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Content Article
In this blog, Steve Turner reflects on why genuine patient safety whistleblowers are so frequently ignored, side-lined or victimised. Why staff don't speak out, why measures to change this have not worked and, in some cases, have exacerbated the problems. Steve concludes with optimism that new legislation going through Parliament offers a way forward from which everyone will benefit.- Posted
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Content ArticleOn the 20 January 2023 the Health and Social Care Select Committee published a reported with reviewed the progress that the UK Government has made in implementing the recommendations of the Independent Medicines and Medical Devices Safety Review, sometimes referred to as the Cumberlege Review. This paper sets out the UK Government’s response to the recommendations set out in this report. Related reading: Health and Social Care Select Committee: Follow-up on the IMMDS report and the Government’s response (20 January 2023) Patient Safety Learning: Response to the Select Committee report on the Independent Medicines and Medical Devices Safety Review (20 January 2023)
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Content ArticleIn this blog, Carl Heneghan, Professor of Evidence-based Medicine at the University of Oxford and Clinical Epidemiologist Tom Jefferson look at the long-term consequences of inadequate regulation and approval of pelvic mesh devices. They argue that regulators and health systems around the world failed to heed the early warnings, which lead to thousands of women being irreversibly harmed. They highlight that as early as 1999, a study of 34 women who had ProteGen mesh implants showed that 50% of mesh devices had eroded through the vaginal wall. Boston Scientific voluntarily recalled 20,000 devices as a result. In spite of this, the FDA continued to approve vaginal mesh devices, citing ProteGen as their predicate device.
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Content ArticleA research paper was published in October 2021 highlighting results of Freedom of Information (FOI) Requests sent to NHS Trusts in England. The FOI Requests asked for the number of incidents of sexual assault reported by hospitals where the victim was aged over 60, and the alleged perpetrator was a member of staff. The resulting findings were that there were at least 75 reports of sexual assault on patients over 60 by hospital staff in the past five years. The findings also show that whilst the majority of victims were female, 30% were male and that a disappointing number were reported to police – only 16. Of these, 14 were closed as “No Further Action” by the police. In this viewpoint paper published in the Journal of Adult Protection, Amanda Warburton-Wynn highlights the findings of this research.
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Content ArticleOn Saturday 17 September 2022, the fourth annual World Patient Safety Day took place, established as a day to call for global solidarity and concerted action to improve patient safety. Medication safety was chosen as the focused for World Patient Safety Day 2022 due to the substantial burden of medication-related harm at all levels of care. In this report, the World Health Organization (WHO) provides an overview of activities in the countries that observed World Patient Safety Day 2022 to make this event.
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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 ArticleWe often hear the mesh scandal blamed on poor surgeon skill. We also hear the argument that high use mesh implanting surgeons are likely to have fewer patients suffering mesh complications, than a less experienced surgeon. However, this study published in JAMA in October 2018, based on NHS data, shows that high mesh implanting surgeons produce the same or even more mesh complications compared to low volume implanters.
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News Article
Dr Michael Watt tribunal was 'unlawful corner-cutting exercise'
Patient Safety Learning posted a news article in News
A tribunal which allowed a doctor's voluntary removal from the medical register was an "unlawful corner-cutting exercise", a judge has said. Neurologist Michael Watt was at the centre of Northern Ireland's biggest recall of patients. The Medical Practitioners Tribunal Service (MPTS) allowed him to voluntarily remove himself in 2021. It meant he would not face a public hearing about any fitness to practice issues. More 2,500 patients who were in his care had their cases reviewed - with around one in five having their diagnosis changed. Having already quashed the decision to grant removal, Mr Justice McAlinden delivered a scathing assessment of how the application was handled on Monday. In Belfast's High Court, he described the process where Dr Watt's request was heard without the necessary jurisdiction as a "fiasco". The court also heard how Dr Watt appeared to have a "get out of jail free card" where patients were denied public scrutiny of their medical care. Read full story Source: BBC News, 17 April 2023 -
News Article
End racial disparities in maternal deaths
Patient Safety Learning posted a news article in News
An MPs' report is calling for faster progress to tackle "appalling" higher death rates for black women and those from poorer areas in childbirth. The Women and Equalities Committee report says racism has played a key role in creating health disparities. But the many complex causes are "still not fully understood" and more funding and maternity staff are also needed. The NHS in England said it was committed to making maternity care safer for all women. The government said it had invested £165m in the maternity workforce and was promoting careers in midwifery, with an extra 3,650 training places a year. Black women are nearly four times more likely than white women to die within six weeks of giving birth, with Asian women 1.8 times more likely, according to UK figures for 2018-20. And women from the poorest areas of the country, where a higher proportion of babies belonging to ethnic minorities are born, the report says, are two and a half times more likely to die than those from the richest. Caroline Nokes, who chairs the committee, said births on the NHS "are among the safest in the world" but black women's raised risk was "shocking" and improvements in disparities between different groups were too slow. "It is frankly shameful that we have known about these disparities for at least 20 years - it cannot take another 20 to resolve," she added. -
Content ArticleIn the UK, maternal mortality for Black women is currently almost four times higher than for White women, and significant disparities also exist for women of Asian and mixed ethnicity. In this report the Women’s and Equalities Select Committee reviews what is currently understood about the reasons for disparities in maternal deaths, analyses Government and NHS action to date and existing recommendations for change and consider the ongoing challenges to addressing disparities.
