Patient Safety Watch: Putting things right when they go wrong

Good afternoon and welcome to the Patient Safety Newsletter, brought to you fortnightly in collaboration with HSJ.

MPs urge government to better redress injured patients

A follow-up report from the health and social care select committee into the Independent Medicines and Medical Devices Safety review raised a number of concerns, including the continued lack of redress for patients and their families who have been harmed by surgical mesh surgery, sodium valproate, and hormone pregnancy tests. Among its many recommendations, the IMMDS – which was published in 2020 and led by Baroness Cumberlege – called for separate redress schemes for the three types of harm it considered. Although the government rejected this suggestion in its response to the review, health minister Maria Caulfield said she would be willing to consider a redress agency and schemes when giving evidence to the committee.

Committee chair Steve Brine said: “We heard heart-breaking accounts of how the health system has failed to provide proper guidance, care and support to women and their families despite them having suffered avoidable harm as a result of medical interventions…

“Crucially, those affected have been unable to get rightful redress because to win a legal claim for compensation they had to prove blame on the part of the healthcare provider. We have been encouraged to hear health minister Maria Caulfield say she is now willing to look at the idea of a redress agency and urge swift progress to rectify years or even decades of hurt.”

…But valproate prescribing problems persist

Research by The Pharmaceutical Journal – which was then reported in the Daily Telegraph – has revealed the number of women prescribed to epilepsy drug sodium valproate has fallen by just 28 per cent between April 2018 and March 2022, from 27,411 to 19,766. This is despite growing concerns about the medication causing devastating birth defects when taken by pregnant women, a ruling from the Medicines and Healthcare products Regulatory Agency to stop prescribing the drug to women of “childbearing potential” and an NHS England target to half the number of women taking the drug by the end of 2023.

Speaking to The Pharmaceutical Journal, England’s patient safety commissioner Henrietta Hughes said she was “very disappointed” so many women were still taking the drug, adding: “This is a far bigger scandal than thalidomide.”

Hospital pays out £39m following error

Frimley Park Hospital in Surrey has reached a settlement for £39m for a girl whose limbs were amputated after she was wrongly sent home from its emergency department, BBC News has reported. Her lawyers said the girl was taken to accident and emergency with “red flags for meningitis and sepsis” but given paracetamol and discharged. When her parents took her back to A&E a few hours later, she was diagnosed with meningococcal sepsis and later developed multi-organ failure, leading to above-knee and elbow amputations in both legs and arms.

Her family brought a claim against the trust, arguing the girl – who has not been named – would have avoided the amputations had she been treated promptly with antibiotics.

More evidence of harm caused by NHS pressures

This week, The Guardian reported on new NHS figures that show a record number of patients suffered severe harm in December due to ambulances waiting to get into A&E. The report states an estimated 57,000 people in England “experienced potential harm”, while 6,000 of these people were exposed to “severe harm”. The Guardian reported health union Unison, which represents many ambulance staff, said the data showed the ambulance service “is barely coping”.

Maternity failures remain in the spotlight…

The past fortnight has sadly seen maternity services remain firmly in the spotlight. Legal firm Irwin Mitchell reported this week that Shrewsbury and Telford Hospital Trust had agreed to accept 80 per cent responsibility for the brain injury of a boy born at the trust in 2011.

Adam Cheshire was born at Shrewsbury Hospital nearly 35 hours after mum Charlotte’s waters broke. In the hours after his birth, Adam struggled to feed, was crying, and started grunting, all signs of early-onset group B strep infection. However, despite the signs of infection, Adam was assessed as “normal” and there was a significant delay before he was transferred to neonatal intensive care.

Commenting on the case, Jane Plumb, chief executive of charity Group B Strep Support said “It’s devastating Adam did not get the care he needed at the time and that the severe disabilities he now lives with as a result of group B strep meningitis could have and should have been prevented.

“The UK falls behind so many countries by not offering GBS testing to pregnant women and people and too often not even telling them about GBS. This needs to change.”

