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Since 2015 Quomodus has developed the digital course 'Diathermy – a practical guide to electrosurgery' for surgeons and other professional users of electrosurgery. The 30-minute course covers the history of electrosurgery, indication and proper use, adverse effects and complications associated with the use of diathermy. The course has been tested and quality assured by health professionals in Scandinavia. The course is flexible, user friendly and applies to all models of diathermy equipment currently on the market.

Misplacement of nasogastric tubes can have disastrous consequences for patients and is listed as a “never event” by NHS England. When Lancashire Teaching Hospitals NHS Foundation Trust had two of these never events, the nutrition nursing team carried out a system-wide evaluation to identify problems and develop plans to address them. An e-learning package, robust standardisation in staff’s approach to patient care, re-setting “red lines” to support and empower staff, and the introduction of monitoring and reporting systems have contributed to improving patient safety.

This position paper was prepared by the Nasogastric Tube Special Interest Group of BAPEN. Dr Trevor Smith, BAPEN President commented:  “It is essential that patient safety is at the top of the agenda of every NHS Trust and Health Board. Nobody in need of artificial nutrition should be at risk of a Never Event, so we endorse the special NGT placement training for a select group of staff in every hospital. Our mission is to ensure everybody receives optimal nutritional care, but it is also important to us to protect frontline healthcare professionals from the risk of avoidable and incredibly distressing mistakes. We hope this paper goes some way to encouraging Trusts and Health Boards to move towards far safer practices.” Key points include: Misplacement and use of nasogastric feeding tubes leads to ongoing avoidable complications and deaths classified as Never Events despite multiple NHS Alerts since 2005. The most common cause relates to use of X-rays to confirm intragastric placement, followed by poor adherence to guidance on use of gastric aspirate pH, although the vast majority of nasogastric feeding tubes in the UK are passed safely and have their position confirmed using pH checks without issue. The root cause of these problems is a failure by Hospital Trusts and Health Boards to implement guidelines through rigorous clinical governance over many years. The perception of nasogastric feeding tube insertion as a “simple” procedure must be changed to that of a “complex” and dangerous procedure and limited to properly trained and competent healthcare professionals. The ongoing incidence of nasogastric Never Events is symptomatic of a wider failure of NHS governance procedures centrally and at senior Trust level. It must be accepted that this method of feeding is associated with a risk of complications and death which requires new strategies to mitigate these risks and to place patient safety at the top of the agenda.

These coroner reports relate to two patients, Stephen and Peter, who both died as a result of complications from use of a nasogastric tube. The coroner notes concerns that this issue may be more widespread and has therefore highlighted the report to several relevant bodies who she advises to take action. The author of both reports, Margaret Jones HM Assistant Coroner, notes the matters of concern are as follows: The product description used by Enteral was insufficient to enable the end user to clearly identify that the tube marketed as a carefeed size 14FR feeding and drainage tube would not operate as a 14Fr tube due to the restricting en-fit connector. Enteral sales marketing staff were not trained to recognise the new restriction in the bore of the tube and were consequently unable to advise the end user of the change. The Hospital Trust did not fully evaluate the size 14FR tube prior to replacing all previous drainage tubes (Ryles) with the carefeed 14Fr feeding and drainage tube. Feedback was generally difficult to obtain. Nursing staff did not consider alternative action when the NG tubes were not adequately draining. There was no general recognition of the need to aspirate the tube. There is no compulsory training of clinicians required to undertake root cause analysis. Despite reports to the MHRA and issue of amended instructions for use and a field safety notice the product continues to be promoted as suitable to feeding and drainage. Please see link to the Nursing times. This was a joint inquest into the death of two patients who died in quick succession as a result of the Enteral 14F nasosgastric tube being used for decompression in an emergency situation. Four similar (non-fatal) incidents followed. It was not clear to the hospital that the Enteral connector reduced the bore of the size 14Fr tube. The inquest was aware that other Hospital Trusts had also needed to change the tubes. I am concerned that the product labelling problem identified during these inquests may not be limited to the University Hospital North Midlands but is in fact a much wider problem that merits wider industry investigation and changes. Read the report relating to Peter Hussey Read the report relating to Stephen Oakes

