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Showing results for tags 'Patient harmed'.
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News Article
'My baby died after I was ignored' - families call for NHS maternity inquiry
Patient Safety Learning posted a news article in News
When Tassie Weaver went into labour at full term, she thought she was hours away from holding her first child. But by the time she was giving birth, she knew her son had died. Doctors had previously told Tassie to call her local maternity unit immediately, she says, as she was considered high risk and needed monitoring, due to high blood pressure and concerns about the baby's growth. But a midwife told her to stay at home. Three hours later she called again, worried because now she couldn't feel her baby moving. Again, she was told to stay at home, the same midwife saying that this was normal because women can be too distracted by their contractions to feel anything else. "I was treated as just a kind of hysterical woman in pain who doesn't know what's going on because it's their first pregnancy," the 39-year-old tells us. When she called a third time, a different midwife told her to come to hospital, but when she arrived it was too late. His heart had stopped beating. Tassie and her husband John believe Baxter's stillbirth at the Leeds General Infirmary (LGI), four years ago, could have been prevented - and a review by the trust identified care issues "likely to have made a difference to the outcome". The couple are among 47 new families who have contacted the BBC with concerns about inadequate maternity care at Leeds Teaching Hospitals (LTH) NHS Trust between 2017 and 2024. As well as the new families, three new whistleblowers - two who still work for the trust - have shared concerns about the standard of care at its two maternity units - at the LGI and St James' University Hospital. This is in addition to the two we spoke to in the initial BBC investigation. Read full story Source: BBC News, 17 June 2025- Posted
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News Article
Millions in compensation could be owed to women with mesh implants
Patient Safety Learning posted a news article in News
Mesh implants returned to the national spotlight as Sling the Mesh campaigners appeared on Good Morning Britain to highlight the devastating impact of surgical mesh procedures—and the urgent need for compensation and systemic reform. Campaign founder Kath Sansom was joined by Sharron Mahoney – who suffered severe autoimmune complications and chronic pain following rectopexy mesh surgery. Remarkably, Sharron’s symptoms began to clear within days of mesh removal -powerfully underscoring the direct link between these devices and the serious harm they can cause. Sharron’s story highlights the critical work of researchers such as Nicholas Farr from Sheffield University who recently published this study showing the plastic particles of surgical mesh can trigger autoimmune diseases – even after removal. Watch interview- Posted
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A year after the Infected Blood Inquiry’s final report, serious transfusion risks persist. Trusts must act now to improve safety, reduce waste, and address inequality, warns Cheng Hock Toh in this HSJ article. In May 2024, the UK Infected Blood Inquiry (IBI) published its final report into the devastating failures that led to approximately 30,000 people in the UK being infected with HIV or hepatitis C through transfused blood and blood products. This tragedy has so far claimed more than 3,000 lives. One year on, the UK government has formally accepted all 12 of the report’s recommendations, either in full or in principle. Although rigorous testing has made blood itself safer, serious risks around transfusion practice remain. The government rightly acknowledges that more must be done to prevent future harm. There are already troubling signs, and trusts and commissioners must act urgently to assess and improve the quality, safety, and equity of blood transfusion care across the system.- Posted
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- Blood / blood products
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News Article
A new study has revealed that families of some cancer patients are being denied the opportunity to learn about their potential cancer risk due to inconsistencies in genetic testing. Academics have warned that the absence of adequate testing for Lynch syndrome is leaving some cancer patients unaware of their risk of developing other cancers. Lynch syndrome, a rare hereditary condition, elevates the risk of cancers of the bowel, womb, and ovaries. It arises from a gene mutation affecting DNA error correction during replication, potentially leading to uncontrolled cell growth. NHS guidelines stipulate that patients with bowel or womb cancer should undergo tumour assessments for Lynch syndrome markers. The identification of these markers should prompt a referral for genetic testing, confirming the diagnosis and enabling access to support and guidance regarding cancer risks for both the patients and their families. However, a new study by academics at the University of Edinburgh found not all womb cancer patients are being sent for genetic testing. Researchers said those who were referred faced long waits, resulting in high dropout rates, meaning only 48 per cent of those eligible went on to get the test. Experts from the university said gaps in testing mean some womb cancer patients with Lynch syndrome go undetected. Read full story Source: The Independent, 10 June 2025 -
