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News Article
‘Institutionalised’ staff ‘perpetuating long hospital stays’
Patient Safety Learning posted a news article in News
Nearly half of NHS patients with a learning disability or autism are still being kept inappropriately in hospitals, several years into a key programme to reduce inpatient care, a national review reveals. The newly published review by NHS England suggests 41% of inpatients, assessed over an eight-month period to May 2022, should be receiving care in the community. Reasons given for continued hospital care in the NHSE review included lack of suitable accommodation, with 19% having needs which could be delivered by community services; delays in moving individuals into the community with appropriate aftercare; legal barriers, with one region citing “ongoing concerns for public safety” as a barrier for discharge; and no clear care plans. In some cases, individuals were placed in psychiatric intensive care units on a long-term basis, because “there was nowhere else to go”, while another instance cited a 20-year stay in hospital. Other key themes included concerns about staff culture, particularly “institutionalisation” and suggestions that discharge delays were not being sufficiently addressed. The report adds: “While the process around discharge can be time consuming, staff may perpetuate this by accepting such delays as necessary or inevitable.” Read full story (paywalled) Source: HSJ, 22 February 2023 -
News Article
Prostate cancer screening breakthrough as harms linked to testing reduced
Patient Safety Learning posted a news article in News
Prostate cancer screening may be a step closer after a study suggested that harms linked to testing have reduced thanks to advances in medical technology. Screening for prostate cancer has been heavily debated in medical circles due to potential harms including side effects from biopsies and unnecessary testing for those with no clinically significant cancer. A new study set out to examine whether the “seesaw has been tipped” in favour of screening. Researchers from Prostate Cancer UK combined the results of the latest clinical trials and real-world data on the “prostate cancer screening pathway” to examine the risk-to-harm benefit. Prostate Cancer UK said that on average 67%t fewer men experienced harm during the diagnostic process with the newer techniques compared with older methods. Prostate Cancer UK said the UK National Screening Committee, which makes recommendations to the Government, is to re-examine prostate cancer screening. Dr Matthew Hobbs, lead researcher on the analysis and director of research at Prostate Cancer UK, said: “We’ve known for some time now that testing more men reduces prostate cancer deaths, but there have always been concerns about how many men would be harmed to achieve this. “However, our evidence shows that screening may now be a lot safer than previously thought. That’s why we are so pleased that the committee is going to review the evidence once more. Read full story Source: The Independent, 23 February 2023 -
News ArticleChildren's services could be forced to close at a hospital that is accused of leaving young patients traumatised and sick through poor care. The care regulator said it had taken action to "ensure people are safe" on Skylark ward at Kettering General Hospital (KGH) in Northamptonshire. Thirteen parents with serious concerns after their children died or became seriously ill have spoken to the BBC. A BBC Look East investigation has heard allegations spanning more than 20 years about the treatment of patients on Skylark ward, a 26-bed children's unit. The BBC discovered: An independent report found staff left a 12-year-old boy - who died at KGH in December 2019 - for four hours suffering seizures, and suggests little effort was made to obtain critical care support. In April 2019, nurses allegedly dragged a "traumatised" four-year-old girl down a corridor in agony, insisting that she could walk. Medics are accused of refusing to carry out an MRI scan, which would have detected a dangerous cyst on her spine. Mothers claim to have been threatened with safeguarding referrals, with one stating a referral was made against her after she complained her son was struggling to breathe, while another likened it to blackmail. Read full story Source: BBC News, 20 February 2023
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News Article
Urgent action ordered at maternity scandal trust
Patient Safety Learning posted a news article in News
The trust at the centre of a maternity scandal has been ordered to report on urgent improvements in services for women and babies, amid ‘significant concerns’ about the risk of harm. The Care Quality Commission (CQC) used its enforcement powers to issue the conditions on East Kent Hospitals University Foundation Trust, after it carried out an unannounced inspection last month. However, the “section 31” warning letter has just been made public, and the first deadline for the trust to report back to the CQC is Monday (20 February). The CQC said some of the problems it found were due to the labour ward environment – but others involved monitoring of women and babies whose conditions deteriorate and the risk of cross-infection due to poor cleanliness standards. “We have significant concerns about the ongoing wider risk of harm to patients and a need for greater recognition by the trust of the steps that can be taken in the interim to ensure safety and an improved quality of care,” Carolyn Jenkinson, CQC’s deputy director of secondary and specialist healthcare, said in a statement today. Read full story (paywalled) Source: HSJ, 17 February 2023 -
