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News Article
Ian Paterson: Eleven further inquests set to open
Patient Safety Learning posted a news article in News
A further 11 inquests are to be opened this week as part of an investigation into dozens of deaths linked to jailed breast surgeon Ian Paterson. Paterson is currently serving a 20-year sentence after he carried out unnecessary or unapproved procedures on more than 1,000 breast cancer patients. Judge Richard Foster said 417 cases of former patients had been reviewed. The inquests will open and be adjourned on Friday. More than 30 deaths are already the subject of an inquest. Paterson worked at Spire Parkway Hospital and Spire Little Aston Hospital in the West Midlands between 1997 and 2011, as well as NHS hospitals run by the Heart of England NHS Foundation Trust. Paterson was jailed in 2017 after being convicted of 17 counts of wounding with intent. An independent inquiry found he had been free to perform harmful surgery in NHS and private hospitals due to "a culture of avoidance and denial" in a healthcare system where there was "wilful blindness" to his behaviour. Read full story Source: BBC News, 10 July 2023- Posted
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Nottingham maternity review set to become UK's largest
Patient Safety Learning posted a news article in News
A review into failings in maternity care in hospitals in Nottingham is set to become the largest in the UK, the BBC understands. Donna Ockenden, chair of the inquiry, is expected to announce that 1,700 families' cases will be examined. She was in charge of the probe into services in Shropshire, which found at least 201 babies and mothers might have survived had they received better care. The review comes after dozens of baby deaths and injuries in Nottingham and focuses on the maternity units at the Queen's Medical Centre and City Hospital. So far, 1,266 families have contacted the review team themselves directly and to date, 674 of these have given consent to join it. But Ms Ockenden has called for a "radical review" to ensure "women from all communities" were being contacted by the trust and "felt confident" to come forward. Read full story Source: BBC News, 10 July 2023- Posted
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News ArticleNearly half of all NHS hospital maternity services covered so far by a national inspection programme have been rated as substandard, the Observer can reveal. The Care Quality Commission (CQC), which regulates health and care providers in England, began its maternity inspection programme last August after the Ockenden review into the Shropshire maternity scandal, which saw 300 babies left dead or brain damaged by inadequate NHS care. Of the services inspected under the programme, which focuses on safety and leadership, about two-thirds have been found to have insufficient staffing, including some services that were rated as good overall. Eleven services saw their rating fall from their previous inspection. Dr Suzanne Tyler of the Royal College of Midwives said: “Report after report has made a direct connection between staffing levels and safety, yet the midwife shortage is worsening. Midwives are desperately trying to plug the gaps – in England alone we estimate that midwives work around 100,000 extra unpaid hours a week to keep maternity services safe. This is clearly unsustainable and now is the time for the chancellor to put his hand in the Treasury pocket and give maternity services the funding that is so desperately needed.” Read full story Source: The Guardian, 9 July 2023
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Patient dies and three hospitalised in Sciensus chemotherapy incident
Patient Safety Learning posted a news article in News
A cancer patient has died and three others have been hospitalised after they were administered unlicensed versions of chemotherapy by Sciensus, a private company paid millions by the NHS to provide essential medication. Three health regulators have launched inquiries into the incident, according to people familiar with the matter. It was caused by an issue at the firm’s medicines manufacturing unit. In a statement, Sciensus confirmed an “isolated incident” had “affected four patients” and that it was “deeply saddened” that one of them had died. Sciensus offered its “sincere condolences” to the family and friends of the patient who died, and is conducting a thorough investigation, it added. The four patients received unlicensed versions of cabazitaxel, a licensed chemotherapy used to treat prostate cancer. The versions administered to the patients differed from the licensed product and therefore were considered unlicensed medicines. Sciensus is required to comply with official standards to ensure the quality of the products it produces and the protection of public health. Breaches of these standards can result in the MHRA suspending or removing a company’s licence. “Patient safety is our highest priority,” said Dr Alison Cave, the MHRA’s chief safety officer. “We are urgently investigating this issue and we will take any necessary regulatory measures to ensure patients are protected." Read full story Source: The Guardian, 7 July 2023- Posted