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Content ArticleThis Strategy is based on a vision of Finland being a model country for client and patient safety in 2026. It is divided into four strategic priorities, each of which have three corresponding objectives aimed at strengthening patient safety. It is accompanied by an Implementation Plan so that these objectives can be translated into everyday activities. It was published by the Finnish Ministry of Social Affairs and Health, supported by preparatory work by the Finnish Centre for Client and Patient Safety.
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News Article
Investigation launched into gel nail polish allergic reactions
Patient Safety Learning posted a news article in News
The government is investigating reports that growing numbers of people are developing life-changing allergies to some gel nail products. Dermatologists say they are treating people for allergic reactions to acrylic and gel nails "most weeks". Dr Deirdre Buckley of the British Association of Dermatologists urged people to cut down on gel nail use and stick to "old-fashioned" polishes. Some people have reported nails loosening or falling off, skin rashes or, in rarer cases, breathing difficulties, she said. Although most gel polish manicures are safe and result in no problems, the British Association of Dermatologists is warning that the methacrylate chemicals - found in gel and acrylic nails - can cause allergic reactions in some people. It often occurs when gels and polishes are applied at home, or by untrained technicians. Dr Buckley said: "We're seeing it more and more because more people are buying DIY kits, developing an allergy and then going to a salon, and the allergy gets worse." The allergies can leave sufferers unable to have medical treatments like white dental fillings, joint replacement surgery and some diabetes medications. This is because once a person is sensitised, the body will no longer tolerate anything containing acrylates. Read full story Source: BBC News, 15 April 2023 -
News ArticleAn all-out nurses’ strike over the May bank holiday will present “serious risks and challenges” to the NHS, a health leader has warned. Sir Julian Hartley, chief executive of NHS Providers, said the “unprecedented” strike action – which will involve staff in emergency departments, intensive care units and cancer care for the first time – was “extremely worrying”. He also said the threat of coordinated industrial action with junior doctors could result in the “most difficult challenge” for the NHS to date. Sir Julian told BBC Breakfast: “If this takes place in the way that it’s been described, then it would be the first time that we’ve seen nurses not working in those key areas, which of course would present serious risks and challenges for trusts to manage and mitigate that.” Nick Hulme, chief executive of Ipswich and Colchester hospitals, told Radio 4 the latest round of nurses’ strikes will “significantly increase the risk to patients”, adding cancer patients will face greater risks as care could be delayed. He said: “If there is a delay to cancer care, some delays won’t cause significant effects, but there are many people who have been waiting far too long for care and this will only exacerbate that risk." Read full story Source: The Independent, 16 April 2023
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News ArticleA company which ran children's homes where residents were systemically abused also failed to prevent adults being harmed, BBC News has learned. An investigation found 99 cases of abuse at a Doncaster home for vulnerable adults in 2010. One worker even ordered a Taser to use there. The care home company - Hesley - said improvements were made at the time. But children at other Hesley homes were later reported to have been punched, kicked and fed chillies. The BBC reported in January how more than 100 reports of appalling abuse and neglect - dating from 2018 to 2021 - were uncovered at sites run by the Hesley Group. They included children being locked outside in freezing temperatures while naked, and having vinegar poured on wounds. Now the BBC has obtained confidential reports from within Hesley and the local authority which reveal wider safeguarding failings spanning more than a decade at both children's homes and placements for vulnerable young adults. Read full story Source: BBC News, 14 April 2023
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Content Article"One family told me their mum had only been waiting six hours on the floor for an ambulance. Only six hours. For a moment I thought this was a positive outcome. A patient in their 80s, lying on a cold hard floor for the equivalent of three quarters of my shift and I felt this was good patient care. Sadly, this genuinely was better than earlier in the year with patients waiting over 12 hours on the floor and an additional 16 plus hours in an ambulance. I cried when I got home about how far we’ve fallen." An anonymous junior doctor shares his experience on the NHS frontline.
