Patient Safety Watch: Under ‘extreme pressure’ with a ‘significant workload’

Good afternoon and welcome to this fortnight’s Patient Safety Watch newsletter. As always, it’s been a busy period for patient safety news. With spring in the air, this edition covers not only the inevitable challenges and negative stories which come from writing about patient safety but, I hope, also points to early indications that green shoots of positive change are emerging.

Let’s get stuck in.

Patient safety commissioner warns she doesn’t have enough resources

A letter from Commons health committee chair Steve Brine to health and social care secretary Steve Barclay has revealed concerns from patient safety commissioner Henrietta Hughes. These included that “her office is under extreme pressure, with a significant workload” and that “she believes her resource is ‘too little to make the necessary improvements set out in First Do No Harm’”.

Mental health unit branded ‘chaotic and unsafe’

An NHS England-commissioned report into Tees, Esk and Wear Valleys Foundation Trust found its former West Lane Hospital – which has been criticised over the deaths of three teenagers – was “chaotic and unsafe” and used “excessive and inappropriate” restraint. The report, which was carried out by Niche Consulting, also found the trust’s leadership tolerated high levels of safety incidents.

Maternity safety – reasons for optimism

The Times reported this week that NHS England has announced a new network of specialist NHS centres to provide care for women at the greatest risk of dying in pregnancy or childbirth. The move is part of a national drive to halve maternal deaths and will mean that for the first time women in England with conditions such as heart disease, epilepsy or cancer will have access to specialist care from doctors trained to treat medical problems in pregnancy.

Jacqueline Dunkley-Bent, England’s chief midwifery officer, told the newspaper: “We know that pre-existing medical problems are a significant factor in the variation in rates of mortality for black and Asian women. These maternal medical networks will improve every woman’s access to specialist care for medical problems in pregnancy.”

Professor Dunkley-Bent confirmed last week she was stepping down as England’s chief midwife to start a new international role in May. Twitter has been full of tributes from hundreds of people that show how valued Professor Dunkley-Bent is. We wish her the very best for her new role.

Meanwhile, there was some welcome news from Morecambe Bay this week. Following a letter sent by families raising concerns about the International Normal Birth and Normal Labour Conference due to take place close to Morecambe Bay next month, the University of Central Lancashire – which hosts the conference – has confirmed the word “normal” has been removed from the event’s name. Last year, the Royal College of Midwives published a widely welcomed report which made important recommendations around the language used to describe birth. Although the change in language here may seem trivial, it comes as a welcome sign concerns have been heard and offers a glimmer of hope for less divisive conversations about the changes needed to support safer and more personal maternity care in the future.

But still more to do…

Last week, Nicky Lyon and Michelle Hemmington from the Campaign for Safer Births told me of their concerns coroners are still prevented from investigating stillbirths.

At present, coroners do not have the legal jurisdiction to hold inquests for babies who are registered stillborn in England and Wales. This means these deaths do not get the same independent scrutiny and learning as other baby deaths. This issue was highlighted in the Department of Health and Social Care’s 2017 Maternity Safety Strategy and was included in a Private Members’ Bill which got Royal Assent in March 2019. This resulted in the Ministry of Justice holding a consultation on the topic. This closed in June 2019, but the government has not reported back on it.

Ms Hemmington told me: “It is a disgrace that the law has been passed to allow this, yet the government has delayed implementing this for nearly five years. This is a desperate situation that the government needs to address urgently and allow coroners this jurisdiction.”

Tributes to a much respected and well-loved NHS leader

It was with deep sadness this week we learned Andrew Foster, a much loved and highly thought of NHS leader, has passed away. I met Andrew several times and was always struck by his thoughtfulness and kindness.

In the words of Sir David Behan: “Andrew was a hugely valued colleague on the [Health Education England] Board for the last three years. His passion was people which shone through in chairing our people and culture committee. His focus on making HEE the best place to work and his relentless support for equality, diversity and inclusion made HEE a better organisation.

“We will miss him, his wise counsel, and his ability to ask the right question in a way that was both forensic and supportive. The NHS has lost a great friend.”

Sharing some good stuff….

In the last edition, we mentioned the Black Maternity Health Conference which took place on Monday. If you weren’t lucky enough to attend, The Guardian has published a great writeup of the conference highlights. Congratulations to Sandra Igwe who organised the conference. Sandra is a huge force for good and another reason for optimism!

Staying on the subject of conferences, tickets are now available to book for the annual National Maternity Safety Conference hosted by the charity Baby Lifeline. The conference takes place on 21 September in Birmingham. More information and how to book a ticket here.

Finally, this week I attended a regional Patient Safety Incident Response Framework event in the North West of England. I was struck by how much hard work, effort and progress is being made on the ground.

I’m the first to admit that when writing these newsletters, it’s all too easy to focus on the frustrations and negative news. I make no apology for doing so – we have to be honest about where things are going wrong and what needs to change. However, it’s also easy to lose sight of the fact that on the ground, people are working hard and doing good work every day to improve the quality and safety of healthcare.

In this edition, I hope I’ve been able to touch on some of the positive progress we are making and areas where the green shoots of progress just might be beginning to show. Speaking personally, I’m optimistic about the direction of the National Patient Safety strategy and I believe this work is already making a positive difference to patients and families. This is only because of the hard work, under very difficult conditions, of healthcare staff across the country.

Thanks for reading and please look out for our next edition on 14 April (slightly later than normal due to the bank holiday). Please stay safe.