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Found 56 results
  1. Content Article
    The review found that while in many cases care and treatment were appropriate, there were a number of cases that raised specific patient safety concerns. Below is a summary of key themes from this report: Out of area placements An out of area placement occurs when a person with acute mental health needs who requires inpatient care is admitted to a unit that does not form part of the usual local network of services. This review found that there was significant variation for people who are autistic and/or have a learning disability in this regard. This was most striking in the South West of England and Midlands regions, where 73% and 68% of all placements, respectively, were out of area compared to the national average of 57%. The report notes this can have significant impacts on the person affected by this, making it more difficult for them to maintain links with family, local services, communities and clinical/social work professionals. Hospital rather than community care It found that a significant number of patients covered by SWRs did not need to be in a hospital setting to receive the right care and treatment. The national average was 41%, while in the South West of England 53% of individuals did not need to be in hospital settings. The report linked this figure to delays in discharge processes, with patients staying in hospital settings for longer than needed as a result. Concerns about the involvement of family members and carers Concerningly, the report notes that examples of poor communication with family members and carers ‘far outweighed’ examples of effective communication, including: Being excluded from planning and decisions about their loved ones. Not being provided with basic information such as how to contact family members and visiting times. Not being listened to in relation to the care and treatment of their family member, or decisions about their care and wellbeing. There was regional variation in these figures, with one particularly striking case being an Integrated Care System stating that in 39% of their safe and wellbeing reviews, family representatives either could not be contacted for the purposes of the review, they did not want to be contacted or the individual did not want them to be contacted. Advocacy Another area of concern cited was the availability and quality of advocacy for people in hospital, which the report describes as generally inconsistent. Concerns included: Family members having to step into the role of advocates in place of professional advocacy, though they are generally not trained to do so, may not know all the options available and cannot be fully independent. Some provides being resistance to creating a “culture of importance” around advocacy. Poor advocacy awareness in places, which extended to limited attempts by providers to contact advocates and proactively involve them in processes and decisions relating to individuals. Safeguarding In the 3% of cases where safeguarding concerns were raised (50 out of 1,770), serious concerns noted by the report included: Inconsistent and/or high levels of restraint, seclusion and segregation. Patients not being assessed appropriately under the Mental Capacity Act or assessments not being completed in a timely way Harms associated with weight gain during admission (increasing the likelihood of health problems and premature mortality) and long lengths of stay. Issues associated with individuals being placed in inappropriate settings (for example, mixed-gender wards), the absence of CCTV in inpatient settings, issues with staff attitudes and relationships. Low quality and inconsistent of incident reporting. Inappropriate and inconsistent use of medication. The review also said that one region noted that safeguarding referrals were not always made appropriately, and plans were not always implemented to prevent the incidents from happening again. Physical health The report notes that it found multiple references to individuals with a high body mass index and significant weight gain following people being admitted to hospital, including instances where this led to people developing diabetes. This was a key area of concern also raised in the Cawston Park safeguarding adults review. Individual wellbeing and positive mental health The report noted that in many mental health inpatient settings there were not enough activities for people to do and not enough done to help maintain social connections. It noted that meaningful activities were not consistently available and, where they were, were not always age-appropriate, co-planned and person-centred. Workforce The report noted a number of workforce issues, including: Families and advocates raised concerns about whether wards were unsafe when there were significant staff shortages on them. Staff burnout. Heavy reliance on agency and/or temporary staff which can have negative impacts on patients being able to access regular activities and on patient-staff relationships. Reports of staff not having the appropriate training or skillset to effectively meet the needs of individuals. Conclusions and next steps Throughout the report there are a number of sections detailing ‘key considerations’ for providers and Integrated Care Systems, though no specific actions. It notes towards the end of the report that following on from this, NHS England, on a national and regional footprint, working with people with lived experience, family carers, integrated care boards, providers and commissioners, will bring partners together to look at specific actions that will address the challenges and themes highlighted through this thematic review over the next 12 months.