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News ArticleDaniel was about to get the fright of his life. He was sitting in a consulting room at the Royal Free hospital in London, speaking to doctors with his limited English. The 21-year-old street trader from Lagos, Nigeria, had come to the UK days earlier for what he had been told was a "life-changing opportunity". He thought he was going to get a better job. But now doctors were talking to him about the risks of the operation and the need for lifelong medical care. It was at that moment, Daniel told investigators, that he realised there was no job opportunity and he had been brought to the UK to give a kidney to a stranger. "He was going to literally be cut up like a piece of meat, take what they wanted out of him and then stitch him back up," according to Cristina Huddleston, from the anti modern slavery group Justice and Care. Luckily for Daniel, the doctors had become suspicious that he didn't know what was going on and feared he was being coerced. So they halted the process. The BBC's File on 4 has learned that his ground-breaking case alerted UK authorities to other instances of organ trafficking. Read full story Source: BBC News, 4 July 2023
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New data reveals impact of avoidable injuries
Patient Safety Learning posted a news article in News
30,000 people believe they are victims of negligence each week in the UK, new research carried out by YouGov for Injury Awareness Week (26-30 June) has found. Participants were asked if they have suffered an injury or illness in the last year which was caused because of negligence, for example by another road user, an employer, a colleague, or a medic. “We need to shine a light on the impact these injuries can have on people who were doing nothing more than living their lives before they fell victim to the recklessness or carelessness of others,” said Mike Benner, chief executive of the Association of Personal Injury Lawyers (APIL) which commissioned the Injury Awareness Week study. “Often these injures are severe, some are life-changing, and some are life-ending,” he said. “The fact that the harm has been caused by negligence is significant, because negligence could and should be avoided,” said Mr Benner. “An accident is simply an incident which no-one could have reasonably foreseen. Negligence is doing something, or failing to do something, that could cause injury to others. Employers have a duty to make sure we return home from a day’s work unscathed, for example, and drivers need to take care to not harm fellow road users. “If someone were to take one thing away from this Injury Awareness Week, it’s the knowledge that any one of us could be among the 30,000 injured needlessly in a week. Avoidable injuries are an issue we should all be concerned about,” he said. Read full story Source: APIL, 22 June 2023- Posted
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West Midlands Ambulance Service mistakes caused serious incidents
Patient Safety Learning posted a news article in News
More than half of all serious incidents where patients came to harm involving West Midlands Ambulance Service were due to clinical errors. A trust audit found choking management, cardiac arrests and inappropriate patient discharges as themes. It also noted a decision to close all community ambulance stations was taken without first doing a full risk assessment of the impact on safety. After the number of serious incidents increased from 138 in 2021-22 to 327 in 2022-23, an audit by WMAS found 53% were due to mistakes with their treatment. A situation where a person comes to significant harm in care is identified as a serious clinical incident. Sources say the trust also delayed looking into 5,000 serious patient incidents. Read full story Source: BBC News, 29 June 2023- Posted
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Nottingham review scope 'wider than UK's biggest maternity scandal'
Patient Safety Learning posted a news article in News
The midwife leading a review into failings by Nottingham's maternity services said the scope was wider than the UK's biggest maternity scandal. Donna Ockenden previously led the review at Shrewsbury and Telford NHS Trust that found failings led to the deaths of more than 200 babies. The terms of reference for the review in Nottingham were set out on Tuesday. A category of severe maternal harm has been added to include cases that did not lead to a death or injury. Earlier this year Ms Ockenden completed her inquiry into the UK's biggest maternity scandal at Shrewsbury and Telford NHS Trust. She said the scope of the review in Nottingham was wider because an additional category had been added to the investigation. It aims to identify cases of severe maternal harm, like an unexpected admission to intensive care or a major obstetric haemorrhage. Ms Ockenden said: "We felt adding in the category of severe maternal harm would help us to understand women's experiences and help us to learn and help the trust to learn from those cases as well. "So actually there's been a widening of the scope which our review team felt was important and when we tested it out with some families they felt it was important too. "Perhaps there's a mum out there saying 'well I'm ok, and my baby's ok, but x,w,z of my maternity experience really worried me or frightened me' then she can send in her experiences." She said fathers could also send in their experiences. Read full story Source: BBC News, 14 September 2022- Posted