News ArticleA high court judge has expressed her “deep frustration” at NHS delays and bureaucracy that mean a suicidal 12-year-old girl has been held on her own, in a locked, windowless room with no access to the outdoors for three weeks. In a hearing on Thursday, Mrs Justice Lieven told North Staffordshire combined healthcare NHS trust “you are testing my patience”, after she heard that a proposal to move Becky (not her real name), could not progress until a planning meeting that would not be held until next week, and that a move was not anticipated until 2 March. Three sets of doctors at the hospital trust have disagreed as to Becky’s diagnosis; at her most recent assessment doctors said she was not eligible to be sectioned, which would trigger the protections provided by the Mental Health Act, because her mental disorder was not of the “nature and degree” as to warrant her detention. In a robust exchange, the judge demanded: “Where’s the urgency in this … I cannot believe that the life and health of a 12-year-old girl is hanging on an issue of NHS procurement, when you cannot tell me what it is you’re trying to procure. “If the delay is procurement, I’m not having it,” Lieven continued. “I will use the inherent jurisdiction to make an order. We have a 12-year-old child in a completely inappropriate NHS unit for about three weeks, and it’s suddenly dawned on your client that ‘actually we’ll put her in a Tier 4 unit and we might have to do some [building] work.’” Sometimes, the judge said, “public bodies have to move faster”. Read full story Source: The Guardian, 17 February 2023
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News ArticleA government review into mental health hospitals will fail to prevent the “appalling” treatment of patients, campaigners have warned. The urgent inquiry into inpatient mental health services will focus solely on data, the government said on Tuesday. The “rapid review”, launched following investigations by The Independent into “systemic abuse” across a group of children’s mental health hospitals, will last 12 weeks and is being led by a former national NHS mental health director Dr Geraldine Strathdee. In an outline of what it will cover, the Department for Health and Social Care said it would look at what data is collected by the NHS on inpatient mental health services and whether it is used effectively to identify patient safety problems. It will also look at the quality of data and identify good examples of care but it won’t look at individual cases of abuse or community services. Major mental health charity Mind has warned the review “is not enough” and will not provide any learnings on how to prevent poor care. The charity is instead calling for a national statutory public inquiry into inpatient mental health services. Read full story Source: The Independent, 15 February 2023
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News Article
Workers fighting America’s overdose crisis are ‘hanging by a thread’
Patient Safety Learning posted a news article in News
President Biden has endorsed “harm reduction,” which aims to cut down on overdoses by encouraging safer drug use. But the organizations carrying out that strategy are severely underfunded. In his State of the Union address on Tuesday, Mr Biden, the first president to endorse the strategy, highlighted the federal government’s attention to some of the core features of harm reduction work, including a provision in a recently enacted spending package that makes it easier for doctors to prescribe buprenorphine, an effective addiction medication that Ms Krauss works to get to drug users. During his speech, Mr Biden recognised the father of a 20-year-old from New Hampshire who died from a fentanyl overdose, citing the more than 70,000 Americans dying each year from the potent synthetic opioid. But two years after Mr Biden took office, with the nation’s drug supply increasingly complex and deadly, the practice of harm reduction remains underfunded and partially outlawed in many states. Read full story (paywalled) Source: New York Times, 10 February 2023 -
News Article
Ian Paterson victim calls for patient safety to be prioritised
Patient Safety Learning posted a news article in News
A woman who underwent needless surgery at the hands of convicted surgeon Ian Paterson said patient safety was still not being prioritised. Paterson was convicted of 17 counts of wounding with intent in 2017 and was jailed for 20 years. Debbie Douglas, who now campaigns for his victims, said more still needed to be done following a damning report. In December, the Department for Health said it was making "good progress" on changes. The inquiry, published in 2020, made 15 recommendations and Ms Douglas called on health chiefs to "get on" with the improvements. "It's three years and technically none of the recommendations are closed," she said. "It's all around patient safety and it's not being given the priority it deserves." Read full story Source: BBC News, 9 February 2023 -