News Article
Thousands harmed and 87 dead after NHS equipment failures in England
Patient Safety Learning posted a news article in News
Almost 100 people have died and 4,000 have been harmed after equipment malfunctions in the NHS in the past three years, prompting calls for more government funding to upgrade broken and obsolete medical devices. A defibrillator advising paramedics not to administer a shock, an emergency alarm system on a neonatal ward failing, and the camera on an intubation device going dark were just three failures after which patients died. They are included in figures released for the first time by NHS England that show patients were harmed after 3,915 equipment malfunction incidents – with 87 being followed by a death – since 2022. Paul Whiteing, the chief executive of Action against Medical Accidents, said: “These are shocking statistics. Behind these numbers are real people who are needlessly harmed, the impact of which will be life-changing and traumatic. “The scale of the harm and loss of life that has resulted from basic equipment failures and malfunctions shows in stark relief the scale of the tragedy that has resulted from years of underfunding in the NHS.” The vast majority of incidents, which were logged by doctors and nurses when a device was broken, not fit for use or didn’t perform as expected, caused a low level of harm. That meant patients were unlikely to need further treatment beyond dressing changes or short courses of oral medicine. There were 522 moderate harm incidents, in which a patient’s independence could be limited for up to six months. Meanwhile, on top of the 87 deaths, 68 patients were severely harmed – meaning they could have received permanent damage from the incident, or had a reduced life expectancy. Read full story Source: The Guardian, 9 June 2025- Posted
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News Article
Vaginal mesh particles ‘could trigger autoimmune response even after removal’
Patient Safety Learning posted a news article in News
Microscopic particles left behind by vaginal mesh could continue to trigger the immune system to attack healthy tissue even after the material has been removed, according to researchers. Experts suggest allergy testing patients before they are fitted with mesh may help to better understand why complications happen in some cases. Campaign group Sling the Mesh said the majority of its members have developed a reaction they believe is down to the material, including autoimmune diseases, unexplained rashes and chronic fatigue. Transvaginal mesh (TVM) implants are made from synthetic materials such as polypropylene, a type of thermoplastic, and have been used to treat pelvic organ prolapse and incontinence after childbirth. However, they can cause serious harm to some women, with side effects including infection, pelvic pain, and incontinence. The NHS restricted its use of TVM implants in 2018 and they are now used only as a last resort through a high-vigilance programme of restricted practice. A new article led by Dr Nicholas Farr, published in the journal Nature Reviews Urology, analysed studies which suggest polypropylene is a material which causes autoimmune/inflammatory syndrome induced by adjuvants (Asia). Asia arises following exposure to substances that enhance the immune response in the likes of vaccines, silicone implants, or other foreign materials. Symptoms can vary widely, but include chronic fatigue and chronic pain. Read full story Source: The Independent, 6 June 2025 Related reading on the hub: Read a blog Dr Nicholas Farr wrote for the hub on medical device safety- Posted
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Content Article
Evidence of polypropylene mesh degradation has revealed particle accumulation in surrounding tissues, raising concerns about potential local and systemic immune responses. Associations between polypropylene degradation and autoimmune/autoinflammatory syndrome induced by adjuvants-like symptoms have been made, and vigilant clinical assessment is important, especially in patients with a predisposition for allergy or autoimmune diseases. Related reading on the hub: Read a blog author Dr Nicholas Farr wrote for the hub on medical device safety- Posted
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News Article
I had to beg doctors for help, sepsis patient says
Patient Safety Learning posted a news article in News
A man said he was left "begging for help" from doctors after he suffered life-changing injuries due to sepsis caused by failures at his local hospitals. Paul Robinson, 70, developed recurring sepsis for almost a year after being hospitalised on multiple occasions in Brighton and Worthing. The company director from Goring, in West Sussex, said: "I've lost my freedom, confidence, business, very nearly my family home, and almost my will to live." Mr Robinson was diagnosed with cancer in 2018. He successfully had a lump removed from his lung. But during chemotherapy, he became unwell and was diagnosed with sepsis. He said he went through several relapses with sepsis and was in hospital for 13 days. "I was left for 11 months with recurring, untreated sepsis – despite begging for help," he said. Describing his care at Worthing Hospital and Royal Sussex County Hospital in Brighton, he said there was a breakdown in communication between nurses, doctors and departments. He said there had been "systemic failures" and "ignored warnings" with his care. "We asked for help 47 times, and we were ignored 47 times," he added. "Every day I see NHS campaigns about spotting the signs of sepsis. We knew the signs, we pleaded for help, and nobody listened." Read full story Source: BBC News, 5 June 2025- Posted