Getting It Right First Time (GIRFT) is designed to improve the quality of care within the NHS by reducing unwarranted variations. By tackling variations in the way services are delivered across the NHS, and by sharing best practice between trusts, GIRFT identifies changes that will help improve care and patient outcomes, as well as delivering efficiencies such as the reduction of unnecessary procedures and cost savings. Gastrointestinal complaints are very common and account for one in ten GP consultations in England. This GIRFT report reviewed 129 gastroenterology teams in England and contains 24 recommendations to improve patient care, including: extending service hours (by recruiting additional staff). introducing specialist triage of referrals at an earlier stage. introducing more proactive care programmes for patients with chronic conditions. You will need a FutureNHS account to view this report, or you can view a short video summary which includes key recommendations.

Michael Seres was a husband, a father, a successful entrepreneur and many more things. Most importantly in some ways, he was a lifelong Chrohn's patient who finally succumbed to an associated cancer last weekend. His loss has hit hard those who knew and admired him and the tributes have been numerous and from both clinicians and other patients. His death is a real loss for anyone interested in promoting patient engagement, and the involvement of patients in safer medical practise. Michael was diagnosed with Crohn's disease at the age of 12 and had his first operation at 14. He died last weekend and was the same age as me. Our daughters were in the same year at secondary school together, and we got to know each other that way at first and then through our mutual interest in health care. When he awoke from an operation to discover he had a stoma bag, he didn't wallow. He bought items online to make it a 'smart' stoma bag to be able to get an alert when it was near full and provide useful data to his medical consultants. This was the type of person he was. Whenever I needed help in anything and asked him, he would unconditionally do everything he could to help, and never failed to deliver – I wish I had been able to do more for him. When he realised that thousands of other patients would be able to benefit from his smart ostomy bag, he tried to get innovation funding to develop and manufacture it at scale for the NHS. He tried over 40 times and received over 40 rejections. People on the other side of the Atlantic were able to see what the NHS couldn't, and 11 Health (he was the 11th person to have a bowel transplant) moved to the West Coast of the USA and grew quickly. He was 'patient in residence' at Stanford Medical school, one of the first such roles in the world. With the clinicians at Stanford, they created the Everyone Included programme, a joint initiative between clinicians and patients which as he described it is "a framework for healthcare innovation, implementation and transformation based on principles of mutual respect and inclusivity". He mentioned this and his journey as a patient in his Ted X talk in 2018. In that talk, he calls for a Chief Patient Officer to work with healthcare execs in co-designing new services for patients or improving existing services. Involving patients in this sort of work is a key foundation for safer healthcare systems. This is not a non-exec role, it is not an arms length committee tick box role. It is a role that can have a profound effect on the ways that services are delivered to patients. It is hugely important and no UK care providers has anyone like this on their exec teams. If you know different, please comment on it below. I think it is about time that a movement to appoint Chief Patient Officers into Trusts was started, don't you? See here for a detailed interview with Michael in 2018: https://www.highland-marketing.com/interviews/hm-interview-michael-seres/

Emergency abdominal surgery (EAS) refers to high-risk intra-abdominal surgical procedures undertaken for acute gastrointestinal pathology. The relationship between hospital or surgeon volume and mortality of patients undergoing EAS is poorly understood. This study, published in BMJ Open, examined this relationship at the national level.

