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Event
Bevan Brittan webinar: Extravasation & clinical negligence
Sam posted an event in Community Calendar
Amy Walsh, an experienced IV nurse, will address the clinical negligence issues surrounding extravasation including: incidence and aetiology, presentation and recognition, management, treatment and prognosis of this iatrogenic injury. Register -
News ArticleThe care watchdog is investigating possible safeguarding failures at an NHS trust after a documentary uncovered figures showing there were 24 alleged rapes and 18 alleged sexual offences in just three years at one of its mental health hospitals. The Care Quality Commission (CQC) told Disability News Service (DNS) that it had suspended the trust’s ratings for wards for people with learning difficulties and autistic people while it carried out checks. The figures were secured by the team behind Locked Away: Our Autism Scandal, a film for Channel 4’s Dispatches, which revealed the poor and inappropriate treatment and abuse experienced by autistic people in mental health units. None of the alleged rapes at Littlebrook Hospital in Dartford, Kent, led to a prosecution, with allegations of 12 rapes and 15 further sexual offences dropped because of “evidential difficulties” and investigations into 12 other alleged rapes and two sexual offences failing to identify a suspect. A CQC spokesperson said: “Sexual offences are a matter for the police in the first instance. “However, we take reports of sexual offences seriously and review them all, and raise these issues directly with the trust. “We do this alongside involvement from police and local authority safeguarding teams’ own investigations and monitor any actions and outcomes taken by the trust to ensure people are kept safe." Read full story Source: 30 March 2023
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation aims to improve patient safety by supporting healthcare staff in the safe use of central venous catheters to access a patient’s blood supply. Specifically, it looks into the use of tunnelled haemodialysis central venous catheters, which are a type of central line. The reference event involved Joan, who had a cardiac arrest caused by an air embolus after her haemodialysis catheter was uncapped, unclamped, and left open to air. This took place during a procedure to take blood culture samples to test for a possible line infection (where bacteria or viruses enter the bloodstream). This investigation’s findings, safety recommendations and safety observations aim to prevent the future occurrence of an air embolus following uncapped and unclamped haemodialysis catheters, and to improve care for patients across the NHS.
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Content ArticleReducing avoidable healthcare-associated harm is a global health priority. Progress in evaluating the burden and aetiology of avoidable harm in prisons is limited compared with other healthcare sectors. To address this gap, this study, published in PLOS ONE, aimed to develop a definition of avoidable harm to facilitate future epidemiological studies in prisons. Authors conclude: "We have developed a working definition of avoidable harm in prison health care that enables consideration of caveats associated with prison environments and systems. Our definition enables future studies of the safety of prison healthcare to standardise outcome measurement."
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News ArticleMothers and babies are being put at risk because maternity services are still providing unsafe care, despite a series of scandals that have cost lives, the NHS ombudsman has warned. More tragedies will occur unless the health service takes decisive action to put an end to repeated and deeply ingrained problems which lead to “the same mistakes over and over again”, he said. Rob Behrens, the NHS ombudsman for England, voiced his concerns when he launched a report on Tuesday which details the failings several women experienced while giving birth. It also sets out the lessons the NHS needs to learn, but Behrens claimed that too many trusts were not doing so. Behrens voiced alarm that, although efforts have been made to improve the care mothers and their children receive, progress is too slow – and that means patients remain in danger. His report says that: “We recognise that people working in maternity services want to provide high-quality care. Culture, systems and processes can get in the way of achieving that goal. “But improvements are not happening quickly enough, and we have not seen sustainable change. We must do more to make services safer for everyone.” Read full story Source: The Guardian, 28 March 2023 Further reading on the hub: Patient Safety Learning - Mind the implementation gap: The persistence of avoidable harm in the NHS
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Content ArticleWomen should be able to have confidence that they will receive safe, effective, compassionate maternity care that focuses on their individual needs. That is the experience of many people. But too many families still face care that puts the safety and wellbeing of women and babies at risk. This Parliamentary and Health Service Ombudsman (PHSO) report looks at themes from maternity complaints families have brought to us, to shine a light on their experiences and encourage others to let their voices be heard. It shares case summaries and guidance to help families complain and help NHS organisations understand the issues.
