Patient Safety Watch: Managers’ regulation long overdue but watch out for unintended consequences

Good afternoon, and welcome to this fortnight’s edition of the Patient Safety Watch newsletter.

Managers to be made legally accountable for patient safety

The Department of Health and Social Care has proposed new protections for whistleblowers, including “a statutory duty of candour which would make NHS managers legally accountable for responding to concerns about patient safety”.

Currently, the duty of candour extends only to organisations registered with the Care Quality Commission, so individuals such as managers and bodies such as integrated care boards, which are not CQC-registered, are exempt.

However, DHSC said the proposed rules – which also include regulation for managers – would apply “at a minimum” to “all board-level directors, integrated care board members, and arms-length body board directors”.

Health minister Karin Smyth, a former NHS manager, said: “To turn around our NHS, we need the best and brightest managing the health service, a culture of transparency that keeps patients safe, and an end to the revolving door that allows failed managers to pick up in a new NHS organisation.”

My view? There have been far too many stories calling into serious question the actions of senior NHS leaders, particularly relating to patient safety concerns and responding to whistleblowers. Strengthening accountability for senior NHS leaders through a system of professional regulation is long overdue, but as with all reform, care must be taken to guard against unintended consequences. This article published by HSJ is well worth a read.

The good news is the government’s consultation on how regulation of managers might work appears detailed and well thought through. We will watch this space with interest…

In other news…

Hospitals under pressure as flu admissions surge

As widely reported – including by The Independent and HSJ – newly published NHS England data has revealed the number of people in hospital in England with flu has increased by more than 350 per cent year on year. 

An average of 1,099 flu patients were in hospital beds each day last week, including 39 in critical care. By comparison, hospitals had an average of 243 flu patients, with nine in critical care, during the equivalent week in 2023.

NHS national medical director Sir Stephen Powis said: “For a while there have been warnings of a ‘tripledemic’ of covid, flu and [respiratory syncytial virus] this winter, but with rising cases of norovirus this could fast become a ‘quad-demic’ so it’s important that if you haven’t had your covid or flu jab to follow the lead of millions of others and come forward and get protected as soon as possible.”

Nursing facing ‘perfect storm for patient safety’

As hospitals face growing pressure, the challenges within the nursing profession further compound the strain on patient care and safety.

Commenting on the most recent Nursing and Midwifery Council registration data – which showed a fall in the number of people joining the profession combined with a rise in the number of people leaving – the Royal College of Nursing warned of a “perfect storm for patient safety”.

The NMC figures revealed the number of people joining the register in the half-year to September 2024 fell by 9.2 per cent compared with the six months to September 2023, while the number of people leaving rose by 6.3 per cent in the same period.

Calling the figures “bad news for patients”, RCN general secretary and chief executive Nicola Ranger said: “As demand for care soars, ministers across the UK need to recognise this as a perfect storm for patient safety and take action to improve recruitment and retention. Working for low pay in understaffed, under-resourced services takes its toll, with burnout pushing highly-trained nursing staff out the door.”

Third of mothers not ‘always’ able to get help during labour

The CQC’s most recent maternity survey has revealed a fall over the past five years in the proportion of mothers who felt they were “always” able to get help from staff while in labour, dropping from 72 per cent in 2019 to 64 per cent in 2024.

The survey also highlighted racial inequalities, with mothers who identified as being from an Indian, Pakistani or any other white background reporting poorer experiences around not being listened to and not receiving help during the antenatal and postnatal periods.

However, the survey revealed some areas of improvement. Among these was a stronger focus on mental health, with three-quarters (76 per cent) of those surveyed saying they were “definitely” asked about their mental health during antenatal appointments.

Families criticise review of disgraced surgeon as ‘final insult’

BBC News has reported that families of children treated by former Great Ormond Street Hospital surgeon Yaser Jabbar have criticised the hospital’s independent reviews of his care, calling them a “whitewash” and a “final insult”.

Mr Jabbar, who performed procedures such as leg lengthening and straightening, left GOSH in 2023 after a Royal College of Surgeons report found some surgeries “inappropriate” and “incorrect”.

GOSH commissioned independent reviews to assess the level of harm suffered by Mr Jabbar’s patients. However, several families have told the broadcaster these reviews failed to accurately reflect their children’s experiences.