Hospital Watchdog is a nonprofit patient advocacy organisation in the US that champions safe hospital care for patients. They are a diverse group that includes nurses, physicians, pharmacists, healthcare experts, attorneys and members of the public. Some of them have experienced or witnessed medical errors that led to an extremely serious or tragic outcome. They are committed to improving unsafe conditions in hospitals. In February 2019, Hospital Watchdog conducted an in-depth interview with Ms. Dena Royal, a former paramedic, and respiratory therapist. Dena’s mother, Martha Wright, bled to death following a colonoscopy and a series of tragic nursing mistakes at Cass Regional Medical Center in Harrisonville Missouri. Dena’s vigilance and persistence as a whistleblower led to an investigation by The Centres for Medicare and Medicaid Services (CMS). Based on interviews and a review of hospital records, CMS found specific events contributing to her mother’s death and issued findings in a Summary Statement of Deficiencies. Among the key problems, Martha had not been thoroughly assessed when changes in her condition occurred. In one instance, at 10:15pm, (14 hours after the procedure), the Registered Nurse failed to perform a thorough assessment, that included vital signs and notifying the doctor. The CMS report also showed how after Martha’s death the hospital tried to cover up what happened.

A blog from Dr Linda Dykes. "Bryn was my patient. He died. He may have stood a better chance of survival had I been aware of the risk of small bowel volvulus in an adult.  I produced this reflective learning resource with some colleagues - and with Bryn's widow, whom we call Fiona.  Please read it... it may help you save a life one day."

Surgical conditions are common in older patient and often require major surgery on frail patients. Strong understanding of the risks for different patients is crucial for decision-making and establishing goals of care. This study in the American Journal of Surgery aimed to find out which clinical factors increase the risk of older patients dying within 30 days of a colectomy or small bowel resection. The results showed that the highest predictors of mortality were American Society of Anesthesiologists (ASA) status 5, septic shock and dialysis. Without risk factors, mortality rates were 11.9% after colectomy and 10.2% after small bowel resection. Patients with all three risk factors had a mortality rate of 79.4% following colectomy and 100% following small bowel resection.

This study examines the prevalence of advanced care planning (ACP) for patients undergoing endoscopic, fluoroscopic, laparoscopic or open surgical gastrostomy tube procedures at an academic hospital in the USA. The authors found that only 10.6% of included patients had accessible ACP documents available within their electronic medical record (EMR) and that Black patients had lower rates of ACP documentation. They also highlight an association between ACP documentation and decreased hospital length of stay, with no difference in mortality. The authors recommend the expansion of ACP in perioperative settings.

Based on data from 22,132 patients who had emergency bowel surgery in England and Wales between December 2020 and November 2021, this report from the National Emergency Laparotomy Audit (NELA) found that improvements in in-hospital mortality have levelled off. As such, it calls for hospitals to continue to engage with NELA data collection and, in particular, to make use of real-time data and resources available to drive clinical and service quality improvement. Key findingsPatients experienced long delays from time of arrival at hospital to time of surgery, including those with sepsis suspected at arrival in hospital (median 15.6 hours to theatre)Many patients (77.7%) with suspected sepsis on arrival did not receive antibiotics within an hour of arrival in hospitalOne in five high-risk patients did not receive postoperative care in a critical care unit.Frailty doubled the risk of mortality of patients aged 65 and over (13.0% vs 5.9%), but review by a member of the elderly care team was associated with a significant reduction in mortality (5.9% vs 9.5% amongst non-frail patients, and 13.0% vs 22.3% amongst frail patients). However, this is not routine practice in many hospitals.

This report from the National Oesophago-Gastric Cancer Audit (NOGCA) focuses on the care received by patients diagnosed with invasive epithelial cancer of the oesophagus, gastro-oesophageal junction (GOJ) or stomach, or high-grade dysplasia (HGD) of the oesophagus between April 2019 and March 2021. For outcomes of curative surgery among people with OG cancer, data are reported for a three year period (April 2018 to March 2021). The report contains a number of findings related to: patterns of care at diagnosis staging and treatment planning waiting times along the care pathway curative surgery non-curative treatments. It also includes findings relating to the impact of the Covid-19 pandemic, including: In April 2020, the number of patients diagnosed with OG cancer was 43.6% of the 2019/20 monthly average, falling from 837 to 365 cases per month. The numbers diagnosed soon returned to normal levels, and in the period from June 2020 to March 2021, the number of monthly cases was 97.8% of 2019/20 levels. The percentage of patients diagnosed with stage 4 disease (advanced cancer) increased from 41.6% in 2019/20 to 44.9% in 2020/21. The report also contains recommendations for healthcare professionals, among which is including a call to review patients diagnosed after emergency admission and undertake root cause analysis to identify opportunities to reduce rates of emergency diagnosis.