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Trust 'hiding serious harm and death' report
Patient Safety Learning posted a news article in News
There was a fair bit of press coverage last week about an employment tribunal case against the Care Quality Commission – in which the regulator was found to have sacked an inspector for making a series of whistleblowing disclosures. However, many of the key details were either skirted over, or missed altogether, in the coverage. The disclosures made by Shyam Kumar related not just to his role as a special adviser for the CQC, but also to his full-time employer, University Hospitals of Morecambe Bay FT, and to understand the case fully, they need to be separated out. The important context (also skirted over) was that Dr Kumar had raised a series of legitimate concerns about another orthopaedic surgeon at UHMB, both internally within the trust, and externally with the CQC, in 2018. This caused major tensions within UHMB, to the extent that Dr Kumar started to be targeted for criticism by a different surgeon, being labelled a ‘traitor’ to Indian doctors in a group email. When challenged by Dr Kumar, the colleague complained to the CQC that Dr Kumar had sought to threaten and intimidate him, along with other accusations. Read full story (paywalled) Source: HSJ, 12 September 2022- Posted
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Nottingham maternity failings: Hundreds of families contact review team
Patient Safety Learning posted a news article in News
More than 350 families have already contacted a review team which is examining failings at maternity units in two Nottingham hospitals. The review was opened on 1 September by Donna Ockenden, who previously led an inquiry into the maternity scandal at Shrewsbury and Telford NHS Trust. She will examine how dozens of babies died or were injured in Nottingham. Nottingham University Hospitals NHS Trust has apologised for "unimaginable distress" caused by its failings. More affected families, as well as staff with concerns, have been asked to come forward. Ms Ockenden said: "We are really pleased with the large numbers of families and staff that have already come forward in the first week of the review, and we actively encourage others to do the same." Read full story Source: BBC News, 12 September 2022- Posted
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News ArticleThe NHS accused vaginal mesh victims fighting for compensation of lying about pain, it has been claimed. Women suing hospitals over harm they suffered following mesh operations are being subjected to “devastating” treatment, according to Robert Rose, the head of clinical negligence at law firm Lime Solicitors. Campaign group Sling the Mesh, which represents thousands of patients, said it had received reports of those injured claiming they have been told their symptoms are psychosomatic, that their evidence is not convincing because of their mental state, or that they are lying about their pain. It comes as MPs are set to hold an inquiry following up on the Independent Medicines and Medical Devices (IMMD) Safety Review, chaired by Baroness Cumberlege in 2020, which looked into cases of patients being harmed by mesh procedures, sodium valproate, and hormone pregnancy tests. Lady Cumberlege called for the government to launch a redress scheme for patients in order to provide them with financial support without the need for them to go through clinical negligence battles. Lisa, whose name has been changed to protect her identity, launched her claim in 2016, and it was settled this summer when a judge ruled in her favour. Documents shared with The Independent reveal that NHS lawyers argued she was being “dishonest” about her injuries, and presented video surveillance. The judge subsequently ruled that she had not been dishonest. Speaking about her ordeal, Lisa said: “Once they decided that I’d been dishonest, it changed from admitting liability to basically working out pain levels and stuff like that, and I had to prove that I wasn’t being dishonest. It was genuinely the worst thing I’ve ever gone through, ever. There’s not even a word that I can use to describe it, to say how it made me feel. The stress of it was just immense." Read full story Source: The Independent, 11 September 2022 Further reading Doctors shocking comments to women harmed by mesh Specialist mesh centres are failing to offer adequate support to women harmed by mesh (Patient Safety Learning and Sling the Mesh) “There’s no problem with the mesh”: A personal account of the struggle to get vaginal mesh removal surgery
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Watchdog finds 'toxic' culture in Manx hospital A&E
Patient Safety Learning posted a news article in News