News Article
Surgeon given warning over life-changing injuries
Patient Safety Learning posted a news article in News
A Norfolk surgeon who left two patients with life-changing injuries has received a formal warning by a disciplinary panel. Camilo Valero Valdivieso was found guilty of "serious misconduct" by an independent medical panel after two operations went wrong in six days. One of his patients, Paul Tooth, 65, said his life was "a constant struggle" since his operation in January 2020. However, the panel found the surgeon had "learned from these events". The findings from the Medical Practitioners Service (MPTS) panel said that his actions had "risked damaging public confidence in the profession". It heard that he twice "misinterpreted the anatomy" - on one occasion severing a patient's gallbladder. The panel also concluded Mr Valero's fitness to practise was not currently impaired, allowing him to continue working. Read full story Source: BBC News, 7 February 2023 -
News Article
Thousands of patients recalled over eye damage concerns
Patient Safety Learning posted a news article in News
Thousands of patients are being recalled for urgent eye checks after regulators raised safety concerns related to a product used in cataract surgery. It is thought around 20 trusts have suspended use of the EyeCee One lenses, after the Medicines and Healthcare Products Regulatory Agency warned of links to higher pressure in the eye, which can cause lost vision. The MHRA has issued an alert ordering trusts to recall patients who have had surgery since October, and estimates between 2 and 4 per cent of patients could have complications. The watchdog stressed reduced vision would only occur if patients were not treated. It is thought the complications could be down to the way the implant was being used in surgery, rather than the product itself. Read full story (paywalled) Source: HSJ, 7 February 2023 -
News ArticleNurses could refuse to carry out any further strikes alongside other health workers because of fears over patient safety, The Independent has learnt. A mass walkout billed as the largest strike in NHS history is due to take place on Monday as tens of thousands of nurses, paramedics and 999 call handlers walk out in a bid to force ministers to the negotiating table. But the coordinated strikes could be a one-off if nurses feel that the decision to take part in direct action compromises patient safety, The Independent has been told. One union source said walkouts are not carried out on a “come what may” basis, and that the unions would have to assess whether striking together was “helpful” or not. Unions have been escalating their industrial action in recent weeks in an attempt to secure higher pay rises. Any de-escalation in tactics will be seen as a blow to their campaign and a boost to Rishi Sunak’s hopes of riding out the wave of protests. With patient safety the priority, sources insisted there are strong local controls that will pull nurses from picket lines if they think there is an issue. Read full story Source: The Independent, 5 February 2023
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News Article
Deadlock over NHS pay putting patients in danger, chief nurses warn
Patient Safety Learning posted a news article in News
Deadlock over NHS pay is putting patients in danger and risks hardening the position of unions, 10 chief nurses have warned. Unions have warned that the government is making no moves towards resolving the strikes, with one general secretary accusing the government of lying about the state of negotiations. In a joint statement shared with the Guardian, chief nurses from 10 leading hospitals known as the Shelford group highlighted their concern that patients’ health could suffer as a direct result of the increasing disruption the stoppages are causing. Tens of thousands of nurses and ambulance workers in England will stage what will be the biggest strike in the NHS’s 75-year history on Monday. In a plea to the government and health unions, but especially ministers, the 10 Shelford group chief nurses stress that they want both sides to end their standoff as a matter of urgency “because of the impact on the patients and communities we serve. “Industrial action means appointments cancelled, diagnostics delayed [and] operations postponed. The longer industrial action lasts, the greater the potential for positions to harden, waits for patients to grow, and risks of harm to accumulate.” This week will see just one day – Wednesday – when there are no NHS strikes. Nurses will strike again on Tuesday, physiotherapists will stage their second walkout on Thursday and ambulance personnel will stage a further stoppage on Friday. Read full story Source: The Guardian, 5 February 2023 -
News Article
'Potential harm' review ordered into county's cancer patients
Patient Safety Learning posted a news article in News