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Content Article
On the 28 March 2025, the Trump administration notified Congress that it planned to shut down USAID (United States Agency for International Development) by 1 July 2025. The State Department would assume responsibility for “certain USAID functions” that align with the administration’s priorities and discontinue the rest. Two weeks earlier, in a post on X, Secretary of State Marco Rubio said that the programmes being cut (including efforts to address emerging infectious diseases, famines, natural disasters, maternal and child mortality, HIV, and tuberculosis) “spent tens of billions of dollars in ways that did not serve, (and in some cases even harmed), the core national interests of the United States.” To date, however, neither Rubio nor the State Department has elaborated on how these cuts and the reduction of USAID’s staff (from about 10 000 employees to 15) will affect the health of people around the world—or in the US itself. Initial reports on the direct effects of the cuts have come from different sources. A leaked USAID document projected that if programmes were permanently halted, the world would see an additional 12.5 million to 17.9 million malaria cases and 71 000 to 166 000 additional malaria deaths annually. If US foreign aid is not restored before the end of 2025, it is estimated that at least 62 000 additional people would die of tuberculosis. Enormous harms to children are also expected because USAID spending has played a pivotal role cutting child mortality rates in half since 2000.- Posted
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News Article
People with cancer face ‘ticking timebomb’ due to NHS staff shortages
Patient Safety Learning posted a news article in News
People with cancer face a “ticking timebomb” of delays in getting diagnosed and treated because the NHS is too short-staffed to provide prompt care, senior doctors have warned. An NHS-wide shortage of radiologists and oncologists means patients are enduring long waits to have surgery, chemotherapy or radiotherapy and have a consultant review their care. Hold-ups lead to some people’s cancer spreading, which can reduce the chances of their treatment working and increase the risk of death, the Royal College of Radiologists (RCR) said. NHS cancer services are struggling to keep up with rising demand for tests, such as scans and X-rays, and treatment, created by the growing number of people getting the disease. All radiology bosses surveyed said during 2024 their units could not scan all patients within the NHS’s maximum waiting times because they did not have enough staff. “Delays in cancer diagnosis and treatment will inevitably mean that for some patients their cancer will progress while they wait, making successful treatment more difficult and risking their survival,” said Dr Katharine Halliday, the RCR’s president. The findings are particularly worrying because research has found that a patient’s risk of death can increase by about 10% for each month they have to wait for treatment. Nine out of 10 cancer centre chiefs said patients were delayed starting their treatment last year while seven in 10 said they feared workforce gaps were putting patients’ safety at risk. Read full story Source: The Guardian, 5 June 2025- Posted
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News Article
"We've got two," explains Emer Szczygiel, emergency department head of nursing at King George Hospital, as she walks inside a pastel coloured room. On one wall, there's floral wallpaper. It is scored through with a graffiti scrawl. The words must have been scratched out with fingernails. There are no other implements in here. Patients being held in this secure room would have been searched to make sure they are not carrying anything they can use to harm themselves - or others. "So this is one of two rooms that when we were undergoing our works, we recognised, about three years ago, mental health was causing us more of an issue, so we've had two rooms purpose built," Emer says. "They're as compliant as we can get them with a mental health room - they're ligature light, as opposed to ligature free. They're under 24-hour CCTV surveillance." There are two doors, both heavily reinforced. One can be used by staff to make an emergency escape if they are under any threat. What is unusual about these rooms is that they are built right inside a busy accident and emergency department. The doors are just feet away from a nurse's station, where medical staff are trying to deal with acute ED (emergency department) attendances. On a fairly quiet Wednesday morning, the ED team is already managing five mental health patients. One, a diminutive South Asian woman, is screaming hysterically. She is clearly very agitated and becoming more distressed by the minute. Despite her size, she is surrounded by at least five security guards. She has been here for 12 hours and wants to leave, but can't as she's being held under the Mental Capacity Act. Her frustration boils over as she pushes against the chests of the security guards who encircle her. "We see about 150 to 200 patients a day through this emergency department, but we're getting on average about 15 to 20 mental health presentations to the department," Emer explains. "Some of these patients can be really difficult to manage and really complex." "If a patient's in crisis and wants to harm themselves, there's lots of things in this area that you can harm yourself with," the nurse adds. "It's trying to balance that risk and make sure every emergency department in the country is deemed a place of safety. But there is a lot of risk that comes with emergency departments, because they're not purposeful for mental health patients." Read full story Source: Sky News, 4 June 2025- Posted