There is a "toxic" culture of bullying and blame in the Isle of Man's emergency department at Noble's Hospital, an inspection has found. The Care Quality Commission's report said it was a "significant concern" along with "ineffective" staff training and medicine storage systems. It found a "significant disconnect" between nursing and medical staff had the potential to "cause or contribute to patient harm". During inspectors' four-day visit in June, some staff said the attitude and behaviour of senior medics was "feral". Manx Care's director of nursing Paul Moore said the understaffed department had been "really struggling" at times. He warned efforts to change governance and culture would take time. Mr Moore said on average the emergency department had about 50% of the required staff over a given month, and recruitment was the "number one priority" to help make lasting changes. "The bottom line is I have to put staff in front of patients before other considerations, especially when we're short", he added. Read full story Source: BBC News, 8 September 2022- Posted
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News ArticleNurses in North Carolina, USA, can now be sued for patient harm that results from them following physicians' orders, the state Supreme Court ruled last month. The 19 August ruling strikes down a 90-year-old precedent set by the 1932 case Byrd v. Marion General Hospital, which protected nurses from culpability for obeying and executing orders from a physician or surgeon, unless the order was obviously negligent. The North Carolina Supreme Court overturned this ruling in a 3-2 opinion as part of a separate case involving a young child who experienced permanent anoxic brain damage during an ablation procedure at a North Carolina hospital in 2010. The ruling means the certified registered nurse anaesthetist involved in the ablation could be held liable for the patient's harm. "Due to the evolution of the medical profession's recognition of the increased specialization and independence of nurses in the treatment of patients over the course of the ensuing ninety years since this Court's issuance of the Byrd opinion, we determine that it is timely and appropriate to overrule Byrd as it is applied to the facts of this case," Justice Michael Morgan wrote in the opinion. Read full story Source: Becker's Hospital Review, 6 September 2022
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MPs to question government on failures over use of epilepsy drug in pregnancy
Patient Safety Learning posted a news article in News
Senior health officials are to face questioning over why pregnant women are still being prescribed sodium valproate despite its known risks as a cause of birth defects or developmental delays. Campaigners for families affected by the drug will also give evidence to the Health and Social Care Committee in a one-off session later this month. Alongside campaigners on sodium valproate, the Committee will also hear from campaigners from Association for Children Damaged by Hormone Pregnancy Tests and on behalf of “Sling the Mesh” campaign. MPs will examine government progress on recommendations made in the Independent Medicines and Medical Devices Safety (IMMDS) Review, which specifically looked into sodium valproate, hormone pregnancy tests and vaginal mesh. An update by Ministers on progress to implement the government’s response was due this summer. A Minister from the Department of Health and Social Care has been invited to appear before the Committee. The IMMDS Review’s report called for better communication to inform women of the risks of sodium valproate in pregnancy. Despite an NHS ‘valproate pregnancy prevention programme’, 247 women since April 2018 were found to have been prescribed the drug in a month in which they were pregnant, 25 as recently as April to September last year. Health and Social Care Committee Chair Jeremy Hunt MP said: “It is incredibly concerning to know that women of child-bearing age can still be prescribed the epilepsy drug sodium valproate despite its known risks as a cause of birth defects or developmental delays. It has been two years since Baroness Cumberlege called for urgent action to prevent this happening. However, dozens of pregnant women were prescribed the drug last year while data published last month has shown that safety requirements were not being fully met. We’re calling in a Minister and senior health officials as well as campaigners to address our concerns.” Read full story Source: UK Parliament, 2 September 2022 -
News ArticleA senior NHS leader has warned of a “life-threatening” situation in which clinically vulnerable people are being admitted to hospital after having their energy supplies disconnected. Sam Allen, chief executive of North East and North Cumbria Integrated Care Board (ICB), has written to Ofgem today to raise “serious concerns” that vulnerable people have seen their electricity or gas services disconnected as a result of non-payment. In the letter, which the ICB has published on its website, Ms Allen said the impact of energy supplies being cut off “will be life threatening for some people” and place additional demand on already stretched health and social care services. She wrote: “It has come to light that we are starting to see examples where clinically vulnerable people have been disconnected from their home energy supply which has then led to a hospital admission. “This is impacting on people who live independently at home, with the support from our community health services team and are reliant on using electric devices for survival. “An example of this is oxygen; and there will be many other examples. There is also a similar concern for clinically vulnerable people with mental health needs who may find themselves without energy supply. “Put simply, the impact of having their energy supply terminated will be life threatening for some people as well as placing additional demands on already stretched health and social care services.” Read full story (paywalled) Source: HSJ, 5 September 2022