A GOSH spokesperson expressed deep regret, adding the hospital wanted “every patient and family who comes to our hospital to feel safe and cared for”.

Ward’s ‘unbearable’ heat leads to mothers, babies and midwives fainting

According to The Times, hundreds of women who have given birth at London’s Homerton University Hospital are demanding improvements to the postnatal ward.

The newspaper said the ward was so hot that some mothers had fainted shortly after giving birth, while others had been left traumatised as their babies went “floppy” due to the heat.

Deborah Sayagh, chair of the Maternity and Neonatal Voices Partnership at Homerton, is quoted as saying: “Over the years, there have been ongoing cases of women or midwives fainting on the wards because of the heat. The heat is unbearable.”

A Homerton Healthcare FT spokesperson said: “We recognise that there are issues around the state of the environment in our post-delivery ward and have been making efforts to resolve these issues.”

Privacy fears deterring prisoners from attending healthcare appointments

A Health Services Safety Investigations Body report has raised concerns that male prison officers accompanying female prisoners to healthcare appointments – including those involving intimate examinations, such as gynaecological appointments – is compromising women’s privacy and dignity. This is prompting female prisoners to decline appointments, the investigators warned.

Dave Fassam, HSSIB senior safety investigator, acknowledged the “complexity” of prisoners’ healthcare, but added: “It can simply be the case that dignity and privacy of prisoners is not considered in the way it should be. This is concerning and we have emphasised it needs to be a priority when prisons are assessing the arrangements for outpatient appointments.

“It is even more important for female prisoners, who may feel vulnerable and anxious about being escorted to their appointment by male prison officers. We know this is a huge factor in appointment refusals and could have a negative impact on female prisoner health, especially if they are having investigations relating to breast or gynaecological cancers.”

Watchdog examines issues with medication not being administered in A&E

Another report from HSSIB, also published this week, considered a patient safety event involving an 85-year-old patient with Parkinson’s who was not given his usual self-administered Parkinson’s medication following an emergency department admission.

The first in a series of investigations exploring medication delays, the report looked at the systems and processes to support staff in recognising prescribing and administering time-critical medications in the ED.

It’s a superb piece of work looking at a common area of patient safety risk that will be of interest to all trusts with EDs. The report contains a list of local-level learning prompts that acute trusts could use proactively to review systems in their organisation to mitigate the risk of a similar medication delay happening – which I hope is widely used.

Sharing some good stuff…

A couple of quick shares for this edition.

After Action Review webinar

HSSIB is running a free webinar on 23 January about After Action Reviews, aimed at those who are undertaking AARs or intend to do so. It should be of particular interest to those using AAR as a learning response under the Patient Safety Incident Response Framework. You can sign up here.

Getting the best out of SEIPS 

The Clinical Human Factors Group has announced more dates for early 2025 for its brilliant three-hour Systems Engineering Initiative for Patient Safety masterclass. The PSIRF encourages NHS investigations to apply SEIPS. More information and how to book is available here.

Patient Safety APPG update

As mentioned in the last newsletter, Patient Safety Watch is thrilled to be part of the secretariat team for the new Patient Safety All-Party Parliamentary Group, alongside brilliant charities Action against Medical Accidents and the CHFG. Having launched just last week, it’s early days for the APPG, but please watch this space for future updates on the APPG’s work and how people can get involved.

National State of Patient Safety 2024

Before signing off, a quick mention that next week is an important one for Patient Safety Watch. On Thursday 12 December, we will be publishing our third major research report, a detailed analysis of the state of patient safety in England in 2024. The work has been carried out in partnership with the brilliant team at the Institute of Global Health Innovation, at Imperial College London, led by Lord Darzi.

We last looked at the state of patient safety in England in 2022, and this new report provides detailed insights into what has changed since then. It comes at an important time for the NHS, with the Dash review looking at the patient safety landscape and the government working on a new 10-year plan for the NHS. We hope our new report, which contains stark and urgent findings, will be widely read and will help inform discussions and thinking about how we can drive forward greater patient safety progress.

That’s all for this edition. Please look out for the next newsletter from Jeremy in two weeks.

In the meantime, thanks for reading and stay safe.

James Titcombe