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- Mental health
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Content Article
The Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest patient safety data repository of its kind in the United States and one of the largest globally, housing over 5 million reports submitted since 2004. This article presents data from reports submitted to PA-PSRS in 2024. In 2024, 315,418 reports were submitted to PA-PSRS, marking a 9.5% increase from 2023. Reports of serious events rose by 7.3%, while high harm events increased by 1.1%. Of all reports, 96.0% came from hospitals, while 4.0% originated from nonhospital facilities (ambulatory surgical facilities (ASFs), birthing centres, and abortion facilities). The vast majority (96.0%) were incidents, while the remaining 4.0% were classified as serious events. Preliminary 2024 reporting rates show 32.2 reports per 1,000 patient days for hospitals and 11.4 reports per 1,000 surgical encounters for ASFs, with both rates increasing by 1.1 points from 2023 Error Related to Procedure/Treatment/Test (P/T/T) remained the most frequently reported event type overall, accounting for 33.4% of reports from all facilities combined and 47.6% from nonhospital facilities. Among serious events, Complication of P/T/T was the most common type, making up 57.7% of serious event reports from all facilities combined and 71.4% from nonhospital facilities.- Posted
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News Article
Warning over unlicensed weight-loss jabs after woman left in intensive care
Patient Safety Learning posted a news article in News
A woman was left fighting for her life after using a so-called “weight loss jab” sourced from a salon with police making three arrests. The woman suffered internal injuries earlier after using an injection earlier this month. She has since been discharged. Two other people also become unwell. North Yorkshire Police has launched an investigation into the supply of the injections as they arrested three women from the Selby area. Medical professionals in North Yorkshire and the Medicines and Healthcare Products Regulatory Agency (MHRA) issued a warning against using weight loss medicines bought from private clinics or online. They warned that buying products from unregulated suppliers “significantly increases the risk of getting a product which is either falsified or not licensed for use in the UK and can pose a direct danger to health”. NHS Humber and North Yorkshire Integrated Care Board (ICB) Chief Pharmacy Officer, Laura Angus, said: “There has been a lot of attention in the media and on social media about these so-called ‘skinny jabs’, but as with any medicines bought outside of legitimate supply chains, the contents may not match the ingredients on the label. “If you use such products you could be putting your health at serious risk. “If you are thinking of buying a weight-loss medicine, please talk to a healthcare professional first. The only way to guarantee you receive a genuine weight-loss medicine is to obtain it from a legitimate pharmacy – including those trading online – using a prescription issued by a healthcare professional.” Read full story Source: The Independent, 25 May 2025- Posted
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News Article
Plans for NHS staff to restrain and detain people experiencing a mental health crisis, instead of the police doing so, are “dangerous”, doctors, nurses and psychiatrists have warned. The former prime minister Theresa May has proposed legislation in England and Wales that would change the long-established practice for dealing with people who may pose a risk to themselves or others because their mental health has deteriorated sharply. But a coalition of eight medical groups, ambulance bosses and social work leaders said the switch would put mental health staff at risk and damage their relationship with vulnerable patients. The row has echoes of the controversy stirred by the Metropolitan police’s decision in 2023 to stop responding to 999 calls involving mental ill health unless they involved a threat to life. The force said the change meant officers were attending crimes such as robberies faster, but mental health groups said they feared it could result in deaths. May and two ex-health ministers, Syed Kamall and Frederick Curzon, have tabled amendments to the mental health bill going through parliament which, if passed, would lead to mental health nurses, psychiatrists or other doctors being called out to restrain and detain someone under the Mental Health Act. Those professionals would each become an “authorised person” who is allowed to detain someone under the act. But in a joint statement on Monday the eight groups said the risks posed by someone in a mental health crisis meant police officers must continue to always attend. The groups include the Royal College of Psychiatrists, the Royal College of Nursing and the British Medical Association. The groups said: “Removing police involvement entirely has hugely dangerous implications, as entering someone’s home without permission is fraught with huge risks and is only currently done with the assistance of police intelligence. Without this, professionals may be entering homes without police help and therefore lacking crucial intelligence that could ensure their safety.” Read full story Source: The Guardian, 26 May 2025- Posted
