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Good morning and welcome to this week’s patient safety update. Today I take a look at a bumper maternity safety Select Committee session, the latest HSIB reports on never events and supporting staff, as well as COVID-19 and how the vaccine roll out is going. VACCINATION NATION 140 vaccinations a minute, four million jabbed so far and the programme moving onto over 70s…this is a real success story where for once we are at or near the top of the international league tables. There are three significant worries though: firstly delays in the supply of the Pfizer vaccine, which I am told makes the Feb 15th top four categories deadline very tight (and impossible if we don’t get 6 doses out of every vial from now on). Secondly this disturbing study from Israel which suggests only 33% efficacy after one Pfizer dose, albeit with the caveat it has not been peer-reviewed and used the most sensitive PCR tests; finally the Brazil variant which may yet prove immune to the vaccine given it appears to come from Manaus where three quarters of the population are thought to have got the virus. Against that is better news from Israel suggesting the vaccine may stop transmission as well as infection. ALL OF WHICH POINTS TO ANOTHER ALMIGHTY BATTLE between cautious scientists and politicians keen to get the economy going. If we do meet the February deadline and avoid the pitfalls above, then after about two weeks the death rate should start to fall dramatically as those top four groups account for nearly nine out of ten deaths. There will then be an enormous clamour to reopen schools and businesses with a big debate about ‘acceptable risk.’ Having been bitten badly on this one so many times before, I expect the government to remain cautious… YESTERDAY WAS THE DEADLIEST DAY TO DATE and many think it will get even higher before it starts to fall. Tuesday’s BBC News at 10 report from inside the Royal London was a heartbreaking must-watch. Overall cases may be starting to decline (although this is worrying) but there is inevitably a lag between cases coming down, admissions falling and the death rate reducing. WHY WE MUST NOT FORGET TEST AND TRACE This still has a big role now - and is our national insurance policy if there are any hiccups with the vaccine plan. The good news that it seems to be coping well with the recent increase in cases and reaching a high proportion of close contacts although not yet meeting the 24 hour testing turnaround ambition. We still need to offer a better financial package to those asked to isolate - why not simply promise to replace lost salary? If it was done through employers the vast majority of fraud could be avoided and people could continue to get their pay in the normal way. NOSOCOMIAL (AGAIN) I realise this is a bit of a hobby horse of mine (and Alastair McLellan’s) but HSJ research shows that hospital acquired COVID has gone up by nearly 50% in a week. Nearly 4,000 cases were caught in hospitals in the week to 10th January and some trusts have seen cases treble in that period, although the overall proportion of patients has fallen from 25% in December to 15% (albeit with many more patients overall). This is particularly worrying as with staff being vaccinated and better infection control procedures you would expect the overall numbers to be going down. The NHS line that hospital cases simply track community cases doesn’t feel convincing, nor does the NHS decision to only count infections that are picked up more than two weeks after admission given that the incubation period can be a lot less than that. REGULATORS ON MATERNITY SAFETY A fascinating session on Tuesday where the Select Committee heard from a variety of experts as part of our inquiry into the safety of maternity services. Good evidence from both Andrea Sutcliffe of the Nursing and Midwifery Council and Charlie Massey of the General Medical Council about their efforts to reduce the fear of speaking out felt by many doctors, nurses and midwives and the importance of eliminating a blame culture. Andrea also spoke about the adversarial nature of our current system and Charlie on the lessons learned from the Bawa-Garba case. Andrea give a particularly strong condemnation of the ‘normal births’ ideology pointing out that their Future Midwife Standards doesn’t use the phrase. Hopefully we can see something similarly robust from the RCM and RCOG. TRAINING AND HSIB We also heard from Professor Jimmy Walker regarding the work of HSIB and how putting them on a statutory footing would improve their work still further by creating a legal safe space for people to share what went wrong and reiterate their independence and permanence to staff. Sara Ledger from Baby Lifeline made a cracking case for the need for further investment in safety training and to ensure that all staff get time as well as funding for that training. Happy 40th Birthday to Baby Lifeline this year - a remarkable organisation set up by Sara’s force of nature mother Judy after her heartbreaking loss of three babies. MATERNITY STAFFING STANDARDS One of the most interesting themes to emerge was on the need for adequate staffing standards and levels. We have a NICE standard for midwives (although it is not enforced) but not yet for doctors. Gill Adgie from the Royal College of Midwives was interesting on this and promised to write with more information about how Trusts could and should use the Birth Rate Plus Assessment to make sure they have proper midwifery staffing levels. And Jo Mounfield from the Royal College of Obstetricians and Gynaecologists argued passionately that with funding the professions could lead the work that was needed to come up with a safety standard for doctor staffing that took into account the complexity as well as volume of births. All in all a great session and lots to chew over. NEVER EVENTS ACTUALLY SOMETIMES EVENTS An important piece of work from HSIB out this morning examining ‘never events’. They found that a number didn’t actually meet the current definition of a never event as the barriers to prevent them from happening weren’t strong or systemic. They therefore recommend that either systemic barriers are put in place or they be declassified as never events. The data on how often never events in general occur (p.14 of the report) is really eye opening and it is clearly worrying that they are still happening in significant numbers each year despite efforts to reduce them - 207 cases of wrong site surgery in 2019 for instance. My own preference would be rather than reducing the number of official never events to implement their other recommendations - namely for NHSE&I to commission work on what barriers to them happening can be introduced and find ways to reduce the variation across the system. SUPPORT FOR STAFF A bit of a bumper HSIB week as they have also published this timely report into the most effective factors for supporting staff following a patient safety incident. Not only is proper support absolutely the right thing to do for the staff themselves but effectively helping those experiencing high levels of psychological harm is also good for patient safety. Anyone who needs convincing on this should also read Clare Gerada’s excellent book Beneath the White Coat on mental illness amongst medical professionals. And if that wasn’t enough they have also opened a national investigation into oxygen issues during the pandemic. ADVISORY BOARD SESSION Patient Safety Watch had the first meeting of its Advisory Board last Thursday and it was great to reconnect with some old friends and colleagues. We had a brilliant discussion on potential areas for research with some strong arguments made for us to look at the impact of litigation on safety, preventable suicides, social care and of course maternity safety. Thank you to all for sparing the time. SOCIAL CARE A timely BMJ editorial on the need to tackle social care once and for all once again reminding me of my new year’s resolution to secure a 10 year plan for the social care sector… AND FINALLY Some Patient Safety Watch housekeeping. We’ve started a Facebook page where we’ll share patient safety and other health related stories every day. It is early days but do take a look and feel free to post any interesting items you come across. Jeremy Hunt
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