Patient Safety Watch: Don’t let NHS capital get stuck in the Whitehall queue, Rachel

Good afternoon, and welcome to this fortnight’s edition of the Patient Safety Watch newsletter – this time from me, Jeremy. This edition comes a little later than planned due to the Easter break, so, with plenty to cover, let’s dive in.

Health secretary orders review into children’s hearing services

As reported in the Sunday Times, at least 775 children across England have been called for reassessment by hospitals amid fears they were misdiagnosed after hearing tests between 2018 and 2023, with 107 already confirmed to have suffered serious harm. Many were wrongly labelled deaf due to poorly interpreted auditory brainstem response (ABR) tests, and were not given hearing aids or cochlear implants that could have made a difference.

Commenting on these reports, health secretary Wes Streeting said: “Early diagnosis of hearing issues is vital… yet years passed without sufficient action being taken by senior leadership… That is unforgivable.”

Mr Streeting added the scandal was typical of “an NHS culture that buried problems rather than confronting them head-on”.

A full review has now been commissioned and will be chaired by former president of the Royal College of Paediatrics and Child Health Camilla Kingdon. It will look at: NHS England’s response to failures in paediatric audiology; how governance arrangements between NHSE and the Department of Health and Social Care could be improved; and what lessons NHSE should learn from these incidences which could be applied to any similar future service failures.

Also worth checking out is my colleague James Titcombe’s excellent post about what this scandal says about how NHS culture still needs to change.

Sixth of NHS staff don’t think their building is safe

A survey published by Unison this month has revealed approximately a sixth (17 per cent) of NHS staff do not think the building they work in is safe, with 16 per cent saying they had seen vermin in their building in the last year and the same percentage saying they’d seen evidence of other types of infestations, such as cockroaches and silverfish.

More than half (52 per cent) said they’d seen buckets being used to catch leaks in their workplace in the past year, while nearly a quarter (23 per cent) had seen sewage leaks.

We need a plan to get capital funding more quickly into repairs and new hospitals. At the moment, NHS capital needs get stuck in the queue in Whitehall, something that really bothered me when I was chancellor, as a modern health system needs vast levels of investment. Without privatising the NHS or repeating the mistakes of the private finance initiative, we need to find a better solution. Rachel, are you listening?

Baby deaths still not falling

This week’s data from the Office for National Statistics revealed that 2,320 babies under the age of one died in England and Wales in 2023 – an infant mortality rate of 3.9 per 1,000 live births, unchanged from 2022. However, neonatal mortality (for babies born after 24 weeks) improved slightly, dropping from 1.7 to 1.6 per 1,000. That places us at about the Organisation for Economic Cooperation and Development average, but around double the levels in Japan or Sweden. Around 1,000 more babies would live if our maternity safety was as good as either country.

The data again showed stark inequalities: babies born with low birth weight, to mothers under 20, or from Black ethnic backgrounds remain at higher risk. Infants in the most deprived areas were more than twice as likely to die before their first birthday than those in the least deprived. So not surprising that Robert Wilson, head of the Sands and Tommy’s Joint Policy Unit, said ”we are still not on track to halve neonatal deaths and stillbirths in England, an ambition I launched in 2017. Much work to be done, as we will be focusing on in my All-Party Parliamentary Group on Patient Safety.”

Lack of care coordination harming patients and carers, warns watchdog

A Health Services Safety Investigation Body (HSSIB) report, published this month, has found that a lack of coordination across care pathways for those with long-term health conditions is causing harm and distress to patients and carers.

Neil Alexander, HSSIB senior safety investigator, rather depressingly said: “Patients and carers were open about their feelings of anguish and exhaustion, their anger, sadness, and loss of trust in a system they felt sometimes was fighting against them.”

HSSIB report: Staff fatigue poses serious risk to patient safety

Another excellent report from HSSIB has been published this week highlighting how NHS staff fatigue significantly endangers both patient and staff safety. Fatigue has been linked to medical errors, such as incorrect feeding tube placements and mislabelled blood samples, and tragic incidents like fatal car crashes involving staff driving home after long shifts.

Contributing factors include extended working hours, heavy workloads, insufficient rest facilities, and personal circumstances like caregiving responsibilities. Despite its impact, fatigue is often overlooked in patient safety investigations. To mitigate these risks, the report urged healthcare organisations to implement systemic changes, including better rest provisions and more sustainable scheduling.

Several local-level learning prompts are included – essential reading for NHS leaders and patient safety teams.

Pandemic leads to almost one in 10 people saying the NHS has caused them harm

Results of a survey published in the BMJ Quality & Safety journal this month have revealed almost one in 10 (9.7 per cent) people believe they have been harmed by the NHS.

The research, which involved surveying more than 10,000 people during 2021 and 2022, asked people to take into account their experiences with the NHS over the past three years. The proportion of those who believe they were harmed during the pandemic period was notably higher than when the survey was previously carried out in 2001 (4.8 per cent) and 2013 (2.5 per cent).

Patients with vision or hearing impairments face safety risks, warns report

A report commissioned by Patient Safety Commissioner Henrietta Hughes has found that those who have vision or hearing impairments face various unsafe situations when seeking treatment, such as being unable to read or otherwise access the information on medication safety leaflets.

Dr Hughes said the research, carried out by Margaret Watson, revealed how some people were subjected to “degrading experiences using medicines and medical devices because healthcare professionals are not sufficiently trained or have not thought through the consequences of their actions”.

But it’s not all bad news…

…New MHRA boss prioritises patient safety

Lawrence Tallon began his role as chief executive of the Medicines and Healthcare products Regulatory Agency at the start of April following his period as deputy chief executive of Guy’s and St Thomas’ Foundation Trust.

Mr Tallon said: “My priorities are patient safety, improving patient access to new medicines and medical devices through risk-proportionate regulation, innovation and growth, and building partnerships in the UK and internationally.”

…New podcast safety series

If you’re passionate about learning about patient safety, what it is, and who and what has shaped it within the UK and beyond, then don’t miss the Stories of Safety podcast, hosted by the fabulous Jane O’Hara. Each episode shares honest, moving stories from those working in and around health and care, exploring what safety really means in practice. The six-part series starts with Sunday Times health editor Shaun Lintern, with a new episode released each month. 

…and there is a great new ISQua white paper on patient safety

The International Society for Quality in Health Care (ISQua) has released a powerful new white paper on patient safety in healthcare organisations, offering a practical, evidence-informed framework to help healthcare leaders reduce preventable harm and embed safety across all levels of care. Aligned with the World Health Organization Global Patient Safety Action Plan, the paper focuses on four foundational pillars: advocacy and leadership; health worker safety; patient engagement; and improvement in clinical processes.

Parents’ voices matter – share your experience of maternity investigations

Manchester University is conducting a study to understand how parents experience maternity investigations after something goes wrong. The work will help the team understand whether investigations or reviews are meeting people’s needs and make recommendations around improving future reviews and investigations for families whose baby has died or been harmed.

If you or someone you know has been through this process — especially as a parent — your insight could help improve how investigations are handled and how families are supported in the future. 

That’s all we have space for in this edition. Thanks for reading! Look out for the next edition from James in a fortnight’s time.

Jeremy Hunt