Patient Safety Watch: Safety warnings raised amid strike action

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

As the year draws to a close, the healthcare system is prominent in the national news for all the wrong reasons.

NHS strikes and the risk to patient safety

The full impact of the nursing strikes on 15 and 20 December and the ambulance worker strike on 21 December was not yet clear as this fortnight’s Patient Safety Newsletter was being finalised. However, there were plenty of warnings about what the industrial action might mean for patient safety.

Wednesday’s ambulance staff strike, in particular, raised serious safety concerns. The week before, NHS England elective recovery chief Sir Jim Mackey told an event hosted by the King’s Fund: “The ambulance strike is a completely different order of magnitude of risk [than the nurses’ strike]. I think that’s the main thing people are worried about because of the complexity and fragility of urgent care.”

Guardian health editor Andrew Gregory wrote in an analysis piece on Monday: “There is no doubt that many of those patients making 999 calls on Wednesday will not get the care they need. Some will probably die as a result.”

However, one London paramedic told the i the situation was dire before the strikes, saying: “I’ve had patients where a 999 call has come through to us for a chest pain. You turn up seven or eight hours later and there’s no answer at the door, you have to get the fire service to break it down, and you find someone dead.”

There will be different views on the rights and wrongs of industrial action in circumstances such as these, especially when the risks to patient safety are so clear. Let’s hope both sides in this dispute can work together and further industrial action can be averted.

Lastminute.com

Last week, the government published a formal update (originally due in July) on the implementation of recommendations from the 2020 Independent Medicines and Medical Devices Safety Review. The review, chaired by Baroness Julia Cumberlege, looked at how the NHS responded to concerns over vaginal mesh, sodium valproate and Primodos.

To supplement the report, the Health and Social Care Select Committee held a one-off session, hearing from patient campaigners as well as members of the inquiry team and NHS leaders. During the hearing, Baroness Cumberlege branded the delay in publishing the progress update a “disgrace”, adding: “All this lastminute.com is just not good enough in running our country and running our health service.”

For anyone following progress of the IMMDS review recommendations closely, the full transcript of the session is well worth a read, particularly the powerful testimonies from Emma Murphy and Janet Williams from Independent Fetal Anti Convulsant Trust and Kath Sansom, head of campaign group Sling the Mesh, who have worked so hard to bring about change.

Action to tighten prescribing rules on valproate

Albeit too slowly, change does at least seem to be happening. In view of data showing ongoing exposure to valproate in pregnancy, the Medicines and Healthcare products Regulatory Agency last week published an updated policy leaflet Sodium Valproate: reminder of current pregnancy prevention programme requirements; information on new safety measures to be introduced in the coming months.

The leaflet confirms that, from next year, new safety measures for valproate-containing medicines will be put in place, in particular that two specialists will be needed to independently consider and document that there is no other effective or tolerated treatment for patients aged under 55 years.

Investigation reveals avoidable deaths of mental health patients

An investigation by The Independent has revealed coroners have published at least 50 prevention of future deaths reports raising concerns about the quality of physical healthcare for mental health patients since 2012. The cases, which covered 26 NHS trusts and private health providers, included incidents of staff failing to carry out basic health checks, nurses without adequate resuscitation training, and patients whose health was rapidly deteriorating going untreated.

Research by Leary et al (2021) highlights the substantial opportunity for learning from PFD reports but concludes a more systemic approach to analysis could better inform timely patient safety, organisational and workforce learning. It’s hugely concerning that PFD reports from 10 years ago highlight similar themes to much more recent reports – and another reminder of why current efforts to transform local and national systems for learning from patient safety incidents are so important.

Former vaccines minister encourages constituents to come forward to independent review

As many readers will be aware, senior midwife Donna Ockenden is currently leading an independent review of maternity services at Nottingham University Hospitals Trust. Writing to her constituents earlier this month, former vaccines minister Maggie Throup urged those with concerns about maternity care at the trust, including former and current members of staff, to come forward to provide evidence. Ms Throup is the MP for Erewash, which is less than 10 miles from Nottingham.

Ms Ockenden’s final report is expected in spring 2024.

The end of an era…

Before signing off this newsletter, I wanted to take a moment to pay tribute to Peter Walsh, the longstanding chief executive of the charity Action against Medical Accidents, who retires from his role today. I have a personal story of how Peter’s help made a huge difference to me, but the story I could tell would just be one of literally thousands where Peter and AvMA have made an enormous difference.

As well as helping countless individual patients and families, Peter built a second to none reputation during his career as a leading voice in the patient safety movement – a true champion for patient safety and justice whose work has had a profound impact at a national and international level.

A heartfelt thank you for everything, Peter, and wishing you all the best in your retirement – but also hoping you’ll find other ways to continue your work. The patient safety community isn’t ready to lose you completely just yet!

That brings this edition to an end. Wishing everyone a happy Christmas and all the best for the new year. If you are a healthcare professional working over the festive period, a huge thank you for all your hard work in difficult circumstances. Stay safe.

James Titcombe