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NI health campaigners say 'enough is enough'
Patient Safety Learning posted a news article in News
Former patients and families of those affected by some of Northern Ireland's worst health scandals have called for accountability at every level of the health service. The collective of campaigners gathered at Stormont in protest on Saturday. They have demanded change, saying "enough is enough". They included those affected by systemic failures identified in neurology, urology, care homes and hyponatraemia. Danielle O'Neill, a former patient of the neurologist Dr Michael Watt, whose practice led to Northern Ireland's largest patient recall, was among them. "It's important for us to stand here today as a collective with all of the other scandals to show that we demand an individual duty of candour," she said. "We demand accountability, we demand justice. "There have been far too many health scandals in our health service." Read full story Source: BBC News, 4 September 2022- Posted
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NHS whistleblower Shyam Kumar wins case against regulator
Patient Safety Learning posted a news article in News
A doctor who was sacked for raising patient safety concerns has won a case against England's hospital regulator, the Care Quality Commission (CQC). Orthopaedic surgeon Shyam Kumar worked part-time for the CQC as a special adviser on hospital inspections, but Manchester Employment Tribunal found that he was unfairly dismissed. Between 2015 and his dismissal in 2019, Mr Kumar wrote to senior colleagues at the CQC with a number of serious concerns. They included a hospital inspection, at which he claims patient safety was significantly compromised when a group of whistleblowing doctors was prevented from discussing their concerns. Mr Kumar said, on many occasions, he reported concerns about a surgeon at his own trust, Morecambe Bay, who had carried out operations that were "inappropriate" and of an "unacceptable" quality and harmed patients. He warned the CQC that the trust management wanted to bury it "under the carpet". The tribunal noted that his concerns were found to be justified and the surgeon eventually had conditions placed on his licence to practise. The CQC "accepted the findings". Mr Kumar, who has been awarded compensation, says his concerns were ignored. "The whole energy of a few individuals in the CQC was spent on gunning me down, rather than focusing on improvement to patient safety and exerting the regulatory duties," he said. Read full story Source: BBC News, 5 September 2022- Posted
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Family welcomes new guidance to prevent breathing tube deaths
Patient Safety Learning posted a news article in News
A grieving family has welcomed new guidance to try to prevent a common surgical procedure from going wrong and causing deaths. Oesophageal intubation occurs when a breathing tube is placed into the oesophagus, the tube leading to the stomach, instead of the trachea, the tube leading to the windpipe. It can lead to brain damage or death if not spotted promptly. Glenda Logsdail died at Milton Keynes University Hospital in 2020 after a breathing tube was accidentally inserted into her oesophagus. The 60-year-old radiographer was being prepared for an appendicitis operation when the error occurred. Her family welcomed the guidance, saying in a statement: “We miss her terribly but we know that she’d be happy that something good will come from her tragic death and that nobody else will go through what we’ve had to go through as a family." Oesophageal intubation can occur for a number of reasons including technical difficulties, clinician inexperience, movement of the tube or “distorted anatomy”. The mistake is relatively common but usually detected quickly with no resulting harm. The new guidance, published in the journal Anaesthesia, recommends that exhaled carbon dioxide monitoring and pulse oximetry – which measures oxygen levels in the blood – should be available and used for all procedures that require a breathing tube. Experts from the UK and Australia also recommended the use of a video-laryngoscope – an intubation device fitted with a video camera to improve the view – when a breathing tube is being inserted. Read full story Source: The Independent,18 August 2022- Posted
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Donna Ockenden urges families to come forward for Nottingham maternity review
Patient Safety Learning posted a news article in News