Nottingham University Hospitals Trust, currently the subject of a major investigation chaired by Donna Ockenden, has also been in the news this week after pleading guilty to care failures over the death of baby Wynter Andrews. The Care Quality Commission brought the prosecution under regulation 12 of the Health and Social Care Act (2014 amendments) and is only the second such prosecution brought by the CQC in relating to maternity care failings. As this newsletter was going to press, it was announced the trust had been fined £800,000. 

Wynter’s mum Sarah spoke eloquently and powerfully after the court hearing: “We hope that this criminal prosecution against the trust for its unsafe care will finally be the jolt they need to prioritise patient safety and result in meaningful change… Until there is proper accountability and learning from mistakes, babies and mothers will continue to be harmed and families will continue to have their hearts broken.”

Reflecting personally, so long after the Morecambe Bay Investigation (2015), it is deeply troubling to see maternity safety problems not just persisting, but the same themes reoccurring repeatedly. There seems to be widespread acceptance that, despite a large number of national initiatives to improve maternity safety in recent years, progress to date has been insufficient. Is it time for an honest look back at why this is the case so that lessons can be learned to ensure this history doesn’t keep repeating?

Who cares for those who care?

This week, the Resolution Foundation has published an important briefing note looking at the experience of social care workers, and the enforcement of employment rights in the sector. The notes highlights that pay is “likely unlawfully low for many workers in the domiciliary sector once their travel time is accounted for” and “this, along with funding constraints and the particular demands of the covid period, have contributed to a staffing crisis which is having serious negative knock-on effects on workload and safety”.

Sharing some good stuff…

New guidance to reduce human error and improve safety published

New guidance has been published this week in the journal Anaesthesia (a journal of the Association of Anaesthetists) for clinicians, departments, hospitals, and national healthcare organisations, to enable them to design and maintain safe systems that will reduce the risk and potential impact of human error by individuals or teams.

The wide-ranging guidance addresses issues including the design of operating theatres; well-designed medical equipment and using the most effective equipment; effective use of checklists before operating; encouraging staff of any seniority to speak up if they have safety concerns; the ability to learn from not only situations where things have gone wrong, but also from situations where things have gone well; and training and education.

I can also highly recommend this paper, which accompanies the new guidance and gives a comprehensive overview of current evidence and practice around human factors in anaesthesia.

New standards to improve the safety of invasive procedures in the NHS

The Centre of Perioperative Care has published new National Safety Standards for Invasive Procedures this week to help NHS organisations provide safer care and reduce the number of patient safety incidents. The standards empower patients to be active participants in safety checks, by encouraging them to engage in informed decision-making, to ask questions if something is unclear and to speak up if they have any concerns. The guidance is the result of a huge amount of work and commitment from some brilliant people and represents important progress and significant milestone for the safety on invasive procedures.

Detection of jaundice in newborn babies

A important learning report was published this week by the Healthcare Safety Investigation Branch looking at the detection of jaundice in newborn babies.

The report explores the detection and diagnosis of jaundice in newborn babies, in particular babies born prematurely (before 37 weeks of pregnancy). Specifically, it explores delayed diagnosis due to there being no obvious visual signs of jaundice apparent to clinical staff. The report makes important safety recommendations, including that the National Institute for Health and Care Excellence reviews the available evidence and considers updating its guidance regarding the reliability of visual signs to detect jaundice in newborn babies, particularly in babies with black and brown skin, and the risk factors for jaundice.

The power of Twitter…

As a final share, I’ve said before that social media has its pros and cons but I was blown away this week by the responses to a tweet asking for examples of good work being done on shared/supported decision-making. If this is an area of interest, there are some brilliant examples of initiatives and resources in the replies.

That brings this edition to an end. As well as hoping to bring together a useful round-up of patient safety news, in future editions, we’ll also be sharing some guest blogs on topics that I hope will be of interest to readers – so please do look out for the next newsletter in two weeks’ time.

Thanks for reading and stay safe.

James Titcombe

@JamesTitcombe