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Content Article
Did you know? Extravasation (November 2022)
Patient_Safety_Learning posted an article in Extravasation
Extravasation is the accidental leakage of any liquid from a vein into the surrounding tissues, which can cause serious harm to the patient (NHS England, 2017). From 1 April 2011 until 31 March 2021 the NHS paid £15.6 million in damages relating to extravasation. This leaflet, published by NHS Resolution, aims to share learning from those claims. -
Content ArticleAn expert review of the clinical records of 44 deceased patients who had been under the care of neurologist Dr Michael Watt has found there were “significant failures” in their treatment and care. Dr Watt, a former Belfast Health and Social Care Trust consultant neurologist, was at the centre of Northern Ireland’s largest ever recall of patients, which began in 2018, after concerns were raised about his clinical work. More than 4,000 of his former patients attended recall appointments. At the direction of the Department of Health, in August 2021, the Regulation and Quality Improvement Authority (RQIA) commissioned the Royal College of Physicians to undertake an expert review of the clinical records of certain deceased patients who had been under the care of Dr Watt, with the intention to understand his clinical practice, to ensure learning for others and to help make care better and safer in the future.
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Content ArticleA recently published report highlights the shortcomings in care provided by the NHS. Peter Walsh, Joanne Hughes and James Titcombe emphasise how millions could be saved if people were empowered early on to have their needs met without the need to turn to litigation
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Content ArticleThis open letter from patient safety campaigner Richard von Abendorff calls for patients, their families and safety campaigners to help improve patient investigation and patient inclusive systems. Richard highlights a new role coming up at the new Health Services Safety Investigations Body (HSSIB).
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Content ArticleThe third leading cause of death in the US is its own healthcare system—medical errors lead to as many as 440,000 preventable deaths every year. To Err Is Human is an in-depth documentary about this silent epidemic and those working quietly behind the scenes to create a new age of patient safety. Through interviews with leaders in healthcare, footage of real-world efforts leading to safer care, and one family’s compelling journey from being victims of medical error to empowerment, the film provides a unique look at the US healthcare system’s ongoing fight against preventable harm.
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Content ArticleThis article in Time reviews the documentary film 'To Err is Human', which explores the tragic outcomes of medical errors and the medical culture that allows them to persist. The film follows the Sheridans, a family from Boise, Idaho on their journey to understand how two major medical errors befell their family: one that contributed to a case of cerebral palsy, and another that involved a delayed cancer diagnosis and ended in death.
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Content ArticleKeeping patients safe during their care and treatment should be at the heart of any health system, including the NHS. Yet avoidable harm still occurs every day, around the world. There have been major efforts to prioritise patient safety in England, but the pandemic has shone a light on areas of care where progress has stalled, or safety has deteriorated. This report by Imperial College London's Institute of Global Health Innovation, commissioned by Patient Safety Watch, brings together publicly available data to present a national picture of patient safety in England.
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Content ArticleA complaint from a patient was made to the Scottish Public Services Ombudsman (SPSO) about the care and treatment provided during the period January 2018 to September 2021. In January 2018 the patient underwent emergency surgery for a perforated sigmoid diverticulum (a complication of diverticulitis, an infection or inflammation of pouches that can form in the intestines). An emergency Hartmann's procedure (a surgical procedure for the removal of a section of the bowel and the formation of a stoma - an opening in the bowel) was performed. In April 2018, the patient was seen in an outpatient clinic and informed it would be possible to have a stoma reversal. The patient complained that the Board had continually delayed the stoma reversal surgery which they required, which as of September 2021 had not taken place. The patient also complained that Covid-19 could not account for the delays between the Board informing patient they were ready for surgery around December 2018 and the start of the pandemic in March 2020. The patient noted that as a consequence they had developed significant complications: a large hernia. The patient added that this had severely impacted their personal life and self-esteem, and left them unable to work and reliant on welfare benefits.
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Content ArticleWhen medical errors result in adverse patient outcomes, many healthcare professionals are concerned about malpractice litigation. Fear of malpractice has been associated with excessive health care use through defensive medicine, which involves doctors ordering additional testing or making extra referrals to protect themselves from malpractice accusations. The authors of this study in JAMA Network Open aimed to examine the perspectives of doctors on patient harm and malpractice litigation. They conducted an online survey targeting all emergency department attending physicians and advanced practice clinicians (APCs) in acute care hospitals across Massachusetts from January to September 2020. The results showed that although clinicians feared legal action, they feared harming patients to a greater degree regardless of specialty, experience or sex.
