs King decided to make their own way to the West Suffolk Hospital. The ambulance service were advised and the response stood down. Within 40 minutes of arrival Mr King had been diagnosed as suffering an ST segment elevation myocardial infarction (STEMI). Treating clinicians assessed his condition as necessitating an urgent transfer to the Royal Papworth and for the angioplasty procedure to be conducted forthwith. The ambulance call centre was contacted by the hospital emergency department with a request for an urgent transfer to the Royal Papworth. Emergency department staff were advised that there would be a 5 hour delay for an ambulance to attend. The call from the hospital emergency department to the ambulance service was graded by the ambulance call handler as a category 2 response. When the response timing was challenged the emergency department matron was advised that the hospital was a place of safety. The ambulance call handler assessment did not seem to take into account the clinical assessment of accident and emergency department staff who, in consultation with the regional cardiac intervention hospital, had determined Mr King's further treatment at the regional cardiac centre was a matter of urgency. An ambulance subsequently arrived at West Suffolk Hospital Accident and Emergency Department and transferred Mr King to the Royal Papworth Hospital where he underwent treatment for what was identified as an occluded left anterior descending artery. About 1 hour after the procedure, Mr King's condition deteriorated and he suffered a left ventricular wall rupture, a recognised complication of either the myocardial infarction he had suffered or the surgical procedure to correct the occluded artery, or both. He received emergency surgery to repair the rupture by way of a patch which was successful. However, his condition deteriorated and he died on the 13 December 2022. The medical cause of death was confirmed as: 1a Multi Organ Failure 1b Post myocardial infarction left ventricular free wall rupture (operated on).
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News Article
USA: ED boarding at crisis levels, Mass General says
Patient Safety Learning posted a news article in News
Boston-based Massachusetts General Hospital is requesting permission from the state to add more than 90 inpatient beds amid what it says is an "unprecedented capacity crisis." The hospital's emergency department has experienced critical levels of overcrowding nearly every day for the past six months, Massachusetts General said in a news release. The hospital boards between 50 to 80 ED patients every night who are waiting for a hospital bed to open. On 11 January, Massachusetts General had 103 patients boarding in the ED, representing one of the most crowded days in the hospital's more than 200-year history. "While hospital overcrowding has significantly affected patient care for many years, COVID-19 and the post-pandemic demand for care has escalated this challenge into a full-blown crisis – for patients seeking necessary emergency care, as well as for staff who are required to work under these increasingly stressful conditions," David F.M. Brown, president of Massachusetts General, said in a news release. Massachusetts General's request comes as hospitals across the state grapple with capacity issues, workforce shortages and a jump in respiratory illnesses this winter. On 9 January. the Massachusetts Department of Public Health issued a memo urging hospitals to expedite discharge planning amid the capacity crunch. Some health plans have also waived the need to obtain prior authorisation for short stays in post-acute care facilities. Read full story Source: Becker Hospital Review, 19 January 2024 -
News Article
Ambulance transfer delays are 'matter of concern', coroner warns
Patient Safety Learning posted a news article in News
The availability of ambulances to transfer patients to specialist units is a "matter of concern", a coroner has warned. Darren Stewart, area coroner for Suffolk, made the comments in a Prevention of Future Deaths report. It followed the death of 84-year-old Dennis King, who waited three hours to be transferred from West Suffolk Hospital to Royal Papworth in 2022. Mr King had made his own way to the West Suffolk Hospital's accident and emergency department in December 2022, after being told an ambulance could take six hours to arrive at his home due to high demand in the area, the report said. His call had been graded as category two, which should have led to a response within 40 minutes - or a target of 18 minutes. After tests at West Suffolk Hospital showed Mr King had suffered a STEMI heart attack, emergency clinicians liaised with experts from the regional heart unit and decided he needed an urgent transfer to Royal Papworth in Cambridgeshire. The report said a matron at West Suffolk told ambulance call handlers they needed an urgent transfer - but because Mr King was classed as being in a "place of safety", control room staff said the delay would be "several hours". Mr Stewart said: "the availability of ambulances to carry out transfers in a timely manner, in urgent cases" was "a matter of concern". In the report, Mr Stewart said the circumstances of the case "raised concerns about the NHS approach to centralising care in regional centres" if the means to deliver it were "inadequate". Read full story Source: BBC News, 23 January 2024 -
News ArticleTo help patients with high-risk pregnancies receive care at hospitals that are staffed and equipped to deliver care appropriate to their needs, the Department of Public Health will require licensed birthing hospitals to use a system called Levels of Maternal Care. The system classifies hospitals based on their capacity to meet the needs of patients with a range of potential complications during childbirth. The impetus is the rising levels of severe maternal morbidity, large racial disparities in outcomes, and concerns that higher-risk patients who deliver in hospitals that over-estimate the level of care they are able to provide are more likely to experience complications. Levels of care describe a hospital’s physical facilities, capabilities and staffing, indicating its ability to serve people giving birth across a range of medical needs. For example, Level 1 is appropriate for low-risk patients with uncomplicated pregnancies, including twins and labor after cesarean delivery. To that group, Level II adds patients with poorly controlled asthma or hypertension and other higher-risk conditions. Subsequent levels include patients at increasingly high risk of complications, up to Level IV, which is appropriate for patients with severe cardiac disease, those who need organ transplant and others. Established by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine in 2015, the classification system is one tool used by states across the country to improve maternal health and birthing outcomes. Read full story Source: Betsy Lehman Center. 17 January 2024