  2. News Article
    Two health watchdogs have issued safety warnings after junior staff were left to work unsupervised on maternity wards previously criticised after a baby’s death. Training regulator, Health Education England (HEE), criticised the “unacceptable” behaviour of consultants who left junior doctors to work without any superiors at South Devon and Torbay Hospital Foundation Trust’s wards. The maternity safety watchdog Healthcare Safety Investigation Branch (HSIB) also raised “urgent concerns” over student midwives and “unregistered midwives” providing care without supervision. The latest criticism comes after the trust was condemned over the death of Arabella Sparkes, who lived just 17 days in May 2020 after she was starved of oxygen. According to a report from December 2022, seen by The Independent, the HEE was forced to review how trainees were working at the trust’s maternity department after concerns were raised to the regulator. It was the second visit carried out following concerns about the department, and reviewers found there had been “slow progress” against concerns raised a year earlier. Read full story Source: The Independent, 16 February 2023
  3. Content Article
    In this blog Helen discusses how Patient Safety Learning is working with Tim Edwards to raise awareness of the findings of his report, and its associated nine calls for action, to help improve pulmonary embolism outcomes. Read the full blog on the National Voices website. Related reading Independent review of pulmonary embolism fatalities in England & Wales – recent trends, excess deaths, their causes and risk management concerns (December 2022, Tim Edwards) Jenny, and why we must learn from her misdiagnosis of pulmonary embolism Pulmonary embolism misdiagnosis – a systemic problem (Tim Edwards, 4 January 2023) House of Commons Debate - Pulmonary Embolisms: Diagnosis (30 November 2022) Royal College of Radiologists: Briefing for pulmonary embolism debate (November 2022) HSIB - Clinical decision making: diagnosis of pulmonary embolism in emergency departments (24 March 2022)
  4. Content Article
    Key recommendations Positively engaging DSCR providers not currently on the assured provider list A standard to ensure the inclusion and consultation of end-users at every stage of the design, production, and implementation process of any new technology A new forum for social care providers, end users, and technology providers to discuss digital solutions for the sector A call for financial support for digital inclusion among people in receipt of adult social care services Mandatory digital training for staff
  5. Content Article
    Jenny, my mother Jenny was a much-admired mother, grandmother and friend. She had a strong determination and an uplifting zest for life; she was loyal and we, her family, miss her. Her passions were many, from her love of travel to places of geographic interest, to line-dancing and amassing a curious Tupperware collection. Jenny attended university in the 1960s, a time when women from her background were discouraged from attending further education. Having graduated, Jenny then worked for British Leyland and later moved to Germany with my father where she taught English. During which time she had me. Jenny returned alone with me to England in 1985, to no home or job. Her ability and determination ensured she quickly got a teaching role, then a home – she subsequently taught GCSE and A-Level for 27 years at Lewes Old Grammar School, living in the Brighton area that she called home. Unfortunately, my mother, Jenny, passed away prematurely from a pulmonary embolism in February 2022 following misdiagnosis. I am seeking to help derive a positive learning from her death and, unfortunately, many other similar recent cases. While she was 74, an extra 5 or 10 years would have made a great difference to our family – it has deprived my mother of time with her first grandchild, my daughter, who was born just weeks earlier in January 2022. A catalogue of errors taking away valuable years’ left of life Jenny, my mum, should likely not, medically speaking, have passed away on Sunday 27 February 2022 of a pulmonary embolism – a blood clot in her vein passing to her lung causing heart failure. Studies indicate that the death rate for diagnosed and treated pulmonary embolism is 8%.[1] She had never smoked in her life, exercised regularly and all had appeared well with her health at the start of 2022. She had received a letter from her GP granting her travel insurance that would have allowed her to travel to the Greek Islands and, later in the year, to the Baltic countries. In early February, despite exhibiting risk factors and sudden symptoms, including fainting and collapse, my mother was wrongly misdiagnosed in the care of an emergency department as having had a heart attack. She was then needlessly fitted with a stent. Upon her discharge from hospital her condition got worse again at home – she was dying – and yet she was reassured by a cardiac nurse who, over the phone, missed the signs of shortness of breath, chest pain (in the centre of the chest) and of fainting. The nurse advised that if the symptoms continued that my mother should call her GP. My mother never made her GP appointment. I don’t want this to continue to happen to other family’s loved ones. This was entirely avoidable. Jenny was waiting in A&E for over 12 hours and there were nine independent decision-making points where at any one of these, pulmonary embolism could and should, in totality, have been diagnosed. Pulmonary embolism was only discovered in an autopsy, and yet she exhibited symptoms consistent with 90% of pulmonary embolism patients.