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News Article
NHS bosses fear for patient safety during six-day junior doctor strike
Patient Safety Learning posted a news article in News
NHS bosses fear patient safety could be compromised during this week’s junior doctors strikes if medics do not honour an agreement to abandon picket lines if hospitals become overwhelmed during the winter crisis. Hospital bosses can ask the British Medical Association (BMA) to allow junior doctors to return to work to help if an emergency arises during their six-day strike starting on Wednesday. But there is concern among health trust leaders that the doctors’ union could reject such “recall requests” – or take worryingly long to consider them – despite “highly vulnerable” hospitals having too few staff on duty to cope with a surge in patient numbers. A spike in cases of flu, Covid and norovirus has left the NHS under intensifying strain in the first week of the new year, a period in which its winter crisis often bites. On the eve of the 144-hour strike – the longest in NHS history – the NHS Confederation, which represents trusts, urged the BMA to ensure the “recall system” worked reliably if it was triggered. “With the next round of junior doctors strikes coinciding with what is always an exceptionally busy week for the NHS, health leaders hope that escalation plans run smoothly and with a shared understanding that protecting patient safety is the most important priority,” Danny Mortimer, the confederation’s deputy chief executive, said. Read full story Source: The Guardian, 1 January 2024 -
Content ArticleRob Behrens reflects on the work the Parliamentary and Health Service Ombudsman (PHSO) has done over the last year to drive improvements in patient safety.
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Content ArticleIn this blog, Scott Ellner, a general surgeon from the US, describes the case of a surgeon colleague who unintentionally harmed a patient, Sarah, during surgery. Sarah ended up in the surgical intensive care unit from septic shock due to a missed bowel injury. Her recovery from what should have been a straightforward procedure was long and complicated. Scott recalls how the surgeon was shocked by the way Sarah's husband responded to him when he explained what had happened—instead of an anger and blame, Sarah's husband expressed compassion for the doctor and reiterated his trust in him. Scott highlights the importance of creating a Just Culture in healthcare systems and outlines challenges to this in the current climate, referring to the case of nurse RaDonda Vaught. He also outlines the impact patient safety incidents and medical errors can have on healthcare professionals, calling on the healthcare community to embrace shared humanity. All of us come with imperfections, vulnerabilities and the capacity for healing and growth.
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News ArticlePatients have been harmed as a result of doctors striking this year, and others needing time-critical treatment will be at risk during next month’s walkout in England, hospital bosses have said. Cancer patients and women having induced or caesarean section births will be in danger of damage to their health unless junior doctors in those areas of care abandon their plans to strike for six days in January, they said. People awaiting urgent eye surgery risk permanent sight loss unless the British Medical Association (BMA) lets junior doctors keep working in that area, according to NHS Employers, which represents health service trusts in England. Its intervention comes amid mounting concern in the NHS that it may prove impossible to maintain patient safety in high-risk, time-sensitive areas of treatment when tens of thousands of junior doctors stage what will be the longest strike in NHS history from 3 January, when hospitals are facing what is often the service’s busiest week of the year. Read full story Source: The Guardian, 21 December 2023
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News Article
‘No doctor in the country will touch you’: how the NHS is failing FGM survivors
Patient Safety Learning posted a news article in News
At least 137,000 women in the UK live with the painful and traumatic consequences of cutting, but there is no provision for reconstructive surgery. In May 2023, Shamsa Araweelo was in the A&E department of a London hospital in excruciating pain. It wasn’t the first time she had sought urgent treatment for the gynaecological damage caused by the female genital mutilation (FGM), or cutting, forced on her as a six-year-old. In fact, this was one of many such visits to emergency departments that Araweelo had made in her desperate attempt to find a surgeon who could help undo the damage done to her as a child and which has caused her so much pain and trauma as an adult. Araweelo says that in A&E she was told that she had severe nerve damage and that it could be reversed through reconstructive surgery. But not in the UK. “No doctor in the country will touch you, because you are an FGM survivor,” Araweelo says she was told. “I felt no compassion, no respect. Only in London did they tell me they wished they had the appropriate training to help me, and it breaks my heart. We are not valued in the UK.” Current NHS rules state that if a health practitioner suspects a patient has been cut, they must report the case to the police and complete a safeguarding risk assessment to determine whether a social care referral is required. Guidance for GPs also recommends referrals for mental health issues related to FGM or referrals to uro-gynaecological specialist clinics. Araweelo says that in all the years she has sought help she has never been offered any kind of support from medical professionals. Read full story Source: The Guardian, 21 December 2023 -