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News Article
Boston Scientific Corp. will have to pay a total of $26.7 million in damages to four women in a court ruling related to its vaginal mesh product. Following a federal court trial in Miami, jurors found that the company’s Pinnacle pelvic floor replacement kit had a faulty design and the company failed to effectively warn patients and doctors about the possible risks associated with the device. Pelvic organ implants are used to treat female patients experiencing major discomfort due to pelvic organ prolapse. This was the first federal trial related to Pinnacle. Others lawsuits are pending. Pelvic organ prolapse occurs when a pelvic organ—such as the bladder—drops (prolapses) from its normal place and pushes against the walls of the vagina. This can happen when the muscles that hold pelvic organs in place are weakened or stretched from childbirth or surgery. Many women will have some kind of pelvic organ prolapse. It can be uncomfortable or painful, but isn’t usually a big health problem. It doesn’t always get worse. And in some women, it can get better with time. Boston Scientific officials told Reuters that they disagree with the verdict and have a strong case for post-trial motions and appeal. Marlborough, Mass.-based Boston Scientific is one of seven companies, including Johnson & Johnson’s Ethicon division and C.R. Bard, faced with lawsuits over similar mesh products. Officials with Endo International plc said in September it the company has set aside $1.6 billion to settle “substantially all” the cases against it and its American Medical Systems unit. Read full story Source: Medical Product Outsourcing- Posted
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Understaffing by nursing staff in hospitals is linked to patients coming to harm and dying unnecessarily. There is a vicious cycle whereby poor work conditions, including understaffing, can lead to nursing vacancies, which in turn leads to further understaffing. Is hospital investment in nursing staff, to eliminate understaffing on wards, cost-effective? This longitudinal observational study analysed data on 185 adult acute units in four hospital Trusts in England over a 5-year period. The study found that exposure to registered nurse understaffing is associated with increased hazard of death, increased chance of readmission and increased length of stay, while exposure to nursing support understaffing is associated with smaller increases in hazard of death and length of stay but reduced readmissions. Rectifying understaffing on inpatient wards is crucial to reduce length of stay, readmissions and deaths. According to the National Institute for Health and Care Excellence £10 000 per QALY threshold, it is cost-effective to eliminate understaffing by nursing staff. This research points towards investing in registered nurses over nursing support staff and permanent over temporary workers. Targeting particular patient groups would benefit fewer patients and is less cost-effective.- Posted
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News Article
Two cyberattacks affecting the NHS last year put patients at risk of clinical harm, according to official data obtained by Recorded Future News. The data, recorded by the government under the Network and Information Systems (NIS) Regulations and obtained under the Freedom of Information Act, does not identify specific incidents but highlights the growing threat that financially motivated cyber incidents pose to public safety. It follows the head of the National Cyber Security Centre, Richard Horne, telling cybersecurity practitioners earlier this month that their work was “not just about protecting systems, it’s about protecting our people, our economy, our society, from harm.” One of the two incidents is likely to be the ransomware attack on pathology services provider Synnovis, which severely disrupted care at a large number of National Health Service (NHS) hospitals and care providers in London by delaying and cancelling operations and appointments. Criminals similarly disrupted care in an attack on Wirral University Teaching Hospital NHS Foundation Trust, causing delays to cancer treatments as reported by The Register. The government data records no incidents that led to excess fatalities or excess casualties, the two highest categories for NIS incidents. Two incidents, however, passed the threshold of the third category of causing potential clinical harm to more than 50 patients, with clinical harm defined as harm resulting from medical care or the lack of it. Patient safety concerns in England and Wales, potentially including concerns resulting from cyberattacks, are investigated by the Health Services Safety Investigations Body (HSSIB). HSSIB’s chief executive Dr Rosie Benneyworth told Recorded Future News that while the board hadn’t “carried out specific investigation work examining the impact of cyberattacks […] as expert independent investigators, we understand the impact of emerging risks, and we can see that there is potential with a cyber attack to make patient safety incidents more likely.” Read full story Source: The Record, 19 May 2025 -
Content Article
My experience of the 'Wait 45' policy
Anonymous posted an article in Florence in the Machine
