Patient Safety Watch: Winter returns with a vengeance

Good afternoon, and welcome to this fortnight’s edition of the Patient Safety Watch newsletter. I start by wishing all our readers a Happy New Year, although I know that for those working in the NHS, it remains an incredibly busy and difficult time.

String of hospitals declare critical incidents amid winter pressures

This week has seen winter pressures bite with a vengeance, with several acute trusts now reported to have declared critical incidents and many others warning their emergency departments are extremely busy.

In particular, the i reported earlier this week that patients at Royal Liverpool Hospital were facing waits of up to 50 hours, while Hampshire Hospitals Foundation Trust said all its beds were full at its Basingstoke and Winchester hospitals.

Meanwhile, ambulance trust East Midlands Ambulance Service declared a critical incident on Monday evening.

It has also been reported this week that patients in the West Midlands may be told to make their own way to hospital due to “significant pressures” on the ambulance service. As first reported in The Sunday Times and subsequently other papers, a leaked memo to staff said category three – urgent cases which could include abdominal pains – and four patients will be told it could be “a number of hours” before an ambulance is available and asked if there is any way they can safely get themselves to the emergency department.

However, the memo added the same message may be given to category two patients – emergency cases, including heart attacks and strokes – when the ambulance service was facing its highest levels of pressure.

Meanwhile, as reported by HSJ, ambulance delays have hit a record high with an average of 2,834 hour-long handover hold-ups every day in the week to 4 January, according to the latest NHS winter sitrep data – the highest this figure has ever been. In addition, the Royal College of Nursing has warned that nursing staff have “never been more worried for patient safety”.

My view? The increased pressure during winter for NHS services, particularly ambulance and emergency services, is largely predictable and happens every year. Personal family experience this week has brought home to me how crucial rapid ambulance responses and admission to urgent care are, with life often hanging in the balance with every additional minute. The pressure and delays reported here will certainly have real-world consequences in lives lost and otherwise avoidable harm.

There must be a better way.

Report downgrades maternity unit to ‘inadequate’, nearly one year after inspection

Mid and South Essex FT’s CEO Matthew Hopkins has described Broomfield Hospital’s “inadequate” Care Quality Commission rating for maternity services as “hugely disappointing”, given the watchdog’s report took 10 months to publish.

The trust claimed the report from the March 2024 inspection took no account of a follow-up inspection in July, adding it had made improvements since the maternity unit was initially assessed.

The report highlighted issues with a lack of staff and beds as well as a lack of understanding about what should be considered a “red flag” staffing event.

My view? Even when problems in maternity services are identified, it is often a struggle for individual services to make the improvements needed. As research commissioned by Patient Safety Watch, published in December, has highlighted, outcome data shows a decline in maternity safety for the first time in a decade, with persisting inequalities and rising costs of harm. This piece from Rob Wilson, head of the Sands and Tommy’s joint policy unit, eloquently describes how maternity services are still not listening hard enough to women and families.

Before Christmas, health secretary Wes Streeting met with families affected by maternity failings (myself included) and has promised to announce further details of the steps the government will take to improve maternity safety soon. Let’s hope that meaningful action will follow soon.

Before moving on from maternity safety, this newsletter has previously covered the tragic case of baby Hayden Nguyen, who died aged six days at the Chelsea and Westminster Hospital in London in 2016.

The full findings from Baby Hayden’s inquest (which concluded in December) have now been published and are available here. Essential reading and learning for anyone working in maternity services.

In other news this edition…

Watchdog failed to properly investigate child’s death, finds ombudsman

The Parliamentary and Health Service Ombudsman has found the CQC failed to fully investigate the circumstances surrounding the death of a five-year-old boy at a specialist centre for children with brain injuries.

While the CQC initially believed the child’s death to be natural, a subsequent inquest found the boy died following entrapment by a loose cot bumper. The PHSO found that, while the CQC had acted correctly based on the information it had immediately following the boy’s death, it should have reconsidered its position once the inquest process brought new details to light.

Ombudsman Rebecca Hilsenrath said: “Regulatory organisations must make sure they examine all the available evidence to uncover the truth for everyone involved and to prevent others from experiencing the same trauma.”

The boy’s foster mother added: “Trying to get answers and accountability for our boy has taken so much time and energy, it’s been a trauma in itself. Your trust in the organisations that you rely on to do the right thing is questioned and it leaves you feeling very vulnerable.”

Mother says son spent last days desperately trying to source much-needed medication

The mother of a man who died following a seizure has spoken about how her son’s last two days were spent trying to obtain the epilepsy medication he had run out of from his GP and then 111, the i has reported.

Henrietta Hastings is now calling for changes to be made to out-of-hours services so those who run out of essential medication do not suffer in the way her son, Charlie Marriage, did.

Learning from deaths – are we getting it right?

Our last newsletter highlighted how recent research had found that the Learning from Deaths guidance, established in 2017, wasn’t fully being followed by most trusts when it was last looked at in 2023. A response to a recent Parliamentary question asking for an update on the percentage of NHS trusts that were meeting all of the national guidance’s requirements confirmed the Department of Health and Social Care does not currently collect this data or monitor compliance. This raises the question as to who does it and whether the situation has improved in recent years.

This is something Patient Safety Watch and the new All-Party Parliamentary Group on Patient Safety will be looking into in more detail in the weeks ahead.

Sharing some good stuff…

Here are a couple of quick highlights for this edition:

SEIPS Masterclasses

The Clinical Human Factors Group has released some new dates for its highly rated Systems Engineering Initiative for Patient Safety masterclass. If your work involves investigating patient safety incidents, please click here for more information.

Investigating the investigators

Many of you will be familiar with Roger Kline, whose fantastic work is always impactful and important. Mr Kline has recently started researching the role of workplace investigations, often commissioned by NHS organisations in response to alleged disciplinary concerns, allegations of discrimination or bullying or in response to staff raising protected disclosures – all areas with clear links to patient safety.

Mr Kline would like to hear from people who have been involved in NHS workplace investigations – whether as the subject of one, as a commissioner, as an adviser or as an investigator – to ask them to complete a survey.

More information and how to get involved is available on Mr Kline’s LinkedIn page here.

Before signing off, I would like to thank paramedics and staff at Furness General and Blackpool Teaching hospitals this week whose care may well have helped save my dad’s life after he suffered a heart attack on Wednesday. Despite the pressures, he received prompt care and the NHS has been outstanding. We have hope that with further surgery and with the brilliant care he is receiving, he could make a good recovery.

That’s all for this edition. Thanks for reading and please look out for our next edition from Jeremy in two weeks.

James Titcombe