Content ArticleIn this article, NHS England reports on progress in achieving the aims of the National patient safety strategy which was released in 2019: saving an additional 1,000 lives and £100 million per year. The article suggests that in 2023, the NHS is halfway to reaching this target and shares the following highlights: The National Patient Safety team, supported by staff across the NHS identifying and recording patient safety incidents, continues to save an estimated 160 lives per year through mitigation of risk. This is also estimated to reduce disability due to severe harm incidents by around 480 cases per year and to save £13.5 million in additional treatment costs. Since the strategy was launched, an estimated 291 fewer cases of cerebral palsy have occurred since September 2019 due to the administration of magnesium sulphate during pre-term labour as part of the PReCePT programme, supported by the Patient Safety Collaboratives. This has saved up to £291 million in lifetime care costs, assuming £1 million per case. Work supported by the Maternity and Neonatal Safety Improvement Programme to ensure optimal cord management during labour has saved up to 465 lives since 2020. We estimate 414 fewer deaths and 2,569 fewer cases of moderate harm due to long term opioids following the work of our Medication Safety Improvement Programme since November 2021. The Medication Safety Improvement programme has also led to: 420 fewer admissions for major bleeds per year from anticoagulants and non-steroidal anti-inflammatory drugs (NSAIDs), 1,979 fewer cases of drug induced acute kidney injury, 104 fewer asthma/COPD admissions due to sub-optimal inhaler prescribing, 1,000 fewer patients at risk of methotrexate overdose and 16,920 hospital readmissions avoided by Discharge Medicines Service. It is estimated this has released over £7 million in admissions costs. Early adopters of the Patient Safety Incident Response Framework (PSIRF) are reporting improved safety cultures, identification of more effective risk reduction strategies and early signs of harm reduction, due to their revised approach. It is estimated that there are 36 fewer gas misconnection events every year, each one representing a potential death or severe harm event, due to a focus on reducing risks through the Never Events Framework and National Patient Safety Alerts (NPSAs). 11,621 care homes have been engaged on work to improve management of patient deterioration. This leads to reduced 999 calls, fewer emergency admissions and shorter lengths of stay. 38 mental health wards piloting work on restraint, seclusion and rapid tranquilisation have seen a 15% reduction in those practices.
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Content ArticleA second victim is a healthcare worker who is traumatised by an unexpected adverse patient case, therapeutic mistake, or patient-associated injury that has not been anticipated. Often, the second victim experiences direct guilt for the harm caused to the patients. Healthcare organisations are often unaware of the emotional toll that adverse events can have on healthcare providers (HCPs) who can be harmed by the same incidents that harm their patients. This study aims to examine the second victim phenomenon among healthcare providers at Al-Ahsa hospitals, its prevalence, symptoms, associated factors, and support strategies.
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Content ArticleThe Health Services Safety Investigations Body (HSSIB) Senior Safety Investigator, Helen Jones, blogs about some of the key benefits and risks of electronic patient record (EPR) systems used in healthcare, sharing what we are learning from our safety investigations.
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Content ArticleThis document provides examples of how the justice system is failing mesh victims and why a Redress Agency is imperative.
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Content ArticleIn this blog by Sling The Mesh, the author reflects on the recent case of a mother left in debilitating pain and faecally incontinent from vaginal mesh being awarded a record settlement of at least £1 million. She highlights that in reality many cases are thrown out before they get to court, some never get off the ground owing to being out of the legal time frame and many more women don’t even attempt a medical negligence claim as the process feels too stressful, triggering PTSD and anxiety.
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News ArticleA mother who endured a botched surgery at the hands of a disgraced neurosurgeon claims NHS Tayside tried to silence her against making complaints. Professor Sam Eljamel removed Jules Rose's tear duct during a failed attempt to operate on a brain tumour - setting the 55-year-old on a path to becoming a prolific campaigner for patients' rights. Ms Rose, however, has received sight of documents that show NHS Tayside writing to the then-health minister Humza Yousaf to say she had been "aggressive" and "vulgar" and they would no longer communicate with her. In a letter in response, Mr Yousaf says he sees no evidence of any such conduct by the mother-of-two and tells the health board to enter into mediation with her. Ms Rose said: "In the letter I have been given, Humza Yousaf writes back and say, 'She's quite right to feel aggrieved at the treatment she's received. "'Therefore, I suggest that you continue liaising with Miss Rose and enter into mediation.' "This was last November but I've only just had copies of the letters sent to me and when I saw them I thought, 'They've tried to shut me down, they're tried to silence me'." The ongoing dispute with NHS Tayside is as a result of Ms Rose's long-running campaign for justice for patients - thought to be as many as 270 - harmed by Eljamel while he was in the health board's employ. Read full story Source: The Herald, 16 December 2023
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Content Article
In this blog, Patient Safety Learning’s Chief Executive Helen Hughes reflects on the charity’s work and some of the key patient safety developments in the past 12 months and looks ahead to 2024. -
News Article
‘Long flu’: study finds flu patients at higher risk of longer-term illness
Patient Safety Learning posted a news article in News
People who have been hospitalised with flu are at an increased risk of longer-term health problems, similar to those with long Covid, data suggests. While the symptoms associated with such “long flu” appear to be more focused on the lungs than ongoing Covid symptoms, in both cases the risk of death and disability was greater in the months after infection than in the first 30 days. “It is very clear that long flu is worse than the flu, and Long Covid is worse than Covid,” said Dr Ziyad Al-Aly, a clinical epidemiologist at Washington University in St Louis, Missouri, who led the research. He was motivated to study the phenomenon after observing the scale of long-term illness experienced by people who have recovered from Covid. “Five years ago, it wouldn’t have occurred to me to examine the possibility of a ‘long flu.’ But one of the major lessons we learned from this pandemic is that a virus we all initially thought could only cause acute disease is leaving millions of people with long Covid, he said. “We wondered whether this could be happening with other things. Could this be happening with the flu, for example?” The research, published in the Lancet Infectious Diseases, found that while Covid patients faced a greater risk of death or hospital readmission in the following 18 months, both infections carried a significant risk of ongoing disability and disease. Read full story Source: The Guardian, 14 December 2023 -
Content ArticleMesh slings made of the same polypropylene plastic as the suspended women’s slings have been implanted into nearly 200 men across the UK suffering incontinence after prostate cancer. The operations were part of a trial in 28 hospitals where half the slings failed to fix men’s urinary leakage. Worse, just like the majority of women’s mesh implant trials, the full range of mesh-related pain was not logged in any paperwork.
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News Article
Only half of trusts’ staff were trained ahead of troubled IT go-live
Patient Safety Learning posted a news article in News
Only half of staff across two acute trusts were fully trained in the use of a new electronic patient record before its introduction, which led to disruption and patient harm, HSJ has revealed. The implementation of Oracle Cerner’s EPR at Royal Surrey Foundation Trust and Ashford and St Peter’s Hospitals FT was carried out, despite the trusts not having achieved their target of 80% of staff having completed the necessary training, newly disclosed documents show. HSJ has also seen an internal report by the Royal Surrey’s informatics team which warned of risks to patient safety and data problems, unless preparations improved in the three months leading up to go-live. The two acute trusts implemented the EPR in May last year under a programme called Surrey Safe Care, but there have been multiple problems ever since – including some of the issues that the internal report warned of. The trusts acknowledged the process had been “challenging” but said they had trained a higher proportion of the staff who were working in the two weeks after go-live, with Royal Surrey describing the findings of the internal informatics report as an “inaccurate representation” of readiness. Read full story (paywalled) Source: HSJ, 13 December 2023 -
Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Tracey talks about how her lived experience of navigating the criminal justice and healthcare systems as a victim of serious violent crime has shaped her role as a Patient Safety Partner. Tracey is passionate about speaking up for patients and families, and she highlights the need to prevent compounded trauma by ensuring services meet their needs. She calls for a more joined-up approach between public services and outlines the importance of clear, compassionate communication following a patient safety incident or other traumatic event. -