The images on the left highlight the increased delays in ambulance responses and the potentially catastrophic consequences. Equally, the panic-inducing headlines of measures brought in to resolve the crisis. I work on the healthcare frontline and I’d like to share my experience of the 'Wait 45' policy in my trust and the impact it is having. Implementation of a new policy In December 2024, all ambulance trusts in England were told to implement a new policy, ‘Release to Respond’, also known as the ‘Wait 45’ policy, which means ambulances will only wait at Emergency Departments (ED) for 45 minutes before patients are left and the crews make their way to the next call. This was initiated following increasing waits for crews to handover patients to the ED. These waits were not inconsiderable periods of time, with many reports of crews spending their entire shift parked outside the ED with just one patient. This has resulted in some appalling headlines—for example, elderly people being left waiting for up to 15 hours for an ambulance to arrive and people having cardiac arrests where ambulances are not available to respond. Based on this, the adoption of the ’Release to Respond' policy makes sense. However, the introduction of this policy has been met with some scepticism and equally horrendous headlines about patients being dumped while crews run. The policy states that crews will not dump and run, and that handovers will be given, and patients will be placed on a chair, trolley or wheelchair in a dedicated space. But this policy is another example of not identifying the whole problem and bringing in a measure that only addresses the needs of one part of the healthcare system, while making it considerably worse for other parts! What is the point of an integrated care system (ICS) and board (ICB) if they do not look at an integrated intervention to address this situation? What is the reality of the ’Wait 45’ policy? The Wait 45 policy in my trust has completely changed the way the ED manages patients. Corridor care is a term used to describe the practice of providing medical attention to patients in hallways or other non-designated clinical areas due to overcrowding or resource shortages. It used to be that corridor care was for patients who had been seen, had a plan and who were either waiting to go home or for a bed on a ward. Now, in my trust, the corridor is for undifferentiated patients (patients who present with symptoms that have not yet been diagnosed or categorised) that come in directly from the ambulances. This has increased the risk to patients and staff. The corridor is used as soon as the department is full and then, only when the corridor is full to capacity, does the Wait 45 policy get initiated. At this point it is almost guaranteed that the corridor will need additional staffing from somewhere, while the first crew need to wait their 45 minutes—the hospital now has 45 minutes to find these additional staff otherwise the nurse: patient ratio increases in the corridor. The ratios of nurse to patients differs depending on the area of the hospital: in major treatment areas it is 1:4 but in the corridor it is 1:6; however, there is no upper limit of patients in the corridor and staff are often moved from other in-patient areas to work in the ED where they are invariably working in the corridor. These nurses will not have a ED background and will find it challenging and may miss the subtle signs that an experienced ED nurse may spot. There is often a lack of support for nurses in the corridor, leaving additional staff having to rely on their previous experience and judgement to guide them on what needs to be done. Handover criteria not being met Ambulance trust and the acute trust staff should at handover discuss the criteria for placing patients in a corridor—i.e., patients are supposed to be independent, able to move themselves to the toilet, be clinically stable and not have an infectious presentation However, in my experience this criteria is often not followed, as highlighted in the following examples I have seen and heard: Suspected neutropenic patients placed in the corridor. These patients have a low neutrophil count (a type of white blood cell) and are more vulnerable to infections. The concern for those on immunosuppressants seems to be non-existent now; there was a significant concern during the Covid-19 pandemic, but now being immunosuppressed is met with a tut, roll of the eyes and a shrug of the shoulders. It rarely features in handovers. Ambulance crews handing over patients that needed a hoist transfer at their nursing home; it is clearly not appropriate to care for these patients in a corridor where they should be mobile to use bedpans or commodes. Elderly patients who have fallen—either with significant trauma or with no apparent injuries—placed in the corridor. One patient had pain in their neck and received a trauma CT scan in the corridor—surely this patient should not have been in a corridor in the first place! Patients with diarrhoea and vomiting placed in the corridor, sometimes next to the neutropenic patients. Those with significant respiratory symptoms suggestive of influenza or Covid-19 placed in the corridor, despite the known risks to those that are in the corridor with them. I have even had a patient with a Glasgow Coma Scale of 10 (this is a tool that healthcare providers use to measure decreases in consciousness) handed over to the corridor… Wouldn’t resuscitation be a better location for them? Unintended consequences It is easy to understand why ‘Release to Respond’ policies are needed. With no external pressure, it appeared that many trusts lacked the willingness to investigate changes