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Good morning and welcome to my latest patient safety email. This week we look at rising numbers of preventable, hospital acquired COