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BAPEN recognises that resources will be limited and often patchy depending on availability of appropriately trained staff – doctors, nurses, dietitians and pharmacists. The demands posed by large numbers of COVID -19 patients with pneumonia, especially on CPAP or ventilators in critical care and intensive care settings will test the capacity of all involved. It follows that special care still needs to be taken to ensure nutritional support is given where indicated whilst avoiding complications associated with tube misplacement in the lungs or oesophagus followed by infusion of nutrients, drugs or water – so called “Never Events”. BAPEN has provided the following advice: An overview of opinions on nasogastric tubes as aerosol generating procedures during the Covid-19 crisis COVID-19 & enteral tube feeding safety

The study used quality improvement methods to develop and test interventions to extend drinking opportunities and choice in two care homes. Initial activity included observation of the systems for delivering fluids and involving staff, residents and carers in describing and mapping the organisation of care. An interactive training programme was indicated by staff as an important priority and was therefore introduced as a first step to improve hydration care. Subsequent interventions were co-designed with care staff and tested using Plan Do Study Act (PDSA) cycles. Their efficacy was measured through data captured on the amount of fluids served and consumed, and staff and resident feedback. The long-term impact of the interventions was assessed by measuring daily laxative and antibiotic consumption, weekly incidence of adverse health events, and average fluid intake of a random sample of six residents captured monthly. The link below shows the I-Hydrate presentation which summarises the project and its findings.

The investigation found a significant number of failures in the care and treatment of the patient overall and in the following areas: Nutrition and Feeding the patient – contrary to guidance which highlights the importance of high quality nutritional care based on individual assessment of needs with appropriate planning and monitoring, this investigation found the following failings: The feeding of porridge contrary to Speech and Language Therapy advice on 3 and 4 December 2016 and offering other foods contrary to advice. The recording who fed the patient porridge. The identification that the recommended diet was not provided and the taking of appropriate action. The recording of foodstuffs in a consistent manner. The reporting and recording of adverse incidents in relation to the feeding of porridge on 3 and 4 December 2016. Communication & Reasonable Adjustments – safe, person centred care is underpinned by effective communication. When caring for a patient with a learning disability communication must be timely and sensitive to the needs of the person and involve the family when appropriate. This is particularly essential in relation to pain management and when a patient is non-verbal. This investigation found the following significant failures: Failure to use any kind of pain tool to assess and record the patient’s possible pain or distress. This issue is of particular importance as the patient was unable to verbalise his pain levels. Failure to ensure the care of the patient was consistently tailored for a person with dementia and learning disabilities in accordance with GAIN Guidelines. The investigation also established further failings in relation to: A failure to ensure there was a coordinated approach between the Palliative Care and Care of the Elderly teams. A lack of coordinated communication between the family, Palliative Care and Care of the Elderly teams. The over prescribing of paracetamol to the patient on Ward 3 South due to the inaccurate estimation of the patient’s weight. The investigation established maladministration in relation to: The failure of the Trust to show regard for the patient’s human rights by failing to appropriately support or record the assessment of the patient's possible pain or distress; and to ensure the care of the patient was not consistently tailored for a person with dementia and earning disabilities. The failure to report overprescribing of paracetamol in line with the Trust’s ‘Adverse Incident Reporting and Management Policy’, April 2014 and Guidelines for the administration of intravenous (IV) Paracetamol’, December 2014. The failure to inform the complainant and her family of the overprescribing of paracetamol in line with the Trust’s ‘Being Open Policy’, February 2015 and it’s ‘Guidelines for the administration of intravenous (IV) Paracetamol’, December 2014. The failure to inform the complainant and her family of the overprescribing of paracetamol in line with the Trust’s ‘Being Open Policy’, February 2015. The poor management of complaints has been highlighted in many of the reports and inquiries that have examined the care of people with a learning disability in hospitals. Opportunities were missed in this complaints handling process to provide the family with empathetic and timely responses which may have helped resolve their concerns locally and prevented them having to use time and energy in approaching the Public Services Ombudsman. The investigation established failings in the Trust’s handling of the complaint namely: The failure to meet with the family prior to completing any investigation. The failure to share minutes of the meeting, held on 21 September 2018, with the complainant for comment. The delay in issuing minutes of the