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Content ArticleRadar Healthcare has published its 'Incident Reporting in Secondary Care' whitepaper – an in-depth analysis of reporting within secondary care and its effects on patient safety. It has taken a look into the current state of incident reporting: the good work being done, the concerns across the sector, and how we can all aim to improve the situation. The report was conducted using a panel provided by SERMO from its database of UK Nurses and includes the views from 100 nursing staff members working in hospital wards across the UK. Those surveyed work with hospital in-patients daily and are responsible for reporting safety and regulatory incidents involving patients to senior colleagues.
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News Article
‘It feels very unsafe’: the NHS staff bracing for winter as cuts loom
Patient Safety Learning posted a news article in News
Further funding cuts to the NHS will unavoidably endanger patient safety, an NHS leader warned last week after the chancellor’s promise of spending cuts of “eye-watering difficulty”. Matthew Taylor, the chief executive of the NHS Confederation, said his members were issuing the “starkest warning” about “the huge and growing gulf between what the NHS is being asked to deliver and the funding and capacity it has available”. The warning came as figures showed that paramedics in England had been unavailable to attend almost one in six incidents in September due to being stuck outside hospitals with patients. Service leaders say wait times for A&E and other care are being exacerbated by an acute lack of nurses, with a record 46,828 nursing roles – more than one in 10 – unfilled across the NHS. "Patients are presenting more unwell," says a GP from South Wales, "Wait times in A&E have become unmanageable, so we’re seeing patients who have waited so long to be seen they’re bouncing back to us. Things we can’t deal with, like injuries and chest pain. We tell them they have to go back to A&E. "Abuse of surgery reception and admin staff began last year and it’s just scaled up from there. We’ve had staff members who have been verbally and physically threatened and we’re struggling to recruit and retain staff – people are hired and quit in a couple days. A lot of people are going off sick with stress." Five healthcare workers describe the pressures they are facing, including ambulance stacking, rising A&E wait times and difficulties discharging patients. Read full story Source: The Guardian, 1 November 2022 -
News Article
Eighteen deaths following Tees health trusts' safety lapses
Patient Safety Learning posted a news article in News
Eighteen people died at two Teesside hospital trusts following patient safety lapses over a 12-month period. Sixteen such deaths were recorded at the South Tees Hospitals NHS Foundation Trust, with two at the North Tees and Hartlepool NHS Foundation Trust. Examples of patient safety lapses include a failure to provide or monitor care, a breakdown in communication, an out-of-control infection in a hospital, insufficient staffing or a missed diagnosis. NHS England figures show that, between April 2021 and March this year, there were 16,557 incidents at the South Tees Trust, which operates James Cook University Hospital in Middlesbrough, and Northallerton's Friarage Hospital. Thirty-four resulted in "severe" harm. Middlesbrough MP Andy McDonald told the Local Democracy Reporting Service the figures were a concern and that he planned to take them up with the South Tees Trust's chief executive. He said NHS staff worked under "the most demanding of conditions" but added: "Every person going into hospital rightly expects to receive the best treatment. Patient safety is paramount and no family wants to see a loved one suffer." Dr Mike Stewart, the trust's chief medical officer, said: "We encourage an open and transparent culture and promote the reporting of all patient safety incidents, even when there is uncertainty over a direct link between any problems in care and incidents of severe harm or death. "In the last year there were no deaths graded as definitely preventable due to a problem in the care delivered by the trust. "While our reporting has increased consistently over the last three years, the number of serious incidents has not risen, which is strong evidence of a positive safety culture." Read full story Source: BBC News, 30 October 2022 -
News ArticleMinisters have been urged to launch a public inquiry into the care of mental health patients after The Independent revealed allegations that patients had suffered “systemic abuse” in inpatient units. A joint investigation with Sky News found that teenagers at facilities run by The Huntercombe Group had been left with post-traumatic stress disorder by their treatment despite hundreds of warnings to regulators and the NHS. Now the government is facing calls to review all mental health care services over fears that these cases are “the tip of the iceberg”. Labour’s shadow mental health minister Dr Rosena Allin-Khan has called for a “rapid review” by the government into inpatient mental health services, while Deborah Coles, the chief executive of charity Inquest, has called on the new health secretary Steve Barclay to launch a statutory public inquiry. Read full story Source: The Independent, 28 October 2022
