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News Article
Pregnant women should be asked how much they drink
Patient Safety Learning posted a news article in News
Pregnant women should be asked how much alcohol they are drinking and the answer recorded in their medical notes, new "priority advice" for the NHS says. The advice, from the National Institute for Health and Care Excellence (NICE), is designed to help spot problem drinking that can harm babies. Infants with foetal alcohol spectrum disorder (FASD) can be left with lifelong problems. The safest approach during pregnancy is to abstain from alcohol completely. The more someone drinks while pregnant, the higher the chance of FASD - and there is no proven "safe" level of alcohol. But the risk of harming the baby is "likely to be low if you have drunk only small amounts of alcohol before you knew you were pregnant or during pregnancy", the Department of Health says. An earlier draft of the recommendations for NHS staff in England and Wales suggested transferring data on a woman's alcohol intake to her child's medical notes - but this has now been dropped, following concern women who needed help might hide their drinking. The Royal College of Midwives spokeswoman Lia Brigante said: "As there is no known safe level of alcohol consumption during pregnancy, the RCM believes it is appropriate and important to advise women that the safest approach is to avoid drinking alcohol during pregnancy and advocates for this. "We are pleased to see that the recommendation to record alcohol consumption and to then transfer this to a child's record has been reconsidered. "This had the potential to disrupt or prevent the development of a trusting relationship between a woman and her midwife." Read full story Source: BBC News, 16 March 2022 -
News Article
All women must be able to access to safe abortion services, says WHO
Patient Safety Learning posted a news article in News
The World Health Organization has published new guidelines on abortion aimed at tackling the unsafe care that leads to up to 39 000 maternal deaths and millions of women being admitted to hospital with complications every year. When carried out using a method recommended by WHO, abortion is a safe procedure. Tragically, however, only half of all abortions take place under such conditions, with unsafe abortions causing around 39 000 deaths globally. Most of these deaths are in lower-income countries – with over 60% in Africa and 30% in Asia – and among those living in the most vulnerable situations. “Being able to obtain safe abortion is a crucial part of health care,” said Craig Lissner, acting Director for Sexual and Reproductive Health and Research at WHO. “Nearly every death and injury that results from unsafe abortion is entirely preventable. That’s why we recommend women and girls can access abortion and family planning services when they need them.” Evidence shows that restricting access to abortions does not reduce the number of abortions that take place. In fact, restrictions are more likely to drive women and girls towards unsafe procedures. In countries where abortion is most restricted, only 1 in 4 abortions are safe, compared to nearly 9 in 10 in countries where the procedure is broadly legal. “It’s vital that an abortion is safe in medical terms,” said Dr Bela Ganatra, Head of WHO’s Prevention of Unsafe Abortion Unit. “But that’s not enough on its own. As with any other health services, abortion care needs to respect the decisions and needs of women and girls, ensuring that they are treated with dignity and without stigma or judgement. No one should be exposed to abuse or harms like being reported to the police or put in jail because they have sought or provided abortion care." “The evidence is clear – if you want to prevent unintended pregnancies and unsafe abortions, you need to provide women and girls with a comprehensive package of sexuality education, accurate family planning information and services, and access to quality abortion care,” Dr Ganatra added. Read full story (paywalled) Source: BMJ. 9 March 2022 -
Content Article
WHO: Abortion care guidelines (9 March 2022)
Patient Safety Learning posted an article in Women's health
The World Health Organization (WHO) has released new guidelines on abortion care in a bid to protect the health of women and girls and help prevent over 25 million unsafe abortions that currently occur each year around the world. Based on the latest scientific evidence, these consolidated guidelines bring together over 50 recommendations spanning clinical practice, health service delivery, and legal and policy interventions to support quality abortion care. When carried out according to WHO guidelines, abortion is a simple and safe health intervention. The new guidelines will support access to comprehensive and quality abortion care within national health systems in the WHO European Region and globally. -
Content ArticleGovernment must take a cautious and evidence-based approach to exiting the pandemic, factoring in six key elements for a fail-safe exit strategy.
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Content ArticleIn this episode of the Institute of Economic Affairs (IEA) Podcast, IEA Head of Political Economy Dr Kristian Niemietz discusses the findings of the Independent Medicines and Medical Devices Safety Review, and how the healthcare system in England responds to reports about harmful side effects from medicines and medical devices. Kristian speaks with Simon Whale, panel member and communications lead for the Independent Medicines and Medical Devices Safety Review and Dr Sonia Macleod, lead researcher, Independent Medicines and Medical Devices Safety Review. They discuss how the NHS, and other health bodies, could improve their services to address poor care and prevent harm.
