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Good morning and welcome to my latest patient safety weekly update. Today is the last day of Baby Loss Awareness Week and the most powerful moment for me was my colleague Cherilyn Mackrory MP telling her story which is the most recent in a long line of MPs (such as Sharon Hodgson) being brave enough to talk about their experiences. I co-chair the Baby Loss APPG with Cherilyn and campaigners have had a number of really useful discussions on its Facebook page throughout the week. The big question is what are we doing to do to bring our neonatal death rates down to Swedish levels (saving about 1000 lives a year)? The Select Committee inquiry in maternity safety is underway and my betting is recommendations on a) measures to stop lawyers getting involved in the process so early b) improvements in training c) the dangers of 'normal birth' campaigning and d) an additional scan during pregnancy...but we have only had one evidence session so we will have to see. CQC and East Kent Hospitals University NHS Foundation At the end of last week the CQC announced that it is prosecuting East Kent Hospitals University NHS Foundation Trust following complications which led to the death of a baby in its care. The Trust is charged with exposing Harry Richford and his mother Sarah Richford to significant risk of avoidable harm. I always have mixed feelings about these prosecutions: where there is gross negligence people must be held accountable but there is always a risk that legal action makes people more defensive and less willing/able to learn from mistakes. Tiers for fears The main COVID-19 news this week was the unveiling by the Prime Minister of the three tier local alert system. As I said in Parliament on Monday the evidence from other countries is that decisive, localised interventions are the best way to address a rise in transmission but the question is whether these measures have been taken on time, not least given documents from SAGE showing the scientists arguing for earlier, national restrictions. We will find out soon enough but a two week circuit breaker over half term seems more likely and given the impossibility of these judgements we shouldn't be surprised if the government changes tack. At least we have the return of ministers taking decisions - the problem with 'following the science' is that it turns Chris Whitty into the Secretary of State which is neither constitutionally proper nor fair on him. Testing times More concerning is what these SAGE documents said about the effectiveness of NHS Test and Trace. Despite all the grief the service is getting the numbers do show capacity up to 300,000 a day and heading for 500,000 by the end of this month which is a sea change from the unfortunate comment by Dr Jenny Harries earlier in the year that 'Test Test Test' does not apply to us because we are a rich country. SAGE argued that T & T may only be having a “marginal impact on transmission” given the gap between ONS stated rates of infection and the numbers actually being tested but in the same paper they also say it is impossible to answer the 'counterfactual' question as to what infection levels would be without such measures. It feels unlikely that the impact on the R rate would be 'marginal' if we weren't doing 300,000 tests a day and more likely that the testing regime is holding the doubling rate at 7-10 days rather than the 3 days it went down to at the start of the March lockdown. Which does not mean it cannot get a whole lot better, not least by working more closely with local authorities as Cumbria shows. Joint inquiry into COVID-19 lessons learned Finally on Covid this week saw the first evidence session of the joint Health and Social Care/Science and Technology Select Committees inquiry on lessons learned from the pandemic. We deliberately chose to focus first on the social care system as it so often gets pushed behind the NHS in these discussions. You can watch the whole session which included some heart-rending testimonies here but one early idea to emerge was an enhanced role for the CQC in assessing pandemic-preparedness in its inspections. Care Minister Helen Whately gave a welcome commitment that no one would be discharged from hospital without a test in any future waves but overall there was a sense that despite warm words about the social care sector by many governments (including me when I was Health Secretary) come an emergency the main focus once again became the NHS. As perhaps the best witness of the day, Professor David Oliver, a think tanker who doubles as a geriatrician at the Royal Berks, said the message 'Protect the NHS' meant that everything else was an afterthought. ‘First Do No Harm’ review response It has been more than three months since Baroness Cumberlege published The Independent Medicines and Medical Devices Safety Review so just why is it taking so long for the government to respond? She has complained, reasonably enough, that ‘babies are still being damaged’ and so the pandemic cannot be an excuse for delay. Among its recommendations were the creation of an independent Patient Safety Commissioner (a good idea, perhaps not as a new standalone quango though as we have too many of those already) and a series of changes to how sodium valproate is used. In answer to Yasmin Qureshi my Labour colleague earlier this month Nadine Dorries, the Minister for Patient Safety, said live litigation prevented her from commenting on when they would respond but I don't understand why this stops comments on all the issues other than legal action for compensation. One very pressing issue is that several hundred babies are still being born disabled every year because their epileptic mothers continue to take Valproate. I think we should be done with guidance and just ban prescribing it to anyone known to be pregnant and have written to Matt Hancock today asking him to do that. Stat of the week World Patient Safety Day on 17 September was marked in 87 countries worldwide with 130 monuments being lit up in orange around the world - not bad for year 2. Jeremy Hunt
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