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News Article
A&E staff in England struggling to spot abuse cases in infants, says watchdog
Patient Safety Learning posted a news article in News
Staff in hospital emergency departments in England are struggling to spot when infants are being physically abused by their parents, raising the risk of further harm, an investigation has found. Clinicians often do not know what to do if they are concerned that a child’s injuries are not accidental because there is no guidance, according to a report from the Healthcare Safety Investigation Branch (HSIB) that identifies several barriers to child safeguarding in emergency departments. Matt Mansbridge, a national investigator, said the report drew on case studies of three children who were abused by their parents, which he said were a “hard read” and a “stark reminder” of the importance of diagnosing non-accidental injuries quickly, since these are the warning sign in nearly a third of child protection cases for infants under the age of one. “For staff, these situations are fraught with complexity and exacerbated by the extreme pressure currently felt in emergency departments across the country,” Mansbridge said. He said the clinicians interviewed wanted to “see improvement and feel empowered” to ask difficult questions. “The evidence from our investigation echoes what staff and national leads told us – that emergency department staff should have access to all the relevant information about the child, their history and their level of risk, and that safeguarding support needs to be consistent and timely/ Gaps in information and long waits for advice will only create further barriers to care,” he said. Read full story Source: The Guardian, 13 April 2023 -
Content ArticleClinicians in emergency departments (EDs) will see babies and young children with injuries that may be non-accidental. If the cause of such injuries is missed, there is a risk of further harm to the child. However, making a judgement about whether an injury might be accidental or not is complex and difficult. This Healthcare Safety Investigation Branch (HSIB) investigation explores the issues that influence the diagnosis of non-accidental injuries in infants (children under 1 year of age) who visit an ED. Specifically, it explores the information and support available to ED clinicians to help them to make such a diagnosis. Due to the nature of the subject matter no specific incident was used to explore this area of care. Instead, the investigation analysed 10 serious incident reports (reports written by NHS trusts when a serious patient safety incident occurs) to identify the factors that contribute to non-accidental injuries not being diagnosed. These factors were grouped into themes, which informed the terms of reference for the investigation.