The midwife leading a review into Nottingham's maternity services has urged families and staff to come forward with their experiences. Donna Ockenden was appointed in May to head the inquiry into the services at Queen's Medical Centre and City Hospital. It was launched after more than 100 families with experiences of maternity failings wrote to former Health Secretary Sajid Javid demanding the action. A much-criticised initial review was subsequently scrapped. Ms Ockenden, who uncovered 200 avoidable baby deaths at Shrewsbury and Telford NHS Trust across two decades, said the review is now open to families, NHS workers and others who wish to contribute. "By September 1 we'll be ready to receive contact from families," she told Nottinghamshire Live. "In the mean time if there are either families or members of the NHS that want to get in touch they can use our new email. And also those who represent communities, whether that's safe communities or women's groups in Nottingham." People can contact the review through the email nottsreview@donnaockenden.com, which was launched last week. Ms Ockenden said that positive steps were being made in putting in place the "building blocks" for the review, which is due to start on 1 September 2022. Read full story Source: Nottinghamshire Live, 17 August 2022- Posted
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News ArticleLamborghinis and ski trips to the Swiss Alps were among the incentives a pharmaceutical giant developed to market a surgical device that has ruined the lives of hundreds of Australian women. Documents obtained by the ABC show the extent to which Johnson and Johnson oversold its surgical mesh products, which are used to treat incontinence and prolapse after childbirth. They paint a picture of a company that tried to sell surgeons a jet-setting lifestyle where they could insert four devices "before lunch" and notch up $10,000 in surgeries in a single morning. The mesh devices have left at least 3,000 Australian women with serious side effects including chronic pain, infections and inability to have sex, and are the subject of both a Senate inquiry and a class action. New court documents released in the class action against Johnson and Johnson show that as early as 2009, concerns were raised inside the company that it was making "a huge mistake" by commercialising its latest brand of mesh, was "rushing to market", and opening up the use of the product to "unqualified surgeons". Lawyers from Shine, who are representing the women in the class action, claim the pharmaceutical giant did not investigate proper clinical trials on the possible complications of the mesh. Read full story Source: ABC News, 13 August 2022
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‘We should be offered compensation’ - Mesh campaigner's plea to Steve Barclay
Patient Safety Learning posted a news article in News
Pelvic mesh campaigner Kath Sansom has met with the health secretary Steve Barclay to discuss financial redress for those suffering complications from the procedure. The UK government decided last year not to provide compensation to women whose lives had been affected by vaginal mesh implants. But Kath Sansom, a Cambridgeshire mum and former journalist for this news outlet, has continued campaigning and says she will put pressure on the health secretary to revisit the issue. It also comes as the government revealed victims of the 1970s and 1980s blood scandal will receive compensation for the impact it has had on their lives. Ahead of her meeting with the Secretary of State for Health, she said: “We [mesh injured] deserve to be compensated based on the fact we are suffering lifelong damage from a health treatment that caused avoidable harm. “It is not our fault this happened to us and the State should take responsibility.” Former Health Secretary Matt Hancock issued a public apology when a public inquiry in 2020 revealed a shocking extent of patient failings and lack of regulation for mesh victims. “The State has apologised for the suffering of the mesh community, which is an acknowledgement of responsibility,” Kath added. Read full story Source: Cambs Times, 5 August 2022- Posted
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Use of antipsychotic drugs among dementia patients increasing, study suggests
Patient Safety Learning posted a news article in News
Prescribing potentially harmful antipsychotic drugs to people with dementia has increased by more than 50% on average in care homes during the pandemic, new research suggests. It found that the number of people with dementia receiving these prescriptions had soared from 18% to 28% since 2018 – with prescription rates of over 50% in a third of care homes. Professor Clive Ballard, who was part of a national campaign in 2009 to reduce antipsychotic prescribing by half, said: “Covid-19 put tremendous pressure on care homes, and the majority of them must be applauded for maintaining relatively low antipsychotic prescribing levels amid incredibly difficult circumstances." “However, there were very significant rises in antipsychotic prescribing in one third of care homes and we urgently need to find ways to prioritise support to prevent people with dementia being exposed to significant harms.” Antipsychotic drugs are used to treat some of the more distressing behavioural and psychological symptoms of dementia, such as agitation and psychotic episodes. They have only very limited, short-term benefits in treating psychiatric symptoms in people with dementia – but significantly increase the risk of serious side effects, including stroke, accelerated decline and death. Dr Richard Oakley, from the Alzheimer’s Society, added: “This study shows the shocking and dangerous scale of the use of antipsychotic drugs to treat people with dementia in care homes. “Alzheimer’s Society has been campaigning for a move away from the model of ‘medicate first’ and funded research into alternatives to antipsychotic prescriptions, focused on putting people living with dementia at the centre of their own care. “This drug-free, tailored care can help avoid the loss of lives associated with the harmful side effects of antipsychotic medications.” Read full story Source: The Independent, 4 August 2022- Posted