[2] A lack of learning forcing me to act Upon my complaint to the NHS trust that oversaw my mother’s care, a Serious Incident Report was commissioned by the trust and an inquest set up. However, in my opinion, the NHS trust appears to have exhibited a ‘shrug of the shoulders, these things happen conclusion’, inhibiting sufficient learning from my mother’s case. NHS England’s 2015 Serious Incident Framework was in operation at the time of the trust’s Serious Incident Report,[3] encouraging hospital trusts to appoint independent reviewers to ensure objectivity. However, the subject-matter experts chosen to contribute to the report were all involved with the original care of my mother and, hence, objectivity of the report was lost. The frustration I feel at the loss of my mother has then been compounded by the intransigence of the NHS trust that oversaw my mother’s case, and then the discovery that my mother’s case was not alone. Indeed, far from it. Image: Tim with his wife and little girl. References Belohlavek J, Dytrych V, Linhart A. Pulmonary Embolism, Part I: Epidemiology, Risk Factors and Risk Stratification, Pathophysiology, Clinical Presentation, Diagnosis and Nonthrombotic Pulmonary Embolism. Experimental and Clinical Cardiology 2013: 18; 129-138. The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC), 2008. NHS England. Serious Incident Report Framework, 2015. Read the recently published, independent report Tim authored: Independent Review of Pulmonary Embolism fatalities in England & Wales - recent trends, excess deaths, their causes and risk management concerns Further reading Press release (Patient Safety Learning) House of Commons Debate - Pulmonary Embolisms: Diagnosis (30 November 2022) Royal College of Radiologists: Briefing for pulmonary embolism debate (November 2022) HSIB - Clinical decision making: diagnosis of pulmonary embolism in emergency departments (24 March 2022)
  6. Content Article
    Key findings from the report: There were 400 excess deaths attributable to pulmonary embolism misdiagnosis from March 2021 to April 2022 in England and Wales. In parts of England and Wales the number of deaths due to pulmonary embolism were almost 3 times the national average. The clinical guidelines and diagnostic processes used in England and Wales are out of step with our European counterparts and, in Jenny’s case, were not used correctly. Clinical teams too often lack the training, expertise and/or equipment to deliver safe and effective pulmonary embolism care. Commenting on the report, Tim Edwards said: "My research found that there are hundreds of people who, like my mother Jenny, died from pulmonary embolism following misdiagnosis. It's vital we learn from these deaths, and the errors that have occurred, so we can take action to improve pulmonary embolism care. By publishing this report, I hope to start a dialogue that leads to positive change, so others do not suffer the loss of a loved one as we have." Helen Hughes, Chief Executive of Patient Safety Learning said: “This new report highlights serious patient safety concerns relating to the diagnosis of pulmonary embolisms. Urgent action is now needed to ensure that guidelines and diagnostic processes are up to date and that clinicians have the resources they need to deliver safe and effective care. It is also vital that we increase awareness of the key symptoms of pulmonary embolisms among both healthcare professionals and the wider public. Patient Safety Learning are proud to be supporting Tim and his campaign for improvement in pulmonary embolism care and to reduce avoidable deaths.” Calls for action The report includes nine calls for action to improve pulmonary embolism care: 1 Raise the level of suspicion for pulmonary embolism – given a surge in PE-related deaths, greater awareness amongst frontline emergency department and other clinicians of the importance of considering the possibility of PE during their diagnostic decision-making. More general training alongside specialisms and simulation to support practice and development of decision-making skills. Could the NEWS scoring system be calibrated to consider the aggregate of scores over a 5-6 hour period is one area for further discussion. 2 Buy-in for clinical guidelines - clinical guidance is only as valuable as, firstly, its validity and there is evidence that the NHS is not applying pulmonary embolism guidance considered best practice in comparable European countries and, secondly, adherence, which is evidenced as inconsistent at best and worst, ignored. This report calls for a change, not just a review, of NICE clinical guideline NG158 covering pulmonary embolism diagnosis. 3 Avoidance of high-risk appetite - to achieve operating standards and meet financial incentives, risk appetite should not be a variable that can be compromised or amended. A compliance metric tracking whether clinical guidelines were successfully followed could be included as a diagnostic tool used as part of the Get it Right First Time (GIRFT) initiative 8 to ensure CTPA scanning for pulmonary embolism is not under-used. 4 Ensure radiology departments have the appropriate resources - so they can deliver a safe and effective service. Currently 41% of clinical radiologists do not have the right equipment 3 and the levels of scanners is less than half that in France and a quarter of that in Germany. There are also personnel shortages. There needs to be a plan in place to address these shortages. 