Patient Safety Watch: The end of an era

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

Just as this newsletter was being finalised, news broke that Sir Keir Starmer had announced plans to scrap NHS England. Speaking in Hull on Thursday, Sir Keir said NHSE would be abolished to “cut bureaucracy” and bring the management of the health service “back into democratic control”. 

This move marks a reversal of a key element of the 2012 Lansley reforms, which established NHSE to oversee the day-to-day running of the NHS. It also comes ahead of the widely anticipated Dash Review, which is expected to recommend further changes to the complex landscape of NHS oversight and regulation.

My view? It’s a bold and welcome move, but history shows that major NHS reorganisations often create distraction. At a time when the NHS faces urgent challenges – lengthy waiting times, problems with maternity safety, and achieving the three big shifts (towards community, prevention, and digital) – adding structural reform into the mix increases complexity and risk. We must also acknowledge this will be very difficult news for NHSE staff, many of whom do fantastic and important work and will now be feeling huge anxiety.

Reducing bureaucracy and duplication is a positive step, but too much political centralisation isn’t. If the Department of Health and Social Care takes on greater responsibility for running the NHS, strong, independent regulation will be more important than ever to ensure transparency and accountability – free from political interference.

All eyes now turn to Penny Dash’s forthcoming recommendations…

In other news….

Pharmacists unable to dispense prescriptions due to shortages, finds survey

In a survey of 500 community pharmacies by the National Pharmacy Association, as reported in the Daily Mail, every single pharmacy said it was unable to dispense at least one prescription every day due to supply problems.

Furthermore, 95 per cent of those surveyed reported patients coming to them daily after being unable to obtain their medication elsewhere.

The issue of medicine shortages was highlighted in January by coroner Christopher Long, who linked the death of two-year-old Ava Hodgkinson from sepsis to delays in receiving antibiotics. The pharmacist her parents visited did not have the prescribed dosage in stock, but, despite having an alternative dosage available, the pharmacist was legally unable to dispense it. 

Patients face 55-hour corridor waits and being told to soil themselves in A&E

A Care Quality Commission report on Medway Maritime Hospital’s accident and emergency department has uncovered shocking failings, including patients waiting up to 55 hours in corridors, and frail patients being told to soil themselves due to staff shortages.

The report rated the department “requires improvement” overall, but “inadequate” for safety.

The hospital’s chief executive, Jayne Black, apologised and noted improvements had been made since the CQC’s inspection last February, but acknowledged much more work was needed.

Hospital did not disclose ‘do not resuscitate’ order until after man’s death, finds watchdog

An investigation by the Parliamentary and Health Service Ombudsman found an acute trust did not tell a 73-year-old man and his family that a do not attempt cardiopulmonary resuscitation order had been put in place for him until after his death.

While doctors can put DNACPR orders in place without patient consent, patients – if they have capacity, or their next of kin if they do not – must be told this decision has been made. In light of this case, the PHSO is calling on healthcare providers to make sure their staff are trained to have timely and sensitive conversations about end-of-life care.

Ombudsman Rebecca Hilsenrath said: “It is a legal requirement that a doctor has a conversation with a patient or their family about DNACPR. Failing to do so is a breach of human rights. In a report published last year, we found that these conversations were not always happening. This must improve as a matter of urgency.”

Medication not given: anticoagulation before and after a procedure

The Health Services Safety Investigations Body has published a report examining a patient safety event involving an 87-year-old man on anticoagulation medication, outlining learning prompts for trusts.

The report demonstrates the highly complex and dynamic nature of clinical decision-making, and why a systems view is necessary to improve medication safety.

This is the second in a series of investigations exploring patient safety events that took place in NHS organisations to understand the local factors that may contribute to patients not receiving medications as planned.

More excellent work from HSSIB and essential reading for everyone working in patient safety.

Police investigation at Letby’s former hospital widened

Several outlets, including BBC News, have reported Cheshire Constabulary has widened its investigation into the Countess of Chester hospital – where Lucy Letby worked – to include potential offences of gross negligence manslaughter. The police had already launched an investigation into corporate manslaughter at the hospital in October 2023.

Ms Letby was convicted of murdering seven babies and attempting to kill seven others while working as a neonatal nurse at the hospital. 

The news comes as the Thirlwall inquiry into the case reaches its closing stages. 

Woman wrongly detained for 45 years

BBC News has reported on an autistic woman known as Kasibba, with a learning disability, who was detained in a mental health hospital for 45 years – 25 of them in long-term segregation – despite having no mental illness.

Kasibba was detained at seven years old and is believed to have been trafficked from Sierra Leone. Her plight was only uncovered in 2013 when clinical psychologist Patsie Staite began a nine-year battle for her release.

Despite government pledges since the 2011 Winterbourne View scandal to move autistic people and those with learning disabilities into community care, more than 2,000 individuals remain detained in mental health hospitals, including 200 children.

The DHSC told the BBC it was “unacceptable that so many disabled people were still being held in mental health hospitals and said it hoped reforms to the Mental Health Act would prevent inappropriate detention”.

Sharing some good stuff…

Celebrating excellence in maternity and neonatal care

The fantastic charity Baby Lifeline hosted its third UK Maternity Unit Marvels (MUM) Awards last night in Westminster. This year’s nominations, submitted by both families and colleagues, highlighted exceptional care and dedication to improving services across the UK. The charity also invited nominations from health professionals to recognise teams that are investing in the future of maternity and neonatal care through education and skills, staff retention and wellbeing, teamwork and collaboration, and service improvements.

A huge congratulations to all the winning teams. A truly fantastic way to recognise the good work that is happening and to share good practice and initiatives that are making a difference.

Learning from failure in healthcare

If you have a spare half hour, I highly recommend this podcast from the fabulous folk at THIS Institute. This episode – hosted by Graham Martin, with guests Jane O’Hara, Helen Crump and James McGowan – discusses the benefits of learning from failure, as well as when things go well. Well worth a listen!

Countdown to Congress

The HSJ Patient Safety Congress – this year focused on “Honest conversations: Putting safety at the heart of reform” – has soft launched for 2025, with an already impressive line-up of speakers including:

• Jeremy Hunt, chair of both Patient Safety Watch and the All-Party Parliamentary Group on Patient Safety
• Penny Dash, incoming NHSE chair
• Nicola Ranger, general secretary and chief executive, Royal College of Nursing
• Sir Julian Hartley, chief executive, CQC

…just to name a few. This year is not to be missed!

For 2025, Congress will focus on implementable patient safety and quality improvements, future-fit innovations, and centralising the patient voice and staff wellbeing amid incredible challenges and pressure. Don’t miss out on two days packed with more than 44 sessions, 11 content streams, 150 expert speakers and the best networking opportunity for patient safety in the UK. The programme at a glance can be downloaded here.

Book tickets now to save £76 on the standard ticket price with preview rate tickets. For group bookings of three or more tickets or for more information about Congress, please contact James Elliot on +44(0)20 7490 0049 or email James.Elliott@hsj.co.uk

That’s nearly all for this edition, but before signing off a quick congratulations to Ramani Moonesinghe, who has been confirmed as NHSE’s new interim patient safety director. Ramani is a highly knowledgeable, experienced and compassionate leader – the perfect person for such an important role during a period of transition.

That’s all for now. Thanks for reading and please look out for the next edition of the newsletter from Jeremy in two weeks.

James Titcombe