meeting, held on 21 September 2018, to the complainant. The delay in providing a final response to the complainant. The failure to provide regular and informative updates to the complainant. The failure to ensure coordination between the complaints team and the service area. The failure to recognise the sensitivities around arranging a venue for the meeting with the complainant on 21 September 2018. The investigation did not establish failings in the patient’s care and treatment in relation to: The decision to carry out the procedure of oral suctioning on the patient on the night before he died. The vitamin drip being administered after the patient was deemed End of Life on 6 December 2016. The reducing pain relief without consen. The anaesthetics care of the patient on 10 November 2016. The investigation was unable to make a determination as to whether the vitamin drip was administered prior to the administration of paracetamol on 9 December 2016

In his report, the Coroner lists the following matters of concern: Using a misplaced nasogastric tube is recognised as a 'never event', namely an event which is wholly preventable and should never happen. The court heard evidence at the inquest that an NHS improvement patient safety alert issued in 2016 identified that between 2011-2016 there had been 95 incidents of misplaced nasogastric tubes used to administer fluids or medication, 32 of which resulted in death. The court heard that Barts NHS Trust had at least seven incidents relating to misplaced nasogastric tube since 2012. The court heard that the use of misplaced nasogastric tubes to administer liquids or medications continues to take place in Trusts across the country. The court heard that there is no unified approach to address the ongoing issue of avoidable deaths caused by using misplaced nasogastric tubes. This report was sent to the Secretary of State for Health and Social Care, NHS England and Barts Health NHS Trust. Misplaced nasogastric tubes The life-threatening risk posed by the accidental misplacement of tubes that deliver food or medication to critically ill patients is a known patient safety issue. This was identified as a serious patient safety concern in the UK by the National Patient Safety Agency in 2005, by a formal Patient Safety Alert in 2011 and a further Patient Safety Alert in 2016. The Healthcare Safety Investigation Branch issued a report on the placement of nasogastric tubes in December 2020, making a number of safety recommendations in relation to this for NHS England, NHS Supply Chain, Health Education England and the British Society of Gastrointestinal and Abdominal Radiologists. Frequency of this ‘Never Event’ This patient safety incident is formally classified by NHS England as a ‘Never Event’. This is a type of serious incident that is viewed as wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers. NHS England routinely publishes data on the occurrence of Never Events. These figures highlight the annual frequency of the Never Event ‘Misplaced naso- or orogastric tubes and feed administered’ in England: 2020/21 - 34* 2019/20 - 25 2018/19 - 29* 2017/18 - 22 2016/17 - 26 *When accessed on the 10 March 2022 these figures were marked as provisional rather than final data. Related reading Healthcare Safety Investigation Branch, Placement of nasogastric tubes, December 2020 Tracy Earley, Improving safety with nasogastric tubes: a whole-system approach, 25 November 2019

Key points Smoking, poor diet, physical inactivity and harmful alcohol use are leading risk factors driving the UK’s high burden of preventable ill health and premature mortality. All are socioeconomically patterned and contribute significantly to widening health inequalities. This report summarises recent trends for each of these risk factors and reviews national-level policies for England introduced or proposed by the UK government in England between 2016 and 2021 to address them. Based on our review, it assesses the government’s recent policy position and point towards policy priorities for the future. Population-level interventions that impact everyone and rely on non-conscious processes are most likely to be both effective and equitable in tackling major risk factors for ill health. Yet recent government policies implemented in England have largely focused on providing information and services designed to change individual behaviour. As well as relying heavily on policies that promote individual behaviour change, the strength of the government’s approach has been uneven for the leading risk factors, and decision making across departments has been disjointed. Action to tackle harmful alcohol use in England has been particularly weak. To reduce exposure to risk factors and tackle inequalities, government will need to deploy multiple policy approaches that address the complex system of influences shaping people’s behaviour. Population-level interventions that are less reliant on individual agency and aim to alter the environments in which people live should form the backbone of strategies to address smoking, alcohol use, poor diet and physical inactivity. These interventions need to be implemented alongside individual-level policies supporting those most in need. The strong role played by corporations in shaping environments and influencing individual behaviour must also be recognised and addressed in a consistent way through government policy. The costs of government inaction on the leading risk factors driving ill health are clear. As the country recovers from the COVID-19 pandemic and seeks to build greater resilience against future shocks, now is the time to act.