Commissioners have begun a ‘serious incident review’ across their integrated care system after early indications showed patients may have suffered harm due to long waits for cancer treatment. The review has been launched by Somerset Integrated Care Board into dermatology services after an initial review found five of 50 patients had seen their skin lesions increase in size since being referred to hospital by their GPs. ICB board papers stated “potential patient harm has been identified” for those patients, who were on the two-week wait pathway to be seen by a specialist following a referral by their GP. Read full story (paywalled) Source: HSJ, 3 February 2023 -
News Article
Patient Safety Commissioner: 'We are heading straight back to Mid Staffs'
Patient Safety Learning posted a news article in News
A seismic shift is needed in the way that patients’ and families’ voices are heard, with shared decision-making and patient partnership as the destination, says Patient Safety Commissioner, Dr Henrietta Hughes, on the day the Patient Safety Commissioner 100 Days Report is published. In the report, Henrietta reflects on her first 100 days in this new role. She sets out what she has heard, what she has done and her priorities for the year ahead. "Everyone... has a part to play in delivering safe care – know that you can make a difference by putting safety at the top of your agenda. Introduce patient voices into your governance – in your board meetings, commissioning and contracts meetings, design of strategies, policies and processes, team meeting agendas, annual objectives, appraisals, reviews of complaints and incidents, inspections, and reward and recognition. "I want us to be able to look back in astonishment on the way that we operate now. This is the moment to set a new course with shared decision-making and patient partnership as our destination. Without listening and acting on patient voices, safety will continue to be compromised and patients and families will continue to suffer the consequences of harm." Read full story (paywalled) Source: HSJ, 2 February 2023 -
News ArticleMesh campaigners claim Scotland's Health Secretary Humza Yousaf refused to meet them to hear their concerns. Patients blame surgical mesh products for leaving them disabled and in chronic pain and want the Scottish Government to hold an independent review into the use of the products. However, followihttps://www.dailyrecord.co.uk/news/mesh-campaigners-claim-humza-yousaf-29075491ng a debate in the Scottish Parliament earlier this month, the Health Secretary denied their request. Campaigner Roseanna Clarkin, of the Scottish Global Mesh Alliance, said Yousaf has refused several requests for meetings with campaigners spanning nearly two years. Roseanna, who has been left with crippling pain after mesh was used on her umbilical hernia in 2015, has blasted him for “ignoring” those affected by mesh procedures. From the late 90s until 2018, women in Scotland were treated with polypropylene mesh implants for stress urinary incontinence and pelvic organ prolapse. In some, it caused severe pain and life-changing side effects. While the Independent Medicines and Medical Devices Safety Review called for a pause in use of vaginal mesh, the products are not banned for all procedures. The Scottish Global Mesh Alliance were behind the petition calling for an independent review which was debated at Holyrood. They want to suspend the use of all surgical mesh and fixation devices while a review is carried out. Roseanna said: “Why do they assume mesh in another part of the body would respond differently and not cause extreme pain and serious infections?” Read full story Source: Daily Record, 29 January 2023
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News Article
North East ambulance staff lacked critical medicines, CQC finds
Patient Safety Learning posted a news article in News
Ambulance crews in the North East frequently responded to emergencies without access to life-saving drugs, a damning inspection report has found. The study of North East Ambulance Service NHS Trust (NEAS) concluded patients were potentially put at risk by the poor management of medicines. The Care Quality Commission (CQC) found a deterioration of services and rated NEAS's urgent care as "inadequate". In response, NEAS said it had faced a year of "unprecedented pressures". The damaging assessment follows the launch of a full independent NHS review into numerous "tragic failings" involving patients. Announcing the review, the then health secretary Sajid Javid said he was "deeply concerned" about claims NEAS had covered up mistakes. Whistleblowers have told Newsnight multiple deaths were not investigated properly because information was not always provided to coroners and families. Read full story Source: BBC News, 1 February 2023 -
News Article
Prolific surgeon found guilty of misconduct and dishonesty
Patient Safety Learning posted a news article in News
A prolific surgeon accused of poor care — some with a ‘catastrophic outcome’ — and altering patient notes has been found guilty of misconduct following a tribunal hearing. Jeremy Parker, who performed hundreds of operations at Colchester Hospital and the private Oaks Hospital until his suspension in 2019, faced a misconduct hearing in December and January. The medical practitioners tribunal investigated allegations that between August 2015 and November 2018, Mr Parker failed to provide good clinical care to six patients. It was also alleged he performed surgery in breach of restrictions on his clinical practice between October 2018 and January 2019 and that his actions were dishonest. Richard Holland, opening the tribunal case for the General Medical Council, said Mr Parker’s care of six patients – referred to as patients A-F – was “deficient” in a number of ways, with that provided to patient A leading to a “catastrophic outcome” where their leg was amputated below the right knee following “catastrophic blood loss” caused by severing of an artery during surgery. Read full story (paywalled) Source: HSJ, 1 February 2022 -