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News ArticleA scandal-hit children’s mental health hospital will close months after an investigation by The Independent uncovered claims of poor care and systemic abuse. Taplow Manor hospital, in Maidenhead, was threatened with closure by the NHS safety watchdog, the Care Quality Commission, only last week if it failed to make improvements following a damning report. Active Care Group, which runs the hospital, confirmed it would close by the end of May, saying a decision by the NHS to stop admitting patients had rendered its “service untenable”. The move comes after an investigation by The Independent and Sky News heard from more than 50 patients who alleged “systemic abuse” by the provider, while Taplow Manor is facing two police probes – one into a patient death and a second into the alleged rape of a child involving staff. Read full story Source: The Independent, 29 March 2023
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Content ArticleCan you imagine the distress of going to hospital for an operation and having to return to theatre to have forceps removed because they were left inside your abdomen. Or going in for a left hip operation because of years of agonising pain and waking up to find out they had operated on your good hip. Or having surgery to preserve your ovaries — but they are accidentally removed. Or, worst of all, realising you have had a procedure intended for a different patient. Fanciful stories made up for a TV drama? Sadly not. These were just some of the awful mishaps that occurred in hospitals in England over the space of just ten months. Professor Rob Galloway, writing for the Daily Mail, shares his tips on what patients can you do to protect themselves.
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News Article
Birmingham hospital apologises after delays leave baby disabled
Patient Safety Learning posted a news article in News
Dilshad Sultana was 36 weeks pregnant with her second child in 2019 when she experienced stomach pain and noticed her baby was moving less. Mrs Sultana, from Sutton Coldfield, said she had been due to have a Caesarean section on 8 July but on 20 June she started to feel pain in her abdomen and lower back. She said she was confused but that it did not feel like a contraction and called hospital staff at about 17:00 to say it felt like her baby was moving less. After following advice to rest and take pain relief, she attended hospital at about 22:30 and staff started monitoring Shanto's heart rate. It was not until almost three hours later that Shanto was delivered by emergency C-Section. Shanto suffered severe brain damage and would spent the next 22 days in intensive care, suffering seizures and multiple brain haemorrhages. Shanto now requires around-the-clock care and Mrs Sultana enlisted lawyers to pursue a care of medical negligence against the trust. Birmingham Women's and Children's NHS Foundation Trust has admitted liability and made a voluntary interim payment allowing the family to move to a new home specifically adapted to meet Shanto's extensive care, therapy and equipment needs. Fiona Reynolds, the chief medical officer, said: "We'd like to offer our heartfelt apologies again to the family. "It's clear the standard of care we offered to them fell below those required and expected. For this, we are truly sorry." Now, Mrs Sultana is campaigning for change - she wants to see mothers listened to in maternity care and more attention paid to monitoring babies' heart rates. Read full story Source: BBC News, 27 March 2023 -
Content ArticleThis is Patient Safety Learning’s submission to the consultation on the Professional Standards Authority (PSA) draft strategic plan 2023-26. The PSA were seeking the views of patients, service users, regulators, Accredited Registers and other stakeholders on the work that they do, how they work and how their strategic plan can help them to have a meaningful impact on patient and service user safety and public protection. The consultation is now closed.
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News ArticleThe UK is supposed to have one of the best systems in the world for preventing vulnerable people being exploited for their organs. How then did one of its biggest hospitals become embroiled in the macabre trade of kidney harvesting? The UK’s first trial organ trafficking trial has exposed alarming vulnerabilities to a illegal trade that makes up 10% of transplants worldwide. The case has highlighted how poverty can tempt some people to sell their body parts to those willing to exploit an acute global shortage of organs for donation. The case heard that doctors at a private renal unit at London’s Royal Free hospital and the regulators, the Human Tissue Authority (HTA), were fooled by Dr Obinna Obeta, into approving his kidney transplant in July 2021. As the prosecutor, Hugh Davies, said: “If there’s a lesson to be learned here – those clinicians need to set the index of suspicion for safeguarding somewhat lower.” Dominique Martin, a professor of health ethics at Australia’s Deakin University who studies organ trafficking, said the case highlighted the need for robust vetting by hospitals and regulators. She said: “There is a level of complacency, including in the UK, the US and Australia regarding the risks of organ trafficking happening within our borders. Screening programmes may not be as strong as we assume or as consistently implemented as we might expect.” Read full story Source: The Guardian, 23 March 2023
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News ArticlePolice are investigating fresh allegations of sexual assault against a child patient by a care worker at a scandal-hit private mental health hospital group. It is the second time reports have been made about a former Huntercombe Group hospital after two care workers were quizzed over the alleged rape of a child at its Taplow Manor Hospital in Maidenhead last year. The latest allegations are from a patient at the group’s Ivetsy Bank Hospital, in Staffordshire, which was rated as inadequate last week. In a statement, Staffordshire Police confirmed it had received a report of sexual assault and said inquiries were ongoing. The news comes as the NHS’s safety watchdog has threatened to close Taplow Manor after hospital leaders failed to make improvements in care. The action comes after joint investigations by The Independent and Sky News found the private hospital had put the safety of young mental health patients at risk, with more than 50 patients and staff members alleging “systemic abuse” and poor care. Read full story Source: The Independent, 24 March 2023
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Content ArticleIn this BMJ article, Ryan Essex and colleagues consider whether patients have more to gain than to lose from healthcare worker strikes in poorly functioning health systems Available research on the relationship between strikes and patient harm is limited and offers mixed results, most of which are not widely generalisable across different care settings, researchers said. Overall, the researchers in the study observed a substantial decrease in the number of admissions or care visits during strikes, with broader care delivery changes varying based on who is striking. For example, when early-career physicians strike, research suggests wait times and length of stay are unaffected or become shorter. "While patient safety obviously matters, the overly narrow framing of strikes as harmful to patients is not supported by current evidence; this also shifts focus away from the structural failings that drive strike action in the first place," "When health workers lack other avenues to enact change, failing to strike against suboptimal working conditions may actually be more harmful to patient health in the long run."