Martin has managed over the course of his blogs to open our eyes to the world of Human Factors (HF) and, in particular, the area of HF within the medical world. What hasn’t been touched on yet is the topic of fatigue. Why am I mentioning this dreaded word, you ask. Well, unfortunately it impacts all of us. In fact, I would be prepared to bet a lot of money that we have all experienced fatigue at some point. And I will point out that I am not a gambling person, so hopefully that indicates to you how certain I am, but also unfortunately points out the prevalence. Right now we’re all under a great deal of strain; we hear the media talking about stress and mental health and workload. Some people are having flashbacks to the war with references to ‘doing our bit’. In fact, my 94 year old grandfather is adamant that I have it worse right now living through this time than he did living and serving through the war period. In our conversations I have disagreed with him, but upon reflection I can see his point. We live in an instant age, we’re not used to sitting and waiting. Working from home means that despite being remote from our colleagues, we are still accessible. That work pressure still exists and, arguably, it is greater than ever. We are separated from our colleagues, our friends and our families. Of course not all of us are working from home. There are those of us who are still attending the workplace. But again, this is no longer the same; our colleagues cannot come close to us, our words are slightly muffled, we realise how much we rely on lip movement to understand speech. We realise we are removed from others, we realise our workload has multiplied and we realise we are drowning. But, before our heads go under… This stress, this anxiety, this impact on our mental health – perhaps it has a cause we haven’t considered. Perhaps the cause is something we thought was a symptom. Perhaps we are fatigued. So, what is fatigue exactly? Let’s stop bandying this word around and actually get to grips with it. We can attempt to define it, look at some symptoms, some causes and hopefully you can learn some tips on how to deal with fatigue. I should give a disclaimer here – I am not a fatigue expert and it would be arrogant for me to state that. However, I do work within the field of Human Factors. I look at how we as humans interact with the world around us and how we can make that better and safer. I look at what impacts on our ability to do well and a consequence of fatigue is that our performance in our tasks declines. Suffice to say I have made it my business to learn. Fatigue, unfortunately, doesn’t have one single definition. But I’ll attempt to give it a go. Fatigue is a subjective feeling of extreme tiredness. It is likely to have a gradual onset and may come from mental or physical exertion or alternatively be caused by a medical condition (diagnosed or not). Our task performance and decision making abilities are negatively impacted. Concentration decreases and our mind is foggy. It is not the same as finishing an intense gym workout and wanting to lie down. You may not realise you are fatigued as we are very good at ignoring our bodies trying to tell us something is wrong. Across the western world, high levels of fatigue are significantly associated with excessive mortality rates and it is increasingly being recognised as strongly associated with poor long-term quality of life and negatively impacting on our work ability. Essentially, it is being recognised as a problem in more than one aspect of our lives. How do I know if I’m fatigued? Well that is a good question and, as we’ve said, fatigue is a subjective feeling. The warning signs I experience can be different to those experienced by somebody else or the degree to which I experience symptoms could be different. Some key signs are frequent blinking, struggling to keep your eyes open, tiredness that doesn’t improve after sleep, constant headaches, blurred vision, being prone to irritability, slower reflexes and thinking, micro-sleeps, impaired decision making and muscles feeling achy and/or weak. There are some signs where it is important to see your doctor. Lifestyle or work demands are often the cause of fatigue, but where fatigue could be connected to a medical issue it is always worthwhile seeking professional advice. These are generally symptoms such as vomiting, shaking or shortness of breath, but depression is also commonly linked to fatigue. If I’ve noticed the signs can I work out what caused it? As mentioned above, fatigue can be linked with medical conditions. Obesity, insomnia, depression, anaemia, low general health can all be causes of – and conversely symptoms of – fatigue. Some medications can also list fatigue as a side effect. Our age and lifestyle also impact the likelihood of fatigue. Younger members of the population are more likely to experience non-medical fatigue, and drug and alcohol use increases the risk across all age groups. Our need to juggle the multiple daily responsibilities – bills, kids, pets, commuting, laundry, food