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News Article
NHSE wants ‘witch hunt’ lessons shared widely, says trust’s CEO
Patient Safety Learning posted a news article in News
NHS England wants lessons learned by a trust overhauling its culture after a high-profile bullying scandal to be shared systemwide because similar problems have been evident at other trusts, the hospital’s boss has said. West Suffolk Foundation Trust interim chief executive Craig Black said the trust was getting national level “support” to help with a cultural overhaul after a scathing independent review published in December concluded the trust’s hunt for a whistleblower had been “intimidating… flawed, and not fit for purpose”. Mr Black said he thought NHSE would be “looking to learn from what we are doing” because senior managers viewed concerns raised in the West Suffolk review as having ”resonance with a number of organisations in the NHS at the moment”. As well as the specific “witch hunt” case, the review raises wider issues about how trusts respond to whistleblowing and other concerns about care and patient safety. West Suffolk’s executive director of workforce and communications Jeremy Over told the meeting the cultural change required was “organisational development which will take time, significant time”. The report, West Suffolk Review – organisational development plan, sets out nine broad themes of work, linked to the trust’s core functions, “that capture the priority areas for organisational and cultural development at WSFT in light of the learnings from the report”. The document sets out how the trust’s governance, freedom to speak up, HR, staff voice, patient safety and other parts of its corporate infrastructure failed and contributed to a scandal. Read full story (paywalled) Source: HSJ, 1 March 2022 -
Content ArticleThe West Suffolk Review, commissioned by NHS England on behalf of the Department for Health and Social Care, was published last month. NHSE/I asked the West Suffolk Board to produce an action plan for the 28 January meeting of the Board of Directors. This paper summarises the current position in relation to the learning, reflection and response thus far, including the organisational development actions that have already been taken and require further embedding. It also highlights the engagement undertaken to date, and what more needs to happen, to ensure our plans are based on the priorities for staff, governors, patients and teams and can carry the confidence of stakeholders. The report, 'West Suffolk Review – organisational development plan (p. 217)', sets out nine broad themes of work, linked to the trust’s core functions, “that capture the priority areas for organisational and cultural development at WSFT in light of the learnings from the report”. The document sets out how the trust’s governance, freedom to speak up, HR, staff voice, patient safety and other parts of its corporate infrastructure failed and contributed to a scandal.
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Content ArticleThis is an Early Day Motion tabled in the House of Commons on 28 February 2022, which calls on the Government to implement the recommendations of the Independent Medicines and Medical Devices Safety Review in full, including paying compensation to people disabled by Sodium Valproate.
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News Article
Transgender teenager's death preventable, coroner says
Patient Safety Learning posted a news article in News
The death of a "vulnerable" transgender teenager who struggled to get help was preventable, a coroner has said. Daniel France, 17, was known to Cambridgeshire County Council and Cambridgeshire and Peterborough Foundation Trust (CPFT) when he took his own life on 3 April 2020. The coroner said his death showed a "dangerous gap" between services. When he died, Mr France was in the process of being transferred from children and adolescent mental health services (CAMHS) in Suffolk to adult services in Cambridgeshire. The First Response Service, which provides help for people experiencing a mental health crisis, also assessed Mr France but he had been considered not in need of urgent intervention, the coroner's report said. Cambridgeshire County Council had received two safeguarding referrals for Daniel, in October 2019 and January 2020, but had closed both. "It was accepted that the decision to close both referrals was incorrect", Mr Barlow said in his report. Mr Barlow wrote in his report, sent to both the council and CPFT: "My concern in this case is that a vulnerable young person can be known to the county council and [the] mental health trust and yet not receive the support they need pending substantive treatment." He highlighted Daniel was "repeatedly assessed as not meeting the criteria for urgent intervention" but that waiting lists for phycological therapy could mean more than a year between asking for help and being given it. "That gap between urgent and non-urgent services is potentially dangerous for a vulnerable young person, where there is a chronic risk of an impulsive act," Mr Barlow said. Read full story Source: BBC News, 25 February 2022 -
Content ArticleA report looking at how the government can lock in the lessons of the COVID-19 pandemic to build a more robust, sustainable and joined-up system of social care.