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Content Article
In this blog, Patient Safety Learning looks in detail at the results of the NHS Staff Survey 2022, focusing on responses relating to reporting, speaking up and acting on safety concerns. It includes the following key points: It is difficult to imagine other safety critical industries would deem these results acceptable. Nearly half of all respondents did not feel confident their organisation would address their concerns about unsafe clinical practice. It is hugely concerning that over 40% of respondents could not say that they would be treated fairly if involved in a patient safety incident. This could significantly undermine the willingness of staff to raise concerns, with significant consequences for patient safety. There needs to be greater urgency to improve the safety culture in the health service. NHS England needs to recognise the scale of this challenge and provide clarity on how it will work with organisations to tackle this. NHS England, working in partnership with the National Guardian and the Care Quality Commission, should bring forward as a matter of urgency robust and specific commitments to drive forward the work of improving the safety culture in the NHS. -
News Article
Unregulated ‘eating disorder coaches’ putting people at risk, say experts
Patient Safety Learning posted a news article in News
Vulnerable mental health patients are being put at risk by unregulated “eating disorder coaches” who do not have the necessary qualifications, experts have said. As demand for eating disorder support soars – hospital admissions for eating disorders increased by 84% in the last five years – more people are filling gaps in NHS care. So-called eating disorder coaches, who tend to be personal trainers or dietitians recovering from the illness themselves, are charging as much as £1,000 a month for sessions to offer support to others despite having little or no training and expertise. The Guardian has found that many coaches cite short courses, which are intended as professional development for psychologists, as a qualification to practise. The National Centre for Eating Disorders (NCED) offers a number of professional training courses, accredited by the British Psychological Society (BPS). The Guardian found a number of coaches were using these courses to claim they were qualified to offer professional services to people with eating disorders. Agnes Ayton, chair of the Royal College of Psychiatrists’ eating disorders faculty, said she was “amazed” to see people “advertising themselves as experts after going on one course”. “Eating disorders sit between physical and mental health so the risks associated with eating disorders can be physically debilitating and potentially fatal,” Ayton said. “I don’t know why there is not better regulation on that because there is lots of regulation for a medical professional – but therapy is the first line of treatment for eating disorders, and if it is not delivered properly, it can be harmful or misleading.” Read full story Source: The Guardian, 21 March 2023 -
News Article
Warnings against 'reckless' weight loss surgery abroad
Patient Safety Learning posted a news article in News
Seven British patients who travelled to Turkey for weight loss surgery died after operations there, a BBC investigation into the trend has found. Others have returned home with serious health issues after having had gastric sleeve operations, during which more than 70% of the stomach is removed. The operations, used to treat morbid obesity, are carried out in the UK, but, because it can take years to get one through the NHS, some people are looking abroad for treatment. British doctors say that they're treating an increasing number of patients who have travelled to Turkey and returned with serious complications. Dr Ahmed Ahmed, a leading surgeon and member of council at the British Obesity and Metabolic Surgery Society, says he's treated patients returning from Turkey who have had an entirely different operation to the one they understood they had paid for. The BBC has also been told that some people are being accepted for surgery who do not have a medical need for it. The BBC contacted 27 Turkish clinics to see if they would accept someone for treatment who was considered to have a normal BMI. Six of the clinics we approached were happy to accept someone with a BMI of 24.5 for extreme weight loss surgery. Separately, the BBC also found that some clinics who refused the treatment actually then encouraged patients to put on weight, to enable them to be accepted for surgery. One said: "You need to gain 6.7kg to have sleeve surgery. I think you can easily eat some food and then lose weight easily." Another asked: "How soon can you gain weight?" Dr Ahmed says the practices are "reckless" and "unethical". Read full story Source: BBC News, 21 March 2023 -
News Article
Hundreds left with lost or damaged eyesight after NHS delays
Patient Safety Learning posted a news article in News
Hundreds of patients have lost their eyesight or had it irreparably damaged because of NHS backlogs, new research suggests. NHS England clinicians have filed 551 reports of patients who lost their sight as a result of delayed appointments since 2019, with 219 resulting in “moderate or severe harm”, according to an FoI request by the Association of Optometrists, which believes that hundreds more cases are unreported. Its chief executive, Adam Sampson, said sight loss was a “health emergency”, and urged ministers to introduce a national eye health strategy to enable high street and community optometrists to ease some of the burden on hospitals. He said: “There are good treatments available for common age-related eye conditions like macular degeneration but many hospital trusts simply do not have the capacity to deliver services. “Optometry is ideally placed to take away some of that burden – optometrists are already qualified to provide many of the extended services needed and are available on every high street, so patients can be treated closer to home. It’s incomprehensible and absolutely tragic that patients are waiting, losing their vision, in many parts of the country because of the way eye healthcare is commissioned.” Read full story Source: The Guardian, 21 March 2023 -
Content ArticleNiche Health and Social Care Consulting (Niche) were commissioned by NHS England in November 2019 to undertake an independent investigation into the governance at West Lane Hospital (WLH), Middlesbrough between 2017 up to the hospital closure in 2019. WLH was provided by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) and delivered Tier 4 child and adolescent mental health services (CAMHS) inpatient services. This review initially incorporated the care and treatment review findings of two index case events for Christie and Nadia who both died following catastrophic self-ligature at the unit. The Trust subsequently agreed to include the findings of the care and treatment review of Emily which related directly to her time at West Lane Hospital, even though Emily did not die at this site. This is to ensure that optimal learning could be achieved from this review.