News ArticleThe expert tasked by government and NHS England to investigate maternity scandals has criticised ministers for failing to provide the funding necessary to address the problems. Donna Ockenden said the funding provided so far was “nowhere near good enough” and progress made to improve services had been “extremely disappointing”. After her investigation into the deaths and harm of 295 babies and nine mothers at Shrewsbury and Telford Hospitals Trust, the Department of Health and Social Care endorsed recommendations to invest an additional £200m to £350m per year into maternity services. IMs Ockenden suggests the recent impact of inflation, pay awards, and other rising costs means the full £350m is required. According to NHSE an additional £165m per year has been invested since 2021, and the DHSC said this would rise to £187m from April. Ms Ockenden, a senior midwife, told HSJ: “What I would like to say loud and clear to the government is that we are broadly 50 per cent of the way there in receiving the money we know is needed for maternity services. That is nowhere near good enough. “There are workforce issues across [the whole team], whether that’s midwives, obstetricians or neonatologists, and it’s hardly surprising. “The government must now do more – whilst we were grateful for the endorsement [of her report], the lack of progress in providing what is known to be the required funding is extremely disappointing.” Read more (paywalled) Source: HSJ, 11 December 2023
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News ArticleAn overworked nurse who failed to give medication to a patient told a colleague “I don’t care anymore”, a hearing was told. Niall O’loingsigh was lead nurse in the Avon unit within the Charterhouse Care Home in Keynsham, Somerset, which looks after elderly residents and those with dementia. In 2020 a complaint was made by a colleague about him breaching safe medication management protocols and being dishonest in relation to medication administration. A misconduct hearing at the Nursing and Midwifery Council was told later, in May 2021, he was seen behaving in an “unsupportive manner” and told a colleague: “I don’t care anymore”. The panel also heard how on 18 May 2021, Mr O’loingsigh failed to record he had administered medication to three residents, BristolLive reported. A colleague wanted to report Mr O’loingsigh’s conduct, in which Mr O’loingsigh patted her on the back and said “well done mate, you did the right thing but I may lose my PIN though”. Mr O’loingsigh told his colleague of feelings of distress and anxiety about being reported and its impact on his career, but he wanted to reassure her. The colleague however felt “uncomfortable”. The panel found that he underwent “a course of conduct which put patients at risk of suffering harm at the time of the incidents” and noted “there were repeated failures over a period of time”. Read full story Source The Mirror, 10 December 2023
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Content Article
Duty of candour review: terms of reference (6 December 2023)
Mark Hughes posted an article in Culture
The review into the statutory duty of candour has been established by the Department of Health and Social Care to consider the design of operation of this requirement, assess its effectiveness and make advisory recommendations. The duty of candour is about people’s right to openness and transparency from their health or care provider. It means that when something goes wrong during the provision of health and care services, patients and families have a right to receive explanations for what happened as soon as possible and a meaningful apology. -
News Article
Infected blood: Tory rebellion expected on payouts amendment
Patient Safety Learning posted a news article in News
The government faces a rebellion with at least 30 Tories backing an amendment to extend interim payouts to more victims of the infected blood scandal. Up to 30,000 people were given contaminated blood products in the 1970s and 80s. Thousands have died. A Labour amendment will be brought on Monday calling for a new body to be set up to administer compensation. More than 100 MPs, including Tories Sir Robert Buckland, Sir Edward Leigh and David Davis, are backing the move. In a letter sent to Chancellor Jeremy Hunt, shadow chancellor Rachel Reeves called the scandal "one of the most appalling tragedies in our country's recent history." She added: "Blood infected with hepatitis C and HIV has stolen life, denied opportunities and harmed livelihoods." She praised Theresa May, who set up the Infected Blood Inquiry when she was prime minister in 2017. But she warned: "For the victims, time matters. It is estimated that every four days someone affected by infected blood dies." The chancellor, himself a former health secretary, told the inquiry in July that the government accepted the moral case for compensation. But he said no final decisions could be made before the inquiry publishes its findings - now expected in March next year. In August 2022, the government agreed to make the first interim compensation payments of £100,000 each to about 4,000 surviving victims and bereaved widows. But inquiry chairman Sir Brian Langstaff, said in April this year that the parents and children of victims should also receive compensation and also called for a full compensation scheme to be set up immediately. The Commons Speaker will decide on Monday which amendments to the bill MPs will vote on. But the government has said it will not be supporting the amendment. A Department of Health spokesperson said: "We are deeply sympathetic to the strength of feeling on this and understand the need for action. However, it would not be right to pre-empt the findings of the final report into infected blood." Read full story Source: BBC News, 3 December 2023 -
Content ArticleThe MHRA is asking organisations to put a plan in place to implement new regulatory measures for sodium valproate, valproic acid and valproate semisodium (valproate). This follows a comprehensive review of safety data, advice from the Commission on Human Medicines and an expert group, and liaison with clinicians and organisations. This alert is for action by: Integrated Care Boards (in England), Health Boards (in Scotland), Health Boards (in Wales), and Health and Social Care Trusts (in Northern Ireland).