5 National consistency, compliance and risk management - exploration of the underlying causes of regional variation, whether from differentials in resources or processes. Ensure oversight approaches/audits are suitably embedded within existing clinical governance systems. 6 Patient engagement - meaningful engagement with those affected when carrying out an incident investigation to ensure family members’ expertise is harnessed and that they are treated as partners in the learning response (where they so wish), not just in setting the terms of reference. 7 Independence - while independent authors may contribute to investigations, independent subject-matter experts are not always involved therefore undermining the integrity of any report conclusions. NHS England’s 2015 Serious Incident Framework guidelines require independent contributors to ensure objectivity and so clearly there may need to be a review of how 'contributors' is defined and how this process may better ensure lessons are being suitably learnt. 8 Knowledge sharing – effective, timely dissemination of learning from a serious incident investigation carried out in one organisation across the NHS to other organisations which may experience a similar type of PE misdiagnosis incident in the future. Ensure Clinical Knowledge Summaries providing the latest research and clinical findings are sufficiently disseminated and actioned by frontline emergency department and clinical staff in a timely fashion. 9 Public awareness – extension of existing awareness campaign advising those at risk of the symptoms to look out for and when to seek medical attention You can access the report in full via the attached PDF document below. Further reading House of Commons Debate - Pulmonary Embolisms: Diagnosis (30 November 2022) Royal College of Radiologists: Briefing for pulmonary embolism debate (November 2022) HSIB - Clinical decision making: diagnosis of pulmonary embolism in emergency departments (24 March 2022)
  7. News Article
    The NHS staffing crisis will be solved only if doctors and nurses get more flexible about their job descriptions and break down barriers between roles, according to Rishi Sunak’s health adviser. Bill Morgan argues that training times for doctors and nurses may have to be reduced, and suggests developing “sub-consultants” and entirely new medical professions, He wants ministers to create an Office for Budget Responsibility-style body to predict future workforce needs. The Treasury has held down the numbers of doctors and nurses Britain trains to prevent “supply-induced demand”, which encourages people to seek appointments that are not needed, Morgan argues. Chronic shortages of qualified staff are the biggest problem facing the health service, which has more than 130,000 vacancies. Morgan acknowledges that this means “some of the government’s key manifesto commitments will not be met”, citing the promise of 6,000 extra GPs. Sunak said this week that the government was “thinking creatively about what new roles and capabilities we need in the healthcare workforce of the future”. He urged the NHS to shed “conventional wisdom”. Read full story (paywalled) Source: The Times, 24 November 2022
  8. Content Article
    My mother, 87 years, was admitted to hospital with a suspected heart attack. At the time, she was on a strong dose of a GP-prescribed opioid (fentanyl) to manage her growing lung cancer. The Duty doctor in the hospital seemed panicked as she was so unwell and used a drug to totally reverse her morphine as they thought she had overdosed. This caused excruciating pain for most of the last 60 hours of her life. They hadn’t properly assessed the history of her prescription or asked me, her documented health advocate, about the drug or my mother’s end of life wishes. After a 2-year long traumatic journey for the family, the Inquest issued a Prevention of Future Deaths report, agreeing her prior medication should have been properly assessed. After another year and a convoluted journey through the health system, NHS England’s Patient safety team issued a National Safety Alert to all English hospitals around more careful use of pain relief reversing. Five years later, my good friend was on an unusual cocktail of GP-prescribed drugs for her very painful arthritis. She was admitted to hospital after a fall that dislocated her severely arthritic shoulder. For three days in hospital she went through different medical teams, but no one looked at her pain control needs or her unusual medication, and the only pain relief medication that had worked for her for years was removed totally from very early on in the admission. She suffered on those hard hospital beds, unable to move to a comfortable position due to her painful arthritis, lack of adequate pain control and her shoulder that remained painfully dislocated. She could not move on those beds without help. She was in agony for three days. Sadly she died of a pulmonary embolism in hospital in the midst of that traumatic experience. What both these people have in common is the neglect of their medically prescribed, carefully designed pain control to meet their unique needs, their understandable wishes and personal rights. As a result their essential pain control was totally removed while other necessary