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NHS must learn to love smart IV pumps to avoid drug errors
Patient Safety Learning posted a news article in News
Hospitals must start using “smart” intravenous (IV) infusion technology to its full potential if they are to prevent dangerous drug errors, University of Manchester researchers have found. ‘Smart pumps’- which automatically calculate the dose and rate of different drugs before they are pumped into a vein - prevent potentially fatal errors by stopping the administration of the wrong rate. But according to the study published in BMJ Open Quality, though the technology probably saved the lives of 110 people in two Trusts over a year, it has largely failed to be adopted by hospitals. Though many IV pumps used in hospitals have a smart capability, most trusts do not utilise the functionality because they are difficult to configure and maintain. Smart pumps are usually configured by a pharmacist and checked by a consultant or senior nurse. Conventional pumps, however, are set by ward staff who calculate and input infusion rates themselves - increasing the risk of drug errors. The risks are illustrated by previous work from the Manchester team, who demonstrated that 1 in 10 IV drug administrations are associated with an error, and up to 1 in 10 of those were associated with harm. Read full story Source: University of Manchester, 1 August 2022- Posted
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Safety fears as NHS medical negligence claims soar
Patient Safety Learning posted a news article in News
Almost 75 years since its foundation, the NHS is struggling with delays caused by the coronavirus pandemic and the “greatest workforce crisis” in its history. A report from MPs on the health committee this week showed 105,000 vacancies for doctors, nurses and midwives, as thousands quit owing to burnout, bullying, pension rules and low pay. Jeremy Hunt, the committee’s chairman, said that the “persistent understaffing in the NHS poses a serious risk to staff and patient safety”. Lawyers warned that the crisis risked increasing the number of negligence claims. Spending on claims by NHS Resolution rose to £2.5 billion in 2021-22 compared with £2.3 billion in the previous year, according to its annual report published last week. The bill increased despite initiatives to cut the number of cases going to court and foster greater collaboration with claimant lawyers. Claimant lawyers welcomed NHS Resolution’s more collaborative approach and desire to resolve cases sooner. They argued, however, that the defensive culture remained and suggested there should be a greater focus on patient safety and learning from mistakes. John McQuater, president of the Association of Personal Injury Lawyers, said that NHS Resolution’s denials and delays meant that injured patients had to turn to lawyers to find answers. He said that earlier investigation into patient safety incidents and earlier admissions of liability by NHS trusts would speed up the system, cutting costs and human misery. Read full story (paywalled) Source: The Times, 28 July 2022- Posted
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NHS has ‘broken’ its promise to the public over the ambulance service
Patient Safety Learning posted a news article in News
The NHS has broken its “fundamental promise” to the public that life-saving emergency care will be available when they need it, a top NHS doctor has said, as ambulances continue to lose tens of thousands of hours waiting outside hospitals. Katherine Henderson, the president of the Royal College of Emergency Medicine, said that what she described as the fundamental promise of the NHS to provide an ambulance in a real emergency has been “broken”. Her comments come as the West Midlands Ambulance Service (WMAS) University NHS Trust predicted it would lose 48,000 ambulance hours waiting outside A&E departments in July. This would make it the worst month on record. In papers published on Thursday, WMAS said the impact of handover delays means that patients are waiting longer than needed for an emergency response, including patients in category one, which includes those needing immediate life-saving care. It added: “This means that patients who are immediately time-critical medical emergencies do not get the response they need and may suffer significant harm or death.” Read full story Source: The Independent, 26 July 2022- Posted
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