prep, etc – also causes fatigue. This is important to remember because it is so easy to judge ourselves for struggling to do all of this and to decide to get up early and get tasks done, forfeiting sleep and rest. We don’t necessarily realise that this creates a vicious cycle where we find it harder to cope and take longer to finish tasks because we are fatigued so we deprive ourselves of rest in order to get things done ad infinitum. Of course work factors do also positively correlate with the likelihood of fatigue, particularly if you are a shift worker or your role involves long driving hours, e.g., train/bus/HGV driver/pilot. You can imagine that this is due to the stressful demands of the role, which is absolutely correct. But interestingly, when we are experiencing underload we can also experience fatigue because our brains essentially ‘switch off’, e.g., driving on a long, straight, empty stretch of road. Well it’s all good knowing I’m fatigued, but what can I do about it? Let’s talk coping mechanisms – when we start to flag we often use coping mechanisms to keep going. Sugary foods and drink and caffeine are some of the things we automatically reach for. We see our favourite TV characters grab an energy drink or a coffee to keep them going as they study for exams/cover another shift/track down the bad guy, ad nauseam. Unfortunately these coping mechanisms only give us a short burst before we feel just as fatigued as we did before, if not worse – in fact, how often do we see the above characters crash at the end of the episode after they’ve relied on coffee!? This doesn’t mean you can’t have a coffee, etc, it’s rather just a flag to remind ourselves that it doesn’t solve the problem and we need to think about our behaviours. If we have a coffee too late in the day, we could then struggle to fall asleep afterwards. However, if we use the coffee as a break earlier on in the day it not only acts as a stimulant, but the act of consciously taking a break from our task to get the coffee can be beneficial. Similarly, getting some fresh air benefits us by stepping away from our task and going outside – a mental and physical break. However, what we should really be doing is trying to prevent ourselves from reaching the point of fatigue so we’re not reliant on stimulants or coping mechanisms. Having a routine is important. This is something we provide for our children and instil in them for years and seem to promptly forget once we reach adulthood. Going to bed and getting up at the same time each day creates a ‘defence’ against fatigue because our bodies have an expectation of what is required. This is of course assuming we have allowed sufficient time to sleep – this differs for everyone, but I am firmly in the ‘needing 8 hours sleep’ camp. Usually, getting between 7 and 9 hours sleep is recommended. Including regular exercise into our daily lives is equally as important. This helps to keep our bodies healthy and helps with attaining quality sleep. Diet should also be mentioned. The types of food we eat doesn’t just impact our general health, but it impacts on our ability to rest and sleep as well as feeding our brains. If we don’t eat enough nutritious food we can struggle to concentrate and eating large or heavy meals before bed can negatively impact our sleep. Unfortunately, there’s nothing we can really do to prevent fatigue entirely. There’ll always be a time when we experience it to some extent, but knowing what tends to trigger your fatigue will definitely help you to avoid it to the most part. Are you still awake? At this point I think I should ask the question "Are you still awake?" You may have noticed that there can be something quite soporific about the topic of fatigue – and yes I have yawned during the writing of this – although I think this would take many further blogs to attempt to delve into the psychological implications here. There should be no expectation for us all to become experts of our own fatigue and the causes and preventions. But we need to allow ourselves to acknowledge that we’re struggling and attempt some introspection as to the cause. Because remember, our fatigue could be related to our lifestyle or it could be related to a medical issue. Realistically, we probably do notice our fatigue and combat it successfully, but this is likely often on a subconscious level as just a part of our everyday lives. Hopefully the above insights can help you manage fatigue effectively day-to-day. Read the other blogs in this series Why investigate? Part 1 Why investigate? Part 2: Where do facts come from (mummy)? Who should investigate? Part 3 Human factors – the scientific study of man in her built environment. Part 4 When to investigate? Part 5. How or Why. Part 6 Why investigate? Part 7 – The questions and answers Why investigate? Part 8 – Why an ‘It’s an error trap conclusion’ is an error trap Why investigate? Part 9 – Making wrong decisions when we think they are the right decisions Why investigate? Part 11: We have a situation Why investigate? Part 12: Ethics in research