medical interventions occurred. These patient and service user’s rights were not respected. Huge suffering resulted. This I believe needs addressing and learning from. Pain control needs of patients with chronic conditions needs to be carefully assessed and addressed on all hospital admissions from the very start of admission. The current complaint and Inquest systems do not have as their agenda these types of safety learning. There are two routes whereby these incidents can be recorded, with one route that may lead to an investigation and system learning nationally. One is the NHS patient portal, which is just for reporting (no one will get back to you, but the information you share could be used to improve safety for future patients), and the other is the Healthcare Safety Investigation Branch (HSIB) who do national investigations almost always on recently occurring events. I would add there are developments in patient safety learning, including patient safety partners rolling out across some health facilities, but this is relatively early on in a national process: https://www.england.nhs.uk/patient-safety/framework-for-involving-patients-in-patient-safety/ The new NICE guidance on Shared Decision Making also adds to the pressure to learn and change from cases like this. Perhaps special guidance is needed for those admitted for emergency care with complex palliative medication needs? I hope a Body will take this up soon. The patient, service user, family and carer voice must be heard and acted on to improve patient safety at these difficult times. If you or anyone you know has had an experience like this, particularly in the last few months, do let me know by emailing me or commenting on this post below, as the routes above could lead to long lasting learning. It is sorely needed.
  9. Content Article
    Coroner's concerns Asher was entirely dependent upon a complex package of care as a highly vulnerable ventilator dependent child. Evidence at inquest was that on numerous occasions he was not provided with the prescribed 2:1 care. The care package, despite being described as one of the most complex and most expensive was not appropriately reviewed and there was no mandatory system of quality checks or formal review when there was a significant change in family circumstances. Quarterly reviews were not carried out without explanation. The primary responsibility fell upon the family members, namely Asher’s parents, who were also responsible for other children in the family and employed as teachers. Concerns raised by the parents were not taken for discussion to case conference or professional’s meetings and essentially not followed up at all, leaving the situation in the house dangerous with an ultimately calamitous outcome. There was a lack of scrutiny or reconciliation of Asher’s care package, which could have identified gaps that needed to be addressed. Training for the staff involved was unclear to the court and seemingly not in place or inadequate. A high turnover of staff was cited as one of the reasons, but this should have highlighted a need for increased training and scrutiny. The court was advised that new structures would be in place by July 2022. The production of this report therefore has been delayed to give the opportunity for those systems to be in place and reported to the court.
  10. News Article
    Nearly 38,000 vital follow-up appointments with mental health patients were missed at the time when they were most at risk of suicide, the Royal College of Psychiatrists has said. The medical body has called for “urgent action” to ensure more people are seen for follow-ups within 72 hours of their discharge from inpatient care, to prevent them from falling “through the cracks when they are so vulnerable”. The risk of suicide is highest on the second and third days after leaving a mental health ward, but 37,999 follow-up appointments with patients were not made within this timeframe in England between April 2020 and May 2022. According to NHS data, of the 160,430 instances when patients were eligible for follow-up care within 72 hours after discharge from acute adult mental health care, only three-quarters (76%) took place within that period. The Royal College of Psychiatrists is calling for more trained specialists to check on those perceived to be at risk, which they say requires more staffing and funding. The president of the Royal College of Psychiatrists, Dr Adrian James, said: “We simply can’t afford to let people fall through the cracks at a time when they are so vulnerable. It’s vital that our mental health services are properly staffed and funded to offer proper follow-up care and help prevent suicides. “Staff are working as hard as they can to provide high-quality care, but it’s clear that current resources are not enough to meet these targets. We need urgent action to tackle the workforce crisis and achieve the suicide prevention goals set out in the NHS long-term plan.” Read full story Source: The Guardian, 22 August 2022
  11. News Article