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News ArticleTheatre staff at a major hospital “deliberately slowed down” elective activity to limit the number of operations that could be done each day, an NHS England review has been told. The culture in theatres at the William Harvey Hospital in Ashford, run by East Kent Hospitals University Foundation Trust, was a “significant issue” according to an education quality intervention review report into trauma and orthopaedic training at the hospital. The review, dated October and made public by NHSE in December 2023, was launched after concerns were raised by staff at the trust in the General Medical Council’s national training survey, published every July. Problems raised by junior doctors and their supervisors to the NHSE review included perceptions that juniors were made to feel uncomfortable by the trauma theatre team and that there was also “animosity” from the trauma theatre team towards surgeons. The review said trauma theatre staff were heard “bragging” about their behaviour towards surgeons and that they resisted the number of cases scheduled on a list, claiming it was “unrealistic". Read full story (paywalled) Source: HSJ, 19 January 2024
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Content Article
How to cut time out of cancer pathways (HSJ, 19 January 2024)
Patient Safety Learning posted an article in Cancers
Meeting cancer performance targets is a challenge for many trusts with waiting times for diagnosis and treatment growing since the pandemic. But this is a worrying time for patients as well, and they would welcome quicker turnaround of results and diagnosis. Cutting time out of this pathway would benefit everyone but are there ways to do this which do not compromise patient safety? An HSJ webinar, in association with SS&C Blue Prism, addressed this important question and tried to find ways trusts could reduce waiting times. -
News Article
Long Covid: NHS legal action launched by family of girl
Patient Safety Learning posted a news article in News
The mother of an 11-year-old Aberdeenshire girl with Long Covid has launched a legal action against their health board, in what lawyers claim is the first case of its kind in Scotland. Helen Goss, from Westhill, is seeking damages from NHS Grampian on behalf of her daughter, Anna Hendy. The action claims the health board is responsible for "multiple failings" in Anna's treatment and care. The claim alleges failings were avoidable, that they caused Anna "injury and damage", and led to her condition worsening. Anna became unwell after contracting Covid in 2020. The action alleges a number of failings by the health board. These include claims that requests for Anna to be referred to the specialist paediatric services of immunology and neurology were refused. It also claims no further help was offered after Anna was diagnosed with Chronic Fatigue Syndrome (CFS) and Paediatric Acute-onset Neuropsychiatric Syndrome (PANS). And it says these failings "could have been avoided had NHS Grampian followed contemporary guidance on diagnosis and treatment". Read full story Source: BBC, 19 January 2024 -
News Article
Leak reveals trust omitting two-year waits from reported figures
Patient Safety Learning posted a news article in News
A hospital trust has been breaching national guidance by excluding some long waiters from its reported waiting list figures, in a move experts warned could put patient safety at serious risk. The practice appears to have helped Sandwell and West Birmingham Hospitals report zero patients waiting more than two years for treatment during most of last year. Its policy means cases that unexpectedly “pop up” as two-year waits in its datasets are temporarily removed. The trust will then review whether the cases are data errors or genuine two-year waits, and if genuine, aim to provide treatment within a month. If not treated within a month, the cases would be added back to the reported waiting list the following month. Rob Findlay, an expert on RTT waiting lists, said the implications of the SWBH policy are far more serious than simply reporting incomplete numbers for a month. He said allowing a month to deal with the pop-up without declaring it “relieves them of pressure to solve the problems that are causing patients to be lost in the first place”. He added: “Some patients – the hospital would never know – might never pop up and be lost from the waiting list forever. “[This is] a serious patient safety issue which could potentially have a significant impact on how long patients are waiting for treatment.” Read full story (paywalled) Source: HSJ, 19 January 2024 -
News ArticleHalf of surgeons in England have considered leaving the NHS amid frustration over a lack of access to operating rooms, a new survey shows. More than 3,000 surgeons contemplated quitting the health service in the last year, with two-thirds reporting burn out and work-related stress to be their main challenge, a new survey by the Royal College of Surgeons England has revealed. As the NHS tries to reduce the 7.61 million waiting list backlog, the survey, covering one quarter of all UK surgeons, found that 56% believe that access to operating theatres is a major challenge. RCS England president, Mr Tim Mitchell, said: “At a time when record waiting lists persist across the UK, it is deeply concerning that NHS productivity has decreased. “The reasons for this are multifactorial, but access to operating theatres and staff wellbeing certainly play a major part. If surgical teams cannot get into operating theatres, patients will continue to endure unacceptably long waits for surgery. “There is an urgent need to increase theatre capacity and ensure existing theatre spaces are used to maximum capacity. There is also a lot of work to be done to retain staff at all levels by reducing burnout and improving morale.” Read full story Source: The Independent, 18 January 2024