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News ArticleChildren say they were "treated like animals" and left traumatised as part of a decade of “systemic abuse” by a group of mental health hospitals, an investigation by The Independent and Sky News has found. The Department of Health and Social Care has now launched a probe into the allegations of 22 young women who were patients in units run by The Huntercombe Group, which has run at least six children’s mental health hospitals, between 2012 and this year. They say they suffered treatment including the use of “painful” restraints and being held down for hours by male nurses, being stopped from going outside for months and living in wards with blood-stained walls. They also allege they were given so much medication they had become “zombies” and were force-fed. But despite reports to police and regulators dating back seven years, and findings by the Care Quality Commission (CQC) that the units were inadequate, the NHS has still handed Huntercombe nearly £190m since 2015-16 to admit children to its mental health beds. Through witness testimony, documents obtained by Freedom of Information request and leaked reports, the investigation has uncovered: The CQC has received more than 700 whistleblowing and safeguarding reports, including “incidents of concern” and several “sexual safety” concerns. NHS England was notified of 195 safeguarding reports between 2020 and 2021. A 2018 internal report at Meadow Lodge hospital in Newton Abbot (now closed) found staff members using sexually inappropriate language in front of patients. 160 reports investigated by Staffordshire police about Huntercombe Staffordshire between 2015 and 2022. Between March 2021 and 2022, the CQC gave permission for 29 patients to be admitted to Maidenhead hospital after it was placed in special measures. Read full story Source: The Independent, 27 October 2022
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News ArticleHarm to patients has become “normalised” as burned-out paramedics are working without breaks, the national care watchdog has warned. Concerns over the pressures on staff at South East Coast Ambulance Service have been raised by the Care Quality Commission (CQC). Senior staff told the CQC that patients were being adversely affected by ambulance delays but it was now being seen as “part of the culture”. The CQC found pressures on staff within the South East Coast Ambulance Service, such as long waits outside of the emergency department, had led to low morale and staff feeling they were not valued. It said: “Staff described feeling frustrated and burnout and that senior leaders did not understand or respond to the challenges or concerns they raised. Some local senior managers described that harm to patients, caused by delays in reaching them, had become normalised as a culture.” “At times there were many outstanding category 3 [urgent] patients awaiting an ambulance or assessment by a paramedic practitioner. At busy times, these patients waited for extended lengths of time for crews and callbacks. Therefore, this group of patients were at risk of deterioration whilst they were waiting for a response.” Read full story Source: The Independent, 26 October 2022
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News ArticleAn endometriosis sufferer has said her reproductive organs are so damaged by a three-year delay for surgery, it has affected her ability to have children. Claire Nicholls, 29, has been in pain for years with the condition - which involves tissue similar to the lining of the womb growing elsewhere. Ms Nicholls said she was passed from "pillar to post" and for 10 years, medical professionals did not seem to believe how much pain she was actually in. She has stage four endometriosis, which is the most severe and widespread. "The pain can be excruciating, at times I can't get out of bed and I have also had to attend the emergency department," she said. After opting to go private, her surgeon said he was unable to see many of her organs due to the amount of scarred tissue caused by the delay in surgery. "He told me the scarred tissue and adhesions were all around my organs... they couldn't remove it all as it could have damaged other organs including my bladder - it was just too severe," she said. Northern Ireland has the longest gynaecological waiting lists in the UK, according to a professional body. It is calling for two regional endometriosis centres. The report from the Royal College of Obstetricians and Gynaecologists found 36,900 women in Northern Ireland are on a gynaecology waiting list - a 42% increase since the start of the pandemic. Read full story Source: BBC News, 25 October 2022
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News ArticleHospitals “desperate” to free up beds could be putting patients in danger, The Independent has been told. NHS trusts are being forced into “risky behaviours” in the push to free up hospital beds and A&E departments, experts have warned. It comes as new data reveals that waits for ambulance crews outside hospitals hit 26 hours in September, with more than 4,000 patients likely to have experienced severe harm due to delays. In documents leaked to The Independent, hospital leaders in Cornwall warned staff that current pressures in its emergency care system combined with ambulance delays have “tragically resulted in deaths”. Royal Cornwall Hospitals Trust and the Cornwall Partnership NHS Foundation Trust said in the document that ambulance delays and waits in A&E were causing a “risk to life”, and that as a result they were planning to begin discharging patients into the care of the voluntary sector. The document said: “It is likely that the risk of such support not meeting all the patients’ individual requirements is less than the risk to life currently experienced in the community when there are significant handover delays at the hospital front doors.” It comes as North West Ambulance Service launched an investigation after a patient died waiting in the back of an ambulance outside A&E, the Manchester Evening News reported. Read full story Source: The Independent, 24 October 2022
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News Article
Zambia: Avoid buying medicines in undesignated places such as buses
Patient Safety Learning posted a news article in News