    One in 25 people who die of a heart attack in the north-east of England could have survived if the average cardiologist effectiveness was raised to the London level, research shows. The research, undertaken by the Institute for Fiscal Studies (IFS), looked at the record of over 500,000 NHS patients in the UK, over 13 years. It highlights the stark “postcode lottery” of how people living in some parts of the country have access to lower quality healthcare. The results found that while cardiologists treating patients in London and the south-east had the best survival rates among heart attack patients, patients being treated in the north-east and east of England had the worst. Among 100 otherwise identical patients, an additional six patients living in the north-east and east of England would have survived for at least a year if they had instead been treated by a similar doctor in London. Furthermore, if the effectiveness of doctors treating heart attacks in these areas of the country were just as effective as the cardiologists in London, an additional 80 people a year in each region would survive a heart attack. The research also revealed a divide between rural and urban areas of England, with patients living in the former typically receiving treatment from less effective doctors compared with those in more urban areas. Read full story Source: The Guardian, 9 August 2022
  12. Content Article
    The 'Workforce: recruitment, training and retention' report outlines the scale of the workforce crisis: new research suggests the NHS in England is short of 12,000 hospital doctors and more than 50,000 nurses and midwives; evidence on workforce projections say an extra 475,000 jobs will be needed in health and an extra 490,000 jobs in social care by the early part of the next decade; hospital waiting lists reached a record high of nearly 6.5 million in April. The report finds the Government to have shown a marked reluctance to act decisively. The refusal to do proper workforce planning risked plans to tackle the Covid backlog - a key target for the NHS. The number of full-time equivalent GPs fell by more than 700 over three years to March 2022, despite a pledge to deliver 6,000 more. Appearing before the inquiry, the then Secretary of State Sajid Javid admitted he was not on track to deliver them. The report describes a situation where NHS pension arrangements force senior doctors to reduce working hours as a “national scandal” and calls for swift action to remedy. Maternity services are flagged as being under serious pressure with more than 500 midwives leaving in a single year. A year ago the Committee’s maternity safety inquiry concluded almost 2,000 more midwives were needed and almost 500 more obstetricians. The Secretary of State failed to give a deadline by when a shortfall in midwife numbers would be addressed. Pay is a crucial factor in recruitment and retention in social care. Government analysis estimated more than 17,000 jobs in care paid below the minimum wage.
  13. Content Article
    Coroner's concerns Without changes in the NHS Pathway the 111 call handlers will not be adequately assisted by the Pathways to recognise the acutely unwell child, in particular: at the time of the conclusion of the inquest, there was no question within the NHS Pathways questionnaire concerning cold hands and feet for children aged over five at the time of the conclusion of the inquest, the question regarding green vomit, asked in respect to children over five, had an inappropriately high threshold (that is required severe pain for more than four hours before the question was engaged) and would not have been activated in Sebastian's case there is no indication that NHS Pathways/NHS Digital have reviewed the support arrangements for non-clinically qualified advisers to refer unusual cases to clinically qualified staff at the time of the conclusion of the inquest, NHS Pathways' questions did not allow meaningful assessment of pain in a child; that is to say questions about severity of pain and the ability of a child to communicate such pain should be reviewed at national governance level.
  14. Content Article
    Matter of concerns: Inadequate training of doctors and other medical professionals re the risk of sepsis following Early Medical Terminations. Evidence from a wide range of clinicians who had cared for Sarah in March and April 2020 echoed each other. The clinician evidence revealed a common theme of lack of training, knowledge or experience on the part of physicians and medical staff (including GPs, pharmacist and acute hospital doctors) regarding the rare risk of sepsis following Early Medical Termination. The hospital trust accepted that at the time of Sarah’s death, there was confirmation bias in their thinking due to the Covid 19 pandemic and that other differential diagnosis were not considered in this case. Whilst the witness evidence was that Sepsis protocols were in place at both the GP surgery and the hospital trust, what is of particular concern is that none of the professionals who saw or spoke to Sarah were considering Sepsis in this case. Sarah was spoken to and seen by numerous medical professionals in both primary and secondary care but no sepsis protocols were initiated and the coroner found that the compounding delays in screening, diagnosis and treatment more than minimally contributed to a poor outcome in Sarah’s case.
  15. Content Article
    Coroner's concerns There were excessive delays in handing over patients at hospital. The West Midlands Ambulance Service Serious Incident report found that there were excessive handover of patients at the Royal Stoke University Hospital, with some holding for over 4 hours. This impacted on the ability of the West Midlands Ambulance Service getting to patients. Oral evidence was given to the effect that this was a national issue, and not limited to the acute trusts within the West Midlands.
