Patient Safety Watch: Clear signs of extreme pressure

Good afternoon and welcome to our second “new-style” Patient Safety Newsletter, brought to you fortnightly in collaboration with HSJ.

New report describes a mixed picture for patient safety in England

In case you missed it, last week saw the publication of a new report, commissioned by Patient Safety Watch and produced by the Patient Safety and Translational Research Centre and Centre for Health Policy at the Institute of Global Health Innovation. The report, National State of Patient Safety 2022: What we know about avoidable harm in England, explores progress and identifies issues linked to an underresourced and overstretched workforce. The report makes some important recommendations for change, including calling for a robust workforce plan and improvements in the quality and breadth of patient safety data. Patient Safety Watch’s research programme is continuing so let’s hope future reports will show positive changes in the areas identified for action.

In other news this edition, signs the healthcare system is facing extreme pressure with serious implications for patient safety are all too clear.

Problems in emergency care causing hundreds of deaths

Royal College of Emergency Medicine president Adrian Boyle told BBC Radio 4’s Today programme it estimated more than 200 deaths in one week could be linked to the ongoing problems in urgent and emergency care. He added failing to tackle problems with discharging patients to social care was a “massive own goal”. He also said ambulances had effectively become “wards on wheels”, while those most at risk were “the people that the ambulance can’t go to because it’s stuck outside the emergency department”.

Warnings raised about de-conditioning

Dr Boyle wasn’t the only one to highlight concerns about the impact of long waits to discharge this fortnight. Writing in The Guardian, former NHS manager David Lee said older people deteriorating in hospital could not solely be blamed on problems in social care, pointing out a combination of changes in nursing practices, infection control concerns and a failure to appreciate occupational therapists and physiotherapists had left many patients confined to their bed for much of their day while they waited to leave.

He cites the recent experience of his mother, who during her four-week stay on a rehabilitation ward had “nothing to do except stare at the brick wall outside the window. No shared mealtimes, no trips to any day rooms, nothing”.

More than £1bn set aside for covid compensation claims

Accounts for NHS Resolution – the organisation responsible for helping the NHS handle claims and legal cases made against it – reveal a £1.3bn fund has been set up to cover compensation claims made as a result of the covid pandemic. The amount is more than double the sum put aside in the previous year, with the report saying this increase “is [caused by] the indirect impacts of covid-19 of delays, cancellations and misdiagnosis reflecting longer waiting lists”.

Whistleblowers describe poorly performing trust as ‘a bit like the mafia’

Whistleblowers at University Hospitals Birmingham Foundation Trust have claimed patient care is being compromised due to a climate of fear. According to an investigation by BBC Newsnight and BBC West Midlands, one insider described the trust as “a bit like the mafia”. Concerns raised included a lack of nursing staff and poor communications had led to some haematology patients dying without obtaining treatment.

UHB is facing multiple performance problems, including with emergency care, elective provision and cancer delays. The trust told the broadcaster it took “patient safety very seriously” and had a “high reporting culture of incidents”.

Patient safety across the pond

In the United States, the House of Representatives has introduced a bill to set up a federal agency aimed at preventing and reducing healthcare-related harms. Modelled on transport and aviation safety boards, the idea for the National Patient Safety Board sounds similar to this country’s Healthcare Safety Investigation Branch. The announcement for the legislation stated medical error was the third-leading cause of death in the US prior to the covid-19 pandemic, with conservative estimates suggesting more than 250,000 patients die each year due to preventable medical harm. 

A spotlight on patient advocacy

Harmed Patients Alliance (personal interest disclosed!) published a powerful report last week – Signpost to Nowhere – which highlights that, although the NHS considers referring patients to advocacy services when something has gone wrong as good practice, in reality patients often struggle to find support. Meanwhile, advocacy services that do exist have no central funding.

The report was considered at a roundtable meeting of key stakeholders last week, including representatives of NHS England, the Care Quality Commission, the Patient Safety Commissioner, the Parliamentary and Health Service Ombudsman, NHS Resolution, the HSIB, and patient charities and advocacy groups. I am pleased to say there was widespread support for the report’s recommendations, so please watch this space!

Sharing some good stuff…

New ‘Learn Together’ website and resources go live!

The Learn Together research project was established in 2019 to collaborate to create guidance and resources to make investigations more human and meaningful for those involved, and support better organisational learning. The project has just launched a new website which contains loads of useful information, and – most importantly – links to download the guidance and resources developed. As the NHS continues the journey to implement the new patient safety incident response framework, these resources will be invaluable to patients and staff. If this is an area of interest to you, please have a look!

Maternity safety gets a festive feel!

Social media can be a mixed bag, but one thing it’s great for is sharing good ideas. Have a look at this tweet from a midwife at James Paget University Hospitals FT, sharing their “Fetal Monitoring” Advent Calendar – what a great way of engaging staff in daily discussions about a really important topic.

Finally, a plug for a good cause

You may have seen this harrowing report in the Daily Telegraph last week highlighting the dreadful situation healthcare professionals in Ukraine are currently facing. For pregnant women and maternity professionals, the stress of war and limited resources are creating a particularly dreadful situation. A campaign by the charity Baby Lifeline is raising funds and sending much needed equipment, including out of hospital birth bags and other vital resources, to Ukraine so that mothers and babies can have the safest care possible in the circumstances they find themselves in. You can read more about this life-saving work and how you can support it here.

That brings this edition to an end. The next Patient Safety Newsletter will be just a few days before Christmas Day. Do take care as the colder weather approaches and, if you work in the healthcare system, we know things are tough – thank you and stay safe.

James Titcombe

@JamesTitcombe