Copperbelt province Clinical Care Specialist Morgan Mweene has warned people against buying medicines from undesignated places such as buses or on the street as the trend is risky to their health. And stakeholders on the Copperbelt have come together to advocate for reduced deaths or disability related cases resulting from wrong administering of medicine to patients in health facilities. Speaking at the inaugural World Patient Safety Day, commemorated in Ndola under the theme, “Medication Safety”, Dr Mweene emphasised the need for people to avoid buying medicines from undesignated places such as buses and on the streets. He further urged patients to take keen interest in medication given at hospitals. “As health workers, we also need to take interest in patients. As health workers let us not tire as we the custodian of health. It is our duty that we take keen interest of whatever we administer to our patients,” he said. Read full story Source: Mwebantu, 30 September 2022 -
News ArticleParamedics in England cannot respond to 117,000 urgent 999 calls every month because they are stuck outside hospitals looking after patients, figures show. The amount of time ambulance crews had to wait outside A&E units meant they were unavailable to attend almost one in six incidents. Long delays in handing patients over to A&E staff meant 38,000 people may have been harmed last month alone – one in seven of the 292,000 who had to wait at least 15 minutes. Of those left at risk of harm, 4,100 suffered potential “severe harm”, according to the bosses of England’s ambulance services. Read full story Source: The Guardian, 21 October 2022
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News ArticleSome batches of an antibiotic medicine called teicoplanin (brand name Targocid) are being urgently recalled in the UK because of possible contamination. The two affected batches are labelled 0J25D1 and 0J25D2, say safety experts. Patients and prescribers are being asked to check packs and stop using the medicine if it has either batch number. Four patients so far have suffered high fevers just hours after being given a dose from these batches. Other products containing teicoplanin are not affected by the recall. The Medicines and Healthcare products Regulatory Agency (MHRA) says the two batches of Targocid 200mg powder for making a solution to take as an injection, by infusion or by mouth, were found to contain high levels of bacterial endotoxins - a toxic compound found in bacterial cell walls that can cause inflammation-related symptoms, high fever and, in very serious cases, septic shock. Read full story Source: BBC News, 21 October 2022
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News Article
East Kent NHS inquiry finds better care might have prevented 45 babies’ deaths
Patient Safety Learning posted a news article in News
The deaths of at least 45 babies could have been avoided if nationally recognised standards of care had been provided at one of England’s largest NHS trusts, a damning inquiry has found. Dr Bill Kirkup, the chair of the independent inquiry into maternity at East Kent hospitals university NHS foundation trust, said his panel had heard “harrowing” accounts from families of receiving “suboptimal” care, with mothers ignored by staff and shut out from discussions about their own care. The inquiry’s report said: “An overriding theme, raised with us time and time again, is the failure of the trust’s staff to take notice of women when they raised concerns, when they questioned their care, and when they challenged the decisions that were made about their care.” Of 202 cases reviewed by the experts, the outcome could have been different in 97 cases, the inquiry found. In 69 of these 97 cases, it is predicted the outcome should reasonably have been different and it could have been different in a further 28 cases. Of the 65 babies’ deaths examined, 45 could have had a different outcome if nationally recognised standards of care had been provided. In nearly half of all cases examined by the panel, good care could have led to a different outcome for the families. Some of the bereaved parents accused the trust of “victim blaming” mothers for their children’s deaths. Kelli Rudolph and Dunstan Lowe, whose daughter Celandine died at five days old, said: “Doctors sought to blame Kelli for Celandine’s death. This victim blaming was the first in a long line of interactions with those in the trust who sought to delay, deflect and deny our search for the truth about what happened to our baby. “In isolation, these tactics traumatised us after the tragedy of our daughter’s death. But when seen in the light of 10 years of failures, they signal a concerted effort to cover up the trust’s responsibility for what happened to Celandine and the many others who lost their lives due to failures in clinical judgment.” Read full story Source: The Guardian. 19 October 2022 -
News ArticleThe former lead governor of East Kent Hospitals University Foundation Trust has resigned this morning, claiming there is “a cancer at the top of the organisation” and that its services won’t be safe until the government provides funding for critical estates work. His resignation as a governor came hours before the publication of what is expected to be a “harrowing” report into maternity services at the trust from an independent review led by Sir Bill Kirkup. He is also expected to raise concerns about national progress on maternity services safety in recent years. Alex Lister, who is chair of the council of governors’ membership engagement and communications committee, said in the letter: “I believe officials on six-figure salaries continue to mislead, obfuscate, bully and conceal vital information. I consider the way the trust communicates internally and externally to be completely unacceptable and utterly untrustworthy. “Without the valiant efforts of the brave families caught up in a tragedy of the trust’s making, the world may never have found out about the disastrous health failings at our trust.” In the letter to chair Niall Dickson, Mr Lister says he has seen a continuation “of the same apparent policy of manipulation and discrediting dissenting voices that existed prior to the scandal”. Read full story (paywalled) Source: HSJ, 19 October 2022