  16. Content Article
    The report highlights the following key findings: The maternity service was offering care to women whose pregnancies represented a high risk, but did not have the necessary systems or staff with the appropriate skills in place to manage such cases. There was a lack of input from consultants at crucial times, and there was an over reliance on junior staff to manage complex and difficult cases with little guidance or support. Consultant obstetricians did not routinely carry out ward rounds when they were responsible for overseeing care in the labour ward and the teamwork between midwives and obstetricians was not as effective as it should have been. Therefore, there was no adequate mechanism in place for staff to discuss concerns that they may have had about the women. There was an excessive reliance on the use of locum and agency staff, who did not always receive the necessary guidance or support. Deficiencies in the management structures also contributed to the poor quality of care the women received, for example midwives were expected to manage a busy delivery suite that was reliant on agency and locum staff, with at times, little professional or managerial support. Around the time of the first deaths the midwives received little professional support from the supervisors of midwives. In the majority of cases the women attended their hospital and GP antenatal appointments and sought help when they felt unwell. Yet despite this, in a number of the cases, clinical staff failed to recognise and respond to the severity of the condition of the women, thereby reducing the chances of survival of the women. In some of the cases there were minor deficiencies in care which, in isolation, may not have had such a dramatic impact, but when occurring together had serious consequences for the health of the women concerned. The anaesthetic staff involved in the care of the women responded well, often in difficult circumstances. The haematology department responded efficiently in providing the necessary, and at times large, volumes of blood and blood products. In two of the cases there was an absence of documentation for surgical procedures that were carried out by the obstetric staff and in one case there was an absence of contemporaneous documentation. Related reading An independent review of serious untoward incidents and clinical governance systems within maternity services at Northwick Park Hospital (16 September 2008)
  17. News Article
    England’s test and trace service is being sub-contracted to a myriad of private companies employing inexperienced contact tracers under pressure to meet targets, a Guardian investigation has found. Under a complex system, firms are being paid to carry out work under the government’s £22bn test and trace programme. Serco, the outsourcing firm, is being paid up to £400m for its work on test and trace, but it has subcontracted a bulk of contact tracing to 21 other companies. Contact tracers working for these companies told the Guardian they had received little training, with one saying they were doing sensitive work while sitting beside colleagues making sales calls for gambling websites. One contact-tracer, earning £8.72 an hour, said he was having to interview extremely vulnerable people in a “target driven” office that encouraged staff to make 20 calls a day, despite NHS guidance saying each call should take 45 to 60 minutes. Another call centre worker, who had no experience in healthcare or emotional support, said she suffered a nervous breakdown during an online tutorial about phoning the loved ones of coronavirus victims in order to trace their final movements. Read full story Source: The Guardian, 14 December 2020
  18. News Article
    High-risk women at a maternity unit were not monitored closely enough and there was a "lack of learning" from a mother's death, inspectors found. A Care Qualtiy Commission (CQC) report rated the unit at Basildon University Hospital as inadequate with "failings" found in six other serious cases. Inspectors carried out unannounced checks in June after a whistleblower voiced fears about patient safety. The unit was criticised following the deaths of baby Ennis Pecaku in September 2018 and mother Gabriela Pintilie, 36, in February 2019. The CQC previously carried out an inspection of the department the month Mrs Pintilie died and said the unit, which had once been rated outstanding, required improvement. Inspectors returned for the surprise "focused" inspection after being contacted by an anonymous whistleblower. The report found babies were born in a poor condition and then transferred for cooling therapy, which can be offered for newborn babies with brain injury caused by oxygen shortage during birth. During their visit, inspectors found: High-risk women giving birth in a low-risk area. Not enough staff with the right skills and experience. "Dysfunctional" working between midwives, doctors and consultants, which had an impact on the "increased number of safety incidents reported". Concerns over foetal heart monitoring. Women being referred to by room numbers instead of their names. A "lack of response by consultants to emergencies" resulting in delays The CQC also referred to issues relating to the death of Mrs Pintilie, who was not named in the report, and said five serious incidents "identified the same failings of care". Read full story Source: BBC News, 18 August 2020 "This demonstrated there had been a lack of learning from previous incidents and actions put in place were not embedded."