Alexander James Davidson was aged 17 years and 6 months when he died at the Queens Medical Centre on 26 February 2018. Alex was previously fit and well before suddenly taking ill with abdominal pain on 17 January 2018. Between that date and his admission to the Queens Medical Centre on 8 February 2018, Alex made contact with his GP on three occasions, had four telephone triage assessments undertaken by the NHS 111 service and two admissions to his local Accident & Emergency Department at the Kingsmill Hospital. Alex’s symptoms of sudden onset acute abdominal pain, tachycardia, and vomiting and diarrhoea were attributed either to stress or to a bout of gastroenteritis. At no stage prior to 8 February 2018 was gallstones or pancreatitis considered as a differential diagnosis. When Alex was eventually admitted to the Queens Medical Centre Emergency Department on 8 February 2018, he was found to be septic as a result of an infected and necrotic pancreatic pseudocyst, which had evolved as a complication of gallstone pancreatitis, a rare condition in someone of Alex’s age. Despite medical intervention, Alex did not survive. The inquest explored the medical treatment and intervention that Alex received in the six weeks prior to his death. The medical evidence concluded that the pancreatic pseudocyst had likely formed by the time Alex began vomiting on 18 January 2018, and from that point onwards, it was unlikely he would survive even with treatment on account of the high mortality rate associated with this condition Coroner's concerns The NHS 111 telephone triage service uses the NHS Pathways computer system to triage patients via pre-determined question/answer based algorithms. The pre-determined questions are the same whether the caller is an adult or a child. Alex struggled to comprehend some of the medical terminology used during these calls. Call handlers are not permitted to deviate from the prescribed wording of the pre-determined questions, and this created confusion and inconsistency in the patient’s answers. Consideration should be given as to how young and/or vulnerable patients can be assisted to provide accurate information about their symptoms. The NHS Pathways algorithm for triaging vomiting and diarrhoea symptoms is unclear as patients may fail to understand what is meant by ‘soil’ or ‘coffee ground’ vomit. Consideration should be given to how this important diagnostic feature can be explored during telephone triage, especially when the patient is young and/or vulnerable. The NHS 111 telephone triage service provides an electronic copy of the patient triage notes to the patient’s GP within minutes of the call ending. There was a delay of 7 days in the GP surgery uploading the 111 triage document to Alex’s patient record. This prevented Alex’s GP from reviewing the triage note prior to his consultation with the patient. There is no guidance as to expected practise with regards to the timely updating of electronic patient records, and as a result delays are all too frequent. Adults presenting to their GP or Emergency Department with abdominal symptoms receive a lipase and/or amylase blood test as part of the standard package of blood testing. The levels of each of these enzymes can be used to diagnose pancreatitis. Patients under the age of 18 years are not offered this testing as standard, on the basis that pancreatitis is rare in paediatric patients. The coroner heard anecdotal evidence of some doctors at Kingsmill Hospital now add this test to the standard admission bloods for older teenage patients who present with non-specific abdominal symptoms but the NICE guidance (September 2018) is not explicit in this regard. Consideration ought to be given to a national approach for lipase/amylase testing in young people with relevant symptoms. Patients who make an unscheduled return to the Emergency Department within 72 hours of discharge are required to have a review undertaken by an ED Consultant, or a ST4 trainee or above in the absence of a Consultant on the ‘shop floor’: RCEM Guidance June 2016. Some hospitals will admit returning paediatric patients for observations but practise seems to vary doctor-to-doctor and across Trusts. Consideration ought to be given to a national approach.