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Content ArticleThe first 14 minutes of this programme are focused on a Newsnight investigation into allegations of cover-up, avoidable harm and patient deaths relating to University Hospitals Sussex NHS Foundation Trust. At the time of broadcast, Sussex Police were investigating 105 claims of alleged medical negligence at the Trust.
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News Article
Patients at risk from virtual GP appointments
Patient Safety Learning posted a news article in News
GP appointments over the phone or online risk harming patients, a new study published in the BMJ has found. An analysis of remote NHS doctor consultations between 2020 and 2023 found that “deaths and serious harms” had occurred because of wrong or missed diagnoses and delayed referrals. Distracted receptionists were also found to be responsible for deaths after they failed to call patients back. The report, led by the University of Oxford, suggested doctors should stop giving phone appointments to the elderly, people who are deaf, or technophobes. As many as a third of GP appointments are now virtual after face-to-face appointments slumped to less than half during the pandemic. Restoring access to face-to-face appointments has been a priority of multiple health secretaries, with Steve Barclay last year promising to name and shame GPs who did not see patients in person. Patient groups said the study was likely to be “just the tip of the iceberg” given the “potential for tragic misdiagnoses because of the limitations of online or telephone consultations”. Read full story (paywalled) Source: The Telegraph, 29 November 2023 -
Content ArticleTriage and clinical consultations increasingly occur remotely. In this study, published in BMJ Quality & Safety, Payne et al. aimed to learn why safety incidents occur in remote encounters and how to prevent them. They found that rare safety incidents (involving death or serious harm) in remote encounters can be traced back to various clinical, communicative, technical and logistical causes. Telephone and video encounters in general practice are occurring in a high-risk (extremely busy and sometimes understaffed) context in which remote workflows may not be optimised. Front-line staff use creativity and judgement to help make care safer. As remote modalities become mainstreamed in primary care, staff should be trained in the upstream causes of safety incidents and how they can be mitigated. The subtle and creative ways in which front-line staff already contribute to safety culture should be recognised and supported.
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News Article“Gut-wrenching,” says Lisa McManus. She is looking for words to describe how she and other thalidomide survivors feel ahead of a historic apology by Anthony Albanese for government failings in the tragedy. She is grateful for recognition of the medical disaster and relieved that a decade of advocacy has come to fruition. Around 80 of the 146 recognised survivors will witness the apology in Canberra on Wednesday in what McManus hopes will be “a step in the healing process”. But she is also frustrated that too many others have not lived to see the day. Thalidomide caused birth defects including “shortened or absent limbs, blindness, deafness or malformed internal organs”, according to the Department of Health. The drug was not tested on pregnant women before approval, and the birth defect crisis led to greater medical oversight worldwide, including the creation of Australia’s Therapeutic Goods Administration. Survivors and independent reports have criticised the government of the day for not acting sooner to remove thalidomide from shelves when problems became apparent. McManus leads Thalidomide Group Australia, having lobbied governments for a decade for an apology and better support. She’s “extremely grateful” for the apology, and says many survivors are anxious, excited and nervous – but that the apology itself can’t be the end. “I’m relieved it’s happening, I just can’t say ‘thank you’,” McManus says. “I’m very happy to think it’s here, but it won’t fix things, and I don’t want the government thinking they will deliver this and it’ll all be fine.” Read full story Source: The Guardian, 28 November 2023