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News Article
‘Insufficiently curious’ leaders ‘tolerated’ safety failures
Patient Safety Learning posted a news article in News
Leaders at a mental health trust tolerated high levels of safety incidents and accepted verbal assurance with ‘insufficient professional curiosity’, a critical report has found. An NHS England-commissioned review into governance at Tees, Esk and Wear Valleys Foundation Trust has been published, reviewing the organisation’s response to serious safety concerns flagged at the former West Lane Hospital in Middlesbrough. It follows separate reports identifying “systemic failures” over the deaths of inpatients Christie Harnett, Nadia Sharif and Emily Moore. The new report, conducted by Niche Consulting, criticises board and service leaders’ handling of concerns about the regular occurrence of restraint and self-harm. More than a dozen incidents of inappropriate restraint, some seeing patients dragged along the floor, were identified in November 2018, resulting in multiple staff suspensions and some dismissals. Niche found there was a “lack of accountable leadership at all levels” and lack of evidence for decisions in response to the November 2018 incidents. Read full story (paywalled) Source: HSJ, 21 March 2023 -
Content ArticleThis editorial commentary, published in the Journal of the Royal College of Physicians of Edinburgh, looks at the College's response to the Mid Staffordshire inquiry.
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Content ArticleThe National Patient Safety Board (NPSB) is a proposed independent federal agency modelled in part after the National Transportation Safety Board (NTSB) and Commercial Aviation Safety Team (CAST) that would identify and anticipate significant harm in health care; provide expertise to study the context and causes of harm and solutions; and create solutions to prevent patient safety events from occurring. Watch this video from the Pittsburgh Regional Health Initiative.
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Content ArticleSome medical mistakes have been stubbornly hard to eliminate. Now, hospitals hope technology can make a difference. This Washington Post article highlights are some of the biggest problems that caregivers are trying to address with technology.
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Content ArticleECRI’s Top 10 Patient Safety Concerns 2023 list identifies potential sources of danger for patients and staff. ECRI believe these risks require the greatest focus for the coming year and offer actionable recommendations for reducing these risks. ECRI conducts independent medical device evaluations, annually compiles scientific literature and patient safety events, concerns reported to or investigated by the organization, and other data sources to create its top 10 list.
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News ArticleA scandal-hit hospital group has been sanctioned by inspectors after The Independent revealed “systemic abuse” at a string of children’s mental health units. England’s safety watchdog issued an official warning to Ivetsey Bank Hospital in Staffordshire, run by The Huntercombe Group, after an extensive investigation by this newspaper found the private hospital had put the safety of young mental health patients at risk. The Care Quality Commission also downgraded the hospital’s rating to “inadequate”. If improvements are not made in line with the warning notice, the hospital could be forced to close. An inspection was carried out two weeks after The Independent revealed widespread allegations of abuse and excessive restraint across The Huntercombe Group’s hospitals. The investigation revealed the provider, which also runs Taplow Manor children’s hospital in Maidenhead, was facing allegations from more than 50 former patients as well as claims of poor care from staff whistleblowers and dozens of negligence claims. Read full Source: The Independent, 15 March 2023
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Content Article
Patient Safety 5th Global Ministerial Summit 2023
Patient Safety Learning posted an article in WHO
The World Health Organization's 5th Global Ministerial Summit took place on the 23 and 24 February and was an opportunity for experts from across the world to send clear messages to ministers globally, and for ministers to respond with their pledges about what they were going to do to improve patient safety. Watch the opening and read the outcomes and documents from the Summit,