News Article
Ian Paterson: Further 1,500 patients to be recalled
Patient Safety Learning posted a news article in News
A further 1,500 patients of convicted breast surgeon Ian Paterson are to be recalled and their treatment investigated. Spire Healthcare, which runs private hospitals, said patients were being contacted after a trawl of IT systems. Paterson was jailed for 20 years in 2017 for 17 counts of wounding people with intent. The healthcare provider said it remained committed to tracking down all "outstanding patients". The former surgeon subjected hundreds of patients to needless and damaging surgery over 14 years. A 2020 independent inquiry ruled "a culture of avoidance and denial" left him free to perform botched operations in NHS and private hospitals in Birmingham and Solihull. The inquiry recommended all 11,000 patients Paterson treated should be recalled for review. Read full story Source: BBC News, 1 February 2023 -
News Article
Hospital doctor accused of sexual assaults on patients
Patient Safety Learning posted a news article in News
The National Crime Agency and Interpol has been drafted in by detectives investigating a junior doctor accused of multiple sexual assaults on children and adults in A&E departments. Last year, Staffordshire police began an investigation into a 35-year-old medic's work at two hospitals, the Royal Stoke University Hospital in Staffordshire and the Russells Hall Hospital in Dudley, West Midlands. Source: Sunday Times Shared by Shaun Lintern Tweet, 29 January 2023 -
News ArticleChildren came to “significant” harm due to chronically low staffing levels at scandal-hit mental health hospitals, whistleblowers have said. In a third exposé into allegations of poor care at private hospitals run by The Huntercombe Group, former employees have claimed that staffing levels were so low “every day” that patients were neglected, resulting in: Patients as young as 13 being force-fed while restrained. Left alone to self-harm instead of being supervised. Left to “wet themselves” because staff couldn’t supervise toilet visits. One staff member, Rebecca Smith, said she was left in tears after having to restrain and force-feed a patient. Following a series of investigations by The Independent and Sky News, 50 patients came forward with allegations of “systemic abuse” and poor care, spanning two decades at children’s mental health hospitals run by the organisation. The government has since launched a “rapid review” into inpatient mental health units across the country following the newspaper’s reporting. Read full story Source: The Independent, 28 January 2023
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News Article
Trust underplayed ‘catastrophic’ IT outage
Patient Safety Learning posted a news article in News
A major London trust has been criticised for ‘underplaying’ the problems caused by a ‘catastrophic’ IT outage, a new report has revealed. The Guy’s and St Thomas’ Foundation Trust report also noted one patient suffered “moderate harm” and several others “low” level harm after last July’s incident, which was caused by a combination of a heatwave and ageing infrastructure. However, the trust said there was no evidence the “underplaying” of issues was deliberate. The report identified one incident of “moderate” patient harm, in which a patient was unable to receive a pancreas transplant due to staff being unable to safely monitor critical observations. The patient has since had a successful operation, the trust’s report stated. Another 20 “low” harm incidents were reported, which included delays in patients receiving their test results and/or medicines, while the report added the trust could not rule out that “further harm events may be identified” amidst an ongoing harm review. Read full story (paywalled) Source: HSJ, 27 January 2023 -
News Article
Surgeon admits botching surgeries that left patients with life-changing injuries
Patient Safety Learning posted a news article in News
An NHS surgeon has admitted to botching patients’ surgeries which left them with life-changing injuries, a tribunal has heard. Dr Camillo Valero, who works at Norfolk and Norwich NHS trust and is facing allegations over his conduct towards three patients, has been admitted to severing a patient’s gallbladder during an operation. Dr Valero is facing a medical practitioner’s tribunal where he already admitted to failures during two patients’ procedures. Allegations against him include a failure to obtain a “critical view of safety” for his patients during surgeries. He is also accused of shouting at patients during an altercation in an allegedly “aggressive” manner. According to a tribunal document he was accused of asking the patient “are you a doctor?” when discussing his medication. During surgery, Dr Valero is alleged to have misinterpreted the patient’s anatomy or sought assistance from an experienced surgeon following mistakes. In the case of the third patient, allegations which have not been admitted or proven, Dr Valero is reported to have inappropriately discharged a patient with learning disabilities and did not adequately assess their mental capacity. Read full story Source: The Independent, 25 January 2023 -