  19. News Article
    Almost half of hospitals have a shortage of specialist stroke consultants, new figures suggest. One charity fears "thousands of lives" will be put at risk unless action is taken, with others facing the threat of a lifelong disability. In 2016, Alison Brown had what is believed to have been at least one minor stroke, but non-specialist doctors at different hospitals repeatedly told her she did not have a serious health condition. One even described it as an ear infection. Ten months later, aged 34, she had a bilateral artery dissection - a common cause of stroke in young people, where a tear in a blood vessel causes a clot that impedes blood supply to the brain. She was admitted to hospital - but again struggled for a diagnosis. A junior doctor found an issue with blood flow to the brain but she says their comments were dismissed and she was told it was a migraine. It was only when she collapsed again, days later, and admitted herself to a hospital with a dedicated stroke ward that a specialist team was able to give her the care she needed. Alison's case highlights the importance of being seen by stroke specialists. However, according to new figures from King's College London's 2018-19 Snapp (Sentinel Stroke National Audit Programme) report, 48% of hospitals in England, Wales and Northern Ireland have had at least one stroke consultant vacancy for the past 12 months or more. This has risen from 40% in 2016 and 26% in 2014. The Stroke Association charity - which analysed the data - says the UK is "hurtling its way to a major stroke crisis" unless the issue is addressed. Read full story Source: BBC News, 17 January 2020
  20. News Article
    The NHS 111 helpline for urgent medical care is facing calls for an investigation after poor decision-making was linked to more than 20 deaths. Experts say that inexperienced call handlers and the software used to highlight life-threatening emergencies may not always be safe for young children. At least five have died in potentially avoidable incidents. Professor Carrie MacEwen, Chairwoman of the Academy of Medical Royal Colleges, said: “These distressing reports suggest that existing processes did not safeguard the needs of the children in these instances.” Since 2014 coroners have written 15 reports involving NHS 111 to try to prevent further deaths. There have been five other cases where inquests heard of missed chances to save lives by NHS 111 staff; two other cases are continuing and one was subject to an NHS England investigation. Read full story (paywalled) Source: The Times, 5 January 2020
  21. News Article
    A coroner has criticised health professionals for failing to give a young woman who died after suffering severe anorexia the support and care she needed. Maria Jakes, 24, died of multiple organ failure in September 2018 after struggling for years with the eating disorder. Coroner Sean Horstead last week concluded that the agencies involved in the Peterborough waitress’s care missed several key opportunities to monitor her illness properly. Mr Horstead said that there had been insufficient record-keeping and a failure to notify eating disorder specialists in the weeks before her death, following treatment at Addenbrooke’s and Peterborough City Hospital. He also criticised the lack of specialist eating disorder dieticians at Addenbrookes and Peterborough hospitals, “together with a nursing team insufficiently trained and knowledgeable of eating disorder patients”, both of which had contributed to the lack of monitoring of Maria. Despite the criticism the father of another anorexia victim, whose death was described in a Parliamentary and Health Service Ombudsman’s report as an “avoidable tragedy”, has said the inquest failed to properly address or challenge the “lack of care” that Maria received from the NHS. Nic Hart, whose daughter Averil died in 2012 at the age of 19, criticised the inquest as “a very one sided process”. He told The Telegraph: “No real challengers were made of the clinical evidence or indeed of the lack of care that poor Maria received.” Read full story Source: The Telegraph, 21 December 2019
  22. News Article
    A Liverpool NHS trust has been rated as "requires improvement" by the health service watchdog due to concerns over care and safety. The moves comes following inspections at Aintree University Hospital and Royal Liverpool University Hospital. Inspectors said Liverpool University Hospitals NHS Foundation Trust required improvement in safety while it was classed as inadequate for leadership. The trust said "immediate action" had been taken to address the concerns. Ted Baker, chief inspector of hospitals at the Care Quality Commission, said the inspections in June and July highlighted concerns that the trust's leadership team "had a lack of oversight of what was happening on the frontline". Mr Baker said "lengthy delays" and "poor monitoring" were putting patients at serious risk of harm, and the trust was rated as requires improvement overall. He added: "We were particularly concerned about how long people were waiting to be admitted onto medical wards and by the absence of effective processes to prioritise patients for treatment based on their conditions. "There weren't always the right number of staff with the right skills and training to treat people effectively or keep them safe in the trust's emergency departments and on medical wards." Read full story Source: BBC News, 27 October 2021