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News Article
Trust CEOs’ strike warning: ‘If anyone gets sick, we’re stuffed’
Patient Safety Learning posted a news article in News
The leaders of acute trusts across England have told HSJ the second junior doctor’s strike ‘feels very different’ from the first stoppage, and services are much more vulnerable because of ‘thinner’ consultant coverage. They also reported that the instruction from NHS England not to proactively cancel elective procedures and apppointments has been largely ignored by trusts. The chief executive of a large trust in the east of England said they were “more concerned about clinical safety than at any time during covid surges”. A trust CEO in the North West told HSJ this week’s stoppage “feels much more risky than the previous strike. We have managed to cover rotas but we are very stretched and concerned about short notice cancellation from agencies and short term sickness after bank holiday.” Read full story (paywalled) Source: HSJ, 11 April 2023 -
News Article
1,643 ‘sexual safety incidents’ in a single 59-bed children’s unit
Patient Safety Learning posted a news article in News
A single children’s mental health hospital with just 59 beds reported more than 1,600 “sexual safety incidents” in four years, shocking NHS figures reveal. Huntercombe Hospital in Maidenhead was responsible for more than half of the sex investigations reported in the 209 children’s mental health units across the country. Despite warnings at a rate of more than one a day to the health service since 2019, no action was taken to stop vulnerable NHS patients being sent to the scandal-hit unit as a result of the 1,643 sexual incident reports. The private unit is now finally due to be closed after an investigation by The Independent revealed allegations of verbal and physical abuse, prompting the NHS to withdraw patients. The hospital since said it plans to reopen as an adult unit. Figures obtained from the NHS show Huntercombe’s Maidenhead unit, Taplow Manor, was behind 57% of the 2,875 reported sexual incidents and assaults reported at England’s child and adolescent mental health services (CAMHS) over the past four years. Reported incidents can range from sexually inappropriate language to serious sexual assault and rape. Read full story Source: The Independent, 11 April 2023 -
News Article
Junior doctors’ strike will have ‘catastrophic impact’ on waiting lists
Patient Safety Learning posted a news article in News
The four-day strike by junior doctors in England will have a “catastrophic impact” on NHS waiting lists, with up to 350,000 appointments and operations likely to be cancelled, the chief executive of the NHS Confederation has said. Matthew Taylor said the industrial action this week posed risks to patient safety and called on the public to avoid “risky behaviour”. “These strikes are going to have a catastrophic impact on the capacity of the NHS to recover services,” he told Sky News. “The health service has to meet high levels of demand at the same time as making inroads into that huge backlog that built up before Covid, but then built up much more during Covid." He said he hoped everyone who needed urgent care would get it, but added: “There’s no point hiding the fact that there will be risks to patients – risks to patient safety, risks to patient dignity – as we’re not able to provide the kind of care that we want to.” He called on the public to use NHS services responsibly. Read full story Source; The Guardian, 10 April 2023 -
Content ArticleIn this article, critical criminologist Sharon Hartles looks at the ongoing fight for justice by families affected by the hormone pregnancy test (HPT) Primodos. Primodos was given to thousands of women in the 1960s and 70s which has been linked to miscarriages, birth defects and stillbirth. The Department of Health and Social Care (DHSC) and pharmaceutical company Bayer are applying to strike out court proceedings against them in a civil litigation case brought by the Association for Children Damaged by Hormone Pregnancy Tests (ACDHPT). This would prevent a five-day hearing scheduled to take place at the Royal Courts of Justice in May 2023 from going ahead. The article outlines the argument brought by the DHSC and Bayer that no additional evidence has been found to warrant the case being brought by the ACDHPT. It then goes on to highlight recent research that has established a causal link between HPTs and birth malformations and that therefore gives credence to the litigation. Sharon highlights the importance of the legal system acknowledging and confronting the damage inflicted upon the families affected by the use of Primodos, many of whom have been seeking justice for decades. Related reading Primodos, mesh and sodium valproate: Recommendations and the UK Government’s response (Sharon Hartles, August 2021) Sodium Valproate: The Fetal Valproate Syndrome Tragedy A year on from the Cumberlege Review: Initial reflections on the Government’s response (Patient Safety Learning, 23 July 2021)
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Content ArticleNHS Resolution received 2,600 claims for needlestick injuries for incidents occurring between 2012 – 2022. Needlestick injuries can be costly to investigate and increase the risk blood-borne infections. Fortunately, the harm and cost of most needlestick injuries are largely avoidable. NHS Resolution has created two new resources to share the learning from these claims and help organisations identify how to prevent future injuries.
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Content ArticleResearch paper by Toye et al. published in the Lancet on the experience of women reporting damage from vaginal mesh.
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Content ArticleNew study from Farr et al. into the effect of implanting polypropylene (PP) surgical mesh into patients. More evidence is needed to show the harmful effect to patients by implanting a foreign body into them, especially into the pelvic floor.
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Content Article
Surgeon's News: Surgical safety update (March 2023)
Patient Safety Learning posted an article in Surgery
Surgeons' News is a magazine for surgical, dental and allied healthcare professionals. Published quarterly by the Royal College of Surgeons of Edinburgh, it features comment and opinion from leading professionals, plus reviews and reports on subjects relevant to all career levels. Two articles in this month's issue we want to highlight are the Surgical safety update (p.10) on cases from the Confidential Reporting System for Surgery (CORESS) and Safe passage (p.18) discussing the National Patient Safety Syllabus.