to reduce the overcrowding in the ED. However, while I recognise that the ambulance trusts need to have their staff available and not tied up at hospitals, this is making the ED unsafe. Another unintended consequence of these policies is that the working relationships between the ED nurses and the ambulance crews has deteriorated. I have noticed an increasing lack of willingness to help each other and incivility is growing. Asking simple questions results in dirty looks and aggressive questioning about ’who are you‘. The natural feeling is now one of defence, protecting each other against comments, pulling back into areas of comfort and knowledge. The standard replies are now ‘no’ and a feeling that this is not my problem or my fault. Unilateral measures that do not address the whole problem I cannot help but think implementing a unilateral solution like the ‘Release to Respond’ policy is based entirely on ‘work as imagined’ and benefits only one part of a highly complex area. It places additional burdens on already overstretched resources. The worst of which is that EDs are still seen as being made of elastic, with the ability to continually expand even when the evidence shows every hospital is beyond capacity every day of the year! When I first heard about ICSs and ICBs, I really hoped we would start to see a time of collaboration, working together to solve some of the issues within healthcare. Sadly, there does not yet seem to have been a change. In fact, it feels very much that we renamed but stayed the same. Probably, because all that has happened since the ICSs were introduced is restructuring after restructuring. They are not being allowed to work. Please, don’t get me wrong. I can see why these policies are in place. If I called an ambulance, I would like it to be available to respond and unfortunately currently they are not and have not been for a while. But I cannot help but think that until the ICS and regional NHS organisations take ownership of these problems, and all the stakeholders are represented at the table to analyse, design, implement and, most important of all, EVALUATE an intervention, we are condemned to keep implementing unilateral measures that do not address the whole problem. Further reading on the hub The crisis of corridor care in the NHS: patient safety concerns and incident reporting A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift A nurse's response to the NHSE guidance on their principles for providing safe and good quality care in temporary escalation spaces How corridor care in the NHS is affecting safety culture: A blog by Claire Cox Share your insights Do you have experience of corridor care either as a patient or a healthcare professional? What impact have you seen on patient safety? You can comment below (sign up here for free first) or email the editorial team at [email protected]- Posted
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News Article
A 15-year-old boy who was operated on twice by a now unlicensed Great Ormond Street surgeon says he is living with "continuous" pain. Finias Sandu has been told by an independent review the procedures he underwent on his legs were "unacceptable" and "inappropriate" for his age. The teenager from Essex was born with a condition that causes curved bones in his legs. Aged seven, a reconstructive procedure was carried out on Finias's left leg, lengthening the limb by 3.5cm. A few years later, the same operation was carried out on his right leg which involved wearing an invasive and heavy metal frame for months. He has now been told by independent experts these procedures should not have taken place and concerns have been raised over a lack of imaging taken prior to the operations. His doctor at London's prestigious Great Ormond Street Hospital was former consultant orthopaedic surgeon Yaser Jabbar. Sky News has spoken to others he treated. Mr Jabbar also did not arrange for updated scans or for relevant X-rays to be conducted ahead of the procedures. The surgeries have been found to have caused Finias "harm" and left him in constant pain. "Every day I'm continuously in pain," he told Sky News. "It's not something really sharp, although it does get to a certain point where it hurts quite a lot, but it's always there. It just doesn't leave, it's a companion to me, just always there." Read full story Source: Sky News. 18 May 2025- Posted
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News Article
Warning over ‘dangerous’ nasal tanning sprays with cancer risk sold online
Patient Safety Learning posted a news article in News
Unregulated nasal tanning sprays, touted across social media, are raising alarms with Trading Standards due to potential health risks, including a possible link to melanoma skin cancer. These sprays, which contain Melanotan 2, a chemical that darkens skin pigmentation, are being sold outside current UK regulations. The Chartered Trading Standards Institute (CTSI) has issued a warning about these products, highlighting potential dangers beyond skin cancer. Users have reported nausea, vomiting, high blood pressure, and even changes in mole size and shape. While marketed as cosmetics, bypassing regulations applied to medicinal products containing Melanotan 2, these sprays aren't subject to the same scrutiny as other beauty products. This regulatory gap raises concerns about long-term health consequences, with studies suggesting a potential link to melanoma. Read full story Source: The Independent, 16 May 2025- Posted