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News Article
NHS faces £90bn bill for ‘staggering’ maternity blunders
Patient Safety Learning posted a news article in News
The NHS faces a record £90 billion maternity bill, The Telegraph can reveal ahead of a “harrowing” report into failings at East Kent Hospitals Trust. Official figures show the number of claims have risen by almost one quarter in just two years following a series of scandals. The data show 1,243 maternity negligence claims in 2021/22 - up from 1,015 in 2019/20. Safety campaigners said the figures were “staggering” - with £90 billion now set aside to cover the costs of claims. It means that in total, 70% of total liability provision for NHS negligence is associated with failings in pregnancy and childbirth, amid rising claims. The figure - equivalent to two-thirds of the NHS annual budget - represents an estimate for the total costs if all claims it expects to settle were paid out, at today’s prices. An NHS spokesperson said: “Despite improvements to maternity services over the last decade – with significantly fewer stillbirths and neonatal deaths – we know that further action is needed to ensure safe care for all women, babies and their families. “The NHS is ensuring that work is already underway to make these improvements, including a £127 million investment this year to boost the maternity workforce, strengthen leadership and increase neonatal cot capacity – which is on top of an annual boost of £95 million for staff recruitment and training announced last year.” Read full story (paywalled) Source: The Telegraph, 18 October 2022 -
News Article
Secret footage reveals abuse of woman with dementia at luxury UK care home
Patient Safety Learning posted a news article in News
An 88-year-old woman with dementia was physically and mentally abused at a luxury care home charging residents close to £100,000 a year, the Guardian can reveal. Staff misconduct was exposed by secret filming inside the home run by Signature Senior Lifestyle, which operates 36 luxury facilities mostly in the south of England. It has admitted that Ann King was mistreated at Reigate Grange in Surrey earlier this year. Distressing footage from a covert camera inside her room shows: Care staff handling King roughly, causing her to cry out in distress. On one occasion she was left on the floor for 50 minutes. King being taunted, mocked and sworn at when she was confused and frightened. The retired nurse being assaulted by a cleaner, who hits her with a rag used to clean a toilet while she is lying in bed. The cleaner threatening to empty a bin on the pensioner’s head and making indecent sexual gestures in her face. The abuse was exposed by King’s children, Richard Last and Clare Miller. They became so concerned about her wellbeing at the care home, where she lived from January 2021 to March 2022, that they installed a hidden camera on her bedside table. They have shared the footage because they fear what happened to their mother may not be an isolated incident, and because: “She has always been horrified by this type of thing and we felt she would have wanted us to show this is going on.” Read full story Source: The Guardian, 13 October 2022 -
News Article
Shocking scenes uncovered inside Britain's mental health service crisis
Patient Safety Learning posted a news article in News
A shocking undercover investigation has laid bare appalling failures in patient care on Britain’s mental health wards. Reporters from Channel 4’s Dispatches programme spent three months secretly filming at one of the UK’s biggest mental health trusts – Essex Partnership University NHS Foundation Trust. The footage reveals horrifying abuses of vulnerable residents on two acute mental health wards. It includes patients being dragged across the floor, pinned down by staff, mocked while they are in distress and humiliated. On one occasion, a patient who is at high risk of suicide and supposed to be under constant supervision is left unattended and makes an attempt on their own life. Another chaotic scene involves staff trying to locate a crucial bag of specialist cutting devices to save the life of a female patient who got hold of a ligature, after a carer failed to keep watch. In one distressing example, a young woman being treated for anorexia – who is heard hyperventilating with fear – is dragged across the floor by her arms. When she is later discovered making a suicide attempt, she is pinned down by five carers for 40 minutes. As the woman lies sobbing on the floor, one of the staff members discusses the success of his latest diet. Another carer laughs as she marks the rhythm of the woman’s laboured breathing with her hands. The damning footage raises fresh concerns about the state of treatment for the most mentally unwell in this country. While the Essex Trust is just one of 54 across England, mental health professionals and families warn that such failures are widespread. Former mental health nurse Julie Repper, director of imROC, an organisation that helps improve patients’ experiences in mental health services, describes events in the film as ‘literally abusive’. "I asked the peer support workers we train about their experiences of the system, and they described seeing repeated ligaturing, people being dragged by their feet and being restrained. It’s ubiquitous". "These units are supposed to keep people safe, but this film shows they’re not. Everybody has a stake in seeing this improve, because every single one of us may become overwhelmed at some point and find we hit a crisis." Read full story Source: MailOnline, 10 October 2022