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Content ArticleUK experts have issued an update on the timing of elective surgery and risk assessment after COVID-19 infection. Your operation may be delayed if you test positive for Covid-19. Studies of people who had COVID-19 just before or after their surgery show that they had more complications and an increased risk of dying. The risks of chest problems, blood clots or death are about 3 or 4 times greater for a full 7 weeks following COVID-19. These risks are increased even if the patient had no symptoms from COVID-19 (i.e. just a positive test).
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Content Article
This joint letter calls on Maria Caulfield MP, Parliamentary Under Secretary of State for Patient Safety and Primary Care, to implement in full the recommendations of the Independent Medicines and Medical Devices Safety (IMMDS) Review on behalf of those harmed by the side effects of Primodos, Mesh and Sodium Valproate. It is signed by Marie Lyon from the Association for Children Damaged by Hormone Pregnancy Tests, Kath Sansom from Sling The Mesh and Emma Murphy and Janet Williams from In-Fact. -
News ArticleCampaigners found to have been harmed by medical products have written to the health secretary warning that government inaction is "causing pain and destroying lives" by ignoring review recommendations. Some 18 months ago, an independent review recommended financial help for people damaged by some products and drugs that had been prescribed by UK doctors. The government - which set up the Independent Medicines and Medical Devices Safety Review in the first place - has chosen to ignore several of its recommendations. Alleged victims of vaginal mesh, and the drugs valproate and Primodos, have written to Health Secretary Sajid Javid and Maria Caulfield to say they feel ignored. The letter states: "Our members gave evidence to the two-year-long review, sometimes travelling long distances, often with disabilities." "Families shared intimate details of their medical problems, their daily struggles, their difficulties parenting, sometimes even their sex lives. The panel, led by Baroness Cumberlege, was set up by the government to listen, assess and direct policy towards the best course of action. "What was the point of this exercise and the hard work of the panel, if their key recommendations are then ignored by the government?" In the letter, campaigners say: "The decision not to offer an agency for redress (Cumberlege recommendation 3) means that the review has lost its teeth." "Still, no one is facing consequences of medical failures other than the patients. At a time when the public is being asked to put its faith in vaccines, this is a bad look for the government." Kath Sansom, of the campaign group Sling the Mesh, said: "Women must dutifully accept their health has been irreversibly shattered by a medical product they were told was safe, some now needing a disabled blue badge, and they must put up and shut up." Read full story Source: Sky News, 17 February 2022 MeshPrimodosSodiumValproate_LettertoMariaCaulfield_170222.pdf
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Content ArticleSedation for therapeutic and investigative procedures in healthcare is extensively and increasingly used. In 2013 the Academy of Medical Royal Colleges (the Academy) published Safe sedation practice for healthcare procedures: Standards and guidance (this updated and replaced earlier guidance). The guidance recommended core knowledge, skills and competencies required for the safe delivery of effective sedation. It also highlighted that safety will be enhanced by the provision of achievable standards, along with the availability of appropriate facilities and monitoring used under good organisational governance of staffing, equipment, education and practice. However, despite this, avoidable morbidity and mortality continue to occur. Service reviews by the Royal College of Anaesthetists’ (RCoA’s) Anaesthesia Clinical Services Accreditation (ACSA) programme suggest that the recommendations in the 2013 guidance have not been fully acted upon by many hospitals. Therefore, this update summarises the recommendations to provide regulators with a set of standards against which to inspect facilities providing sedation and to ensure that safety standards are being met.
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Content ArticleThis is the transcript of a Westminster Hall debate in the House of Commons on fulfilling the recommendations of the Cumberlege Report.
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Content ArticleThe Hyponatraemia Inquiry is the longest-running public inquiry in recent history: its report was delivered in January 2018, without fanfare. Yet its very existence has gone unnoticed. Marcus Shepheard argues that there are important lessons to be learned for other public inquiries – and for government.
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Content ArticleSurgery is lifesaving or life-enhancing for millions of patients every year. However, the operation is not in itself an isolated ‘event’: it is part of a process which includes preparation and recovery. Ensuring the quality of the entire perioperative pathway is important to achieving the best possible outcome for every patient. This guidance is intended to be used by primary care, surgeons, anaesthetists, perioperative teams and preoperative assessment (POA) services. It applies to all patients who are being considered for surgery, or are on a waiting list for surgery in the non-emergency setting, irrespective of the magnitude of procedure or the type of anaesthesia contemplated. Its recommendations will support the care of individual patients, the recovery of elective services, and achieving key goals of the NHS Long Term Plan including reducing health inequalities and preventing serious health deterioration.