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The fundamental importance of having enough registered nurses present to deliver care is well supported by evidence. Lower registered nurse staffing levels are associated with higher risks to patients and poorer quality care. Here is the Royal College of Nursing's position statement on registered nurse staffing levels for patient safety.- Posted
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Cosmetic surgery patients are returning to the UK with superbugs
Patient Safety Learning posted a news article in News
British patients who travel abroad for cheap cosmetic surgery are bringing back dangerous superbugs, nurses have warned. Some NHS hospitals had a 30 per cent rise in infections caused by potentially fatal antibiotic-resistant bacteria, triggered by patients returning from operations overseas. NHS nurses spoke of “horrific wounds”, infections, sepsis and deaths in patients over the past two years from complications after having surgery overseas — and suggested that foreign clinics should pay the NHS compensation when things go wrong. Thousands of British patients faced with long NHS waiting lists and high costs for private surgery in are going abroad instead, most often to Turkey and eastern Europe. Popular procedures include weight-loss surgery, breast procedures and “Brazilian butt lifts” (BBLs). Clinics often offer “package deals” of several procedures, which adds to the risk. Wes Streeting, the health secretary, has urged people to “think very carefully” before going overseas for surgery — warning that the NHS is left to “pick up the pieces”. Read full story (paywalled) Source: The Times, 14 May 2025 -
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A surgeon was flagged as dangerous — she kept operating for ten years
Patient Safety Learning posted a news article in News
Hospital bosses were warned about an NHS surgeon almost nine years before she was eventually suspended over botched operations on children. A joint investigation by The Sunday Times and Sky News has discovered a confidential report written for managers at Cambridge University Hospitals Trust in 2016 that identified problems with the surgical technique and practice of Kuldeep Stohr, a paediatric orthopaedic surgeon. A series of recommendations were made in the report but Stohr was allowed to continue operating. Managers at the hospital told staff the investigation into Stohr had not raised any concerns. Almost a decade on, Stohr has been suspended by the trust after a new review identified at least nine children whose care “fell below the standard” expected. The trust has begun a review of 800 other patients, including around 560 children, 140 adults and 100 emergency patients, who were operated on by Stohr. It has also commissioned an investigation into what action was taken after the 2016 report. Read full story (paywalled) Source: The Times, 10 May 2025- Posted
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The NHS’s total liabilities for medical negligence have hit an “astounding” £58.2bn amid ministers’ failure to improve patient safety, an influential group of MPs have warned. The Commons public accounts committee (PAC) said the “jaw-dropping” sums being paid to victims of botched treatment and government inaction to reduce errors were “unacceptable”. The Department of Health and Social Care (DHSC) has set aside £58.2bn to settle lawsuits arising from clinical negligence that occurred in England before 1 April 2024, the PAC disclosed. “The fact that government has set aside tens of billions of pounds for clinical negligence payments, its second most costly liability after some of the world’s most complex nuclear decommissioning projects, should give our entire society pause,” said Sir Geoffrey Clifton-Brown, the PAC chair. “This is a sign of a system struggling to do right by the people it is designed to help,” he added. The PAC urged ministers to take urgent steps to reduce “tragic incidences of patient harm” and to also end a situation where lawyers take an “astronomical” 19% of the compensation awarded to those who are successful in suing the NHS. That amounted to £536m of the £2.8bn that the health service in England paid out in damages in 2023-24 – its record bill for mistakes. “Far too many patients still suffer clinical negligence which can cause devastating harm to those affected,” and the ensuing damages drain vital funds from the NHS, the report said. Read full story Source: The Guardian, 14 May 2025- Posted
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A surgeon found to have left patients in "agony" after using artificial mesh to treat prolapsed bowels faces allegations he falsified medical notes. Tony Dixon was suspended after the surgery was found to have caused harm to hundreds of patients at two hospitals in Bristol. Now, a new hearing will examine Dr Dixon's records. He is accused of dishonestly creating patient records long after he was involved in their care, something he "strongly denies". The Medical Practitioners Tribunal Service (MPTS) will begin Monday. It will examine claims medical records for seven patients contained false information, and were not created at the correct time. A spokesperson for Dr Dixon said: "[He] always endeavoured to provide the highest standard of care to his patients. "He strongly disputes falsifying any medical records and will provide his detailed evidence about those serious allegations to the tribunal, initially by way of a detailed witness statement which he has provided to the General Medical Council." Read full story Source: BBC News, 12 May 2025- Posted
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