News Article
Thousands exposed to severe harm due to ambulance wait times last month
Patient Safety Learning posted a news article in News
Record numbers of patients suffered severe harm last month because they spent so long in the back of ambulances waiting to get into A&E, new NHS figures reveal. An estimated 57,000 people in England “experienced potential harm”, of whom 6,000 were exposed to “severe harm”, in December – both the largest numbers on record – because they had to wait at least an hour to be handed over to hospital staff, according to NHS ambulance service bosses. The health union Unison, which represents many ambulance staff, said the data showed that the ambulance service “is barely coping” with the huge number of calls it is receiving. A senior ambulance service official said the high volume of patients being put at risk because they had to wait outside A&E so long before receiving medical attention, and paramedics being prevented from answering other 999 calls, was “horrific” and “astronomical”. He added: “These figures also show that whatever NHS England say they are doing to try to resolve this huge problem, it clearly isn’t working.” Martin Flaherty, Association of Ambulance Chief Executives (AACE) managing director, said: “Our December 2022 data for handover delays at hospital emergency departments shows some of the worst figures we have recorded to date and clearly underlines that not enough is being done to reduce and eradicate these dangerous, unsafe and harmful occurrences.” Read full story Source: The Guardian, 25 January 2023 -
News Article
Trust must pay £200k to whistleblower it subjected to ‘campaign of harassment’
Patient Safety Learning posted a news article in News
A trust that sacked a whistleblower who had warned them about potential patient harm from a new procedure has been told to pay her more than £200,000. Jasna Macanovic won her case against Portsmouth Hospitals University Trust last year after the employment tribunal found board members had broken employment rules, including by telling her she would get a good reference if she agreed to quietly resign. Earlier this month, an employment tribunal judgment to establish the compensation she was owed said the trust had subjected Dr Macanovic to “a campaign of harassment” and rejected Portsmouth’s claim she had contributed to her own dismissal. The consultant nephrologist, who had been at the trust for 17 years, raised concerns about a technique called “buttonholing” – carried out to make kidney dialysis more convenient and less painful – that she claimed had caused harm to patients. After the procedures continued, the dispute escalated, culminating with Dr Macanovic being dismissed in March 2018. The employment tribunal panel said Dr Macanovic had raised her concerns about buttonholing properly, adding: “She was not alone in her concerns. The consultant body were fairly evenly divided. “She, however, went further than others, and where she believed that risks were being downplayed she did not hesitate to describe this as a cover-up or an act of dishonesty. Most people would not use that language, and it did cause very serious offence, but it had a specific meaning. It was not a general slur.” Read full story (paywalled) Source: HSJ, 23 January 2023 -
News Article
Ministers order ‘rapid review’ into mental health inpatient care in England
Patient Safety Learning posted a news article in News
Ministers have ordered an inquiry into the quality of care in mental health inpatient units in England after a series of scandals in which vulnerable patients were abused or neglected. Maria Caulfield, the mental health minister, announced the establishment of a “rapid review” in a written ministerial statement in the House of Commons on Monday. The inquiry “is an essential first step in improving safety in mental health inpatient settings”, she said. In recent years, coroners and the Care Quality Commission, the NHS care watchdog, have repeatedly raised concerns about dangerously inadequate care that inpatients have received. It will examine the evidence of “patient safety risks and failures in care” in units that hold and treat patients who have serious conditions including psychosis and personality disorder. It will look in particular at evidence of failings brought forward by patients and their families and how better use of data can help show that care has fallen below acceptable levels. The inquiry will be headed by Dr Geraldine Strathdee, a psychiatrist who used to be NHS England’s national clinical director for mental health. She is likely to look at problems including patients being subjected to controversial restraint techniques, left at risk of being able to take their own lives and segregated from fellow inpatients, and the impact of their experiences on their recovery. Read full story Source: The Guardian, 23 January 2023