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News Article
Government commits to public repository of consultant details “in principle”
Patient Safety Learning posted a news article in News
The government has committed “in principle” to creating a public repository of consultants’ practice details that sets out their practising privileges and key performance data, including how many times they have performed a particular procedure and how recently. The commitment was part of the response to an independent national inquiry, launched in 2017, following the malpractice of rogue surgeon Ian Paterson. Now serving a 20 year prison sentence, Paterson had undertaken numerous unnecessary breast operations in both private and NHS practice, causing harm to hundreds of patients. The inquiry, published February 2020, found that Paterson was able to harm patients over more than decade because of the “dysfunctional” healthcare system. It outlined 17 recommendations for the government to respond to, mainly focusing on improving oversight and governance, as well as ensuring greater scrutiny of private providers. At the time, some saw the report as a missed opportunity to tackle the systemic patient safety risks of the private hospital business model, such as financial incentives which can lead to overtreatment. Read full story Source: BMJ, 17 December 2021 -
News Article
Government blocks ‘blanket’ rule to suspend all staff where safety is at risk
Patient Safety Learning posted a news article in News
The government has rejected advice from an independent inquiry into the actions of disgraced surgeon Ian Paterson to suspend all healthcare professionals who are suspected of posing a risk to patient safety. The Department of Health and Social Care today published its response to 15 recommendations from the inquiry, which found Mr Paterson, jailed for 20 years in 2017 for 17 offences of wounding with intent, may have conducted up to 1,000 botched and unnecessary operations over a 14-year period. Of its 15 recommendations, the DHSC accepts nine in full, five in principle, rejects one entirely and there is another further point which it is keeping under review. In particular, the inquiry panel members recommended that when a hospital investigates a healthcare professional’s behaviour, including the use of an HR process, any perceived risk to patient safety should result in the suspension of that healthcare professional. DHSC chiefs said they agree practice exclusions and restriction can be necessary, and in some cases immediate exclusion is an appropriate response while an investigation is ongoing. But they added: “However, we do not believe it would be fair or proportionate to impose a blanket rule to exclude practitioners in such cases. “Such a step may inadvertently cause a chilling effect, dissuading healthcare professionals from raising concerns and negatively impacting patient safety.” Read full story (paywalled) Source: HSJ, 16 December 2021 -
Content ArticleThis report from the Department of Health and Social Care sets out the Government’s response to the Independent Inquiry into the Issues raised by Paterson.
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Content ArticleBelow is the recommendation for NHS Scotland made by the Scottish Health Technologies Group (SHTG). SHTG was asked by the Scottish Government to explore a series of questions relating to the use of surgical mesh in the elective repair of abdominal and groin hernias in all adults.
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Content ArticleThe Health and Social Care Committee calls for urgent action to prevent mental health services slipping backwards as a result of additional demand created by the pandemic and the scale of unmet need prior to it.
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EventuntilThis Patient Information Forum webinar will share the key findings of our survey on maternity decisions. Our expert panel will share recommendations to help empower women to make informed decisions about the induction of labour. Open to members and non-members. Register
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Content ArticleProviding high-quality care means putting patient safety at the forefront of every action and decision made in the provision of healthcare services. To achieve this requires the conditions of close cooperation, good communication and the application of effective systems, processes and controls - through good governance. This investigation carried out by Niche Health and & Social Care Consulting describes a complex and evolving set of circumstances where these conditions were not met at Morecambe Bay and which played-out negatively over many years, resulting in uncontrolled legacy. A primary objective of this investigation has been to seek a full and validated understanding of any patient harms or clinically untoward outcomes in Urology. Particularly, but not exclusively, to validate concerns raised publicly in the ‘whistleblowing’ publication Whistle in the Wind. The investigation found a multi-faceted set of contributory issues which cannot, in many cases, be singularly applied to individual Consultant failings.
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Content ArticleThe People’s Covid Inquiry, chaired by the human rights lawyer Michael Mansfield QC, began in January 2021 to learn lessons quickly after the government rejected calls for a public inquiry. The Government was informed of the inquiry on 23 February 2021 and invited to take part. No response was received. The first session of the People’s Covid Inquiry began on 24 February and convened in live sessions fortnightly until 16 June 2021. The Inquiry took evidence over nine sessions from over 40 witnesses including international and UK experts, frontline workers, bereaved families, trade union leaders, and representatives of disabled people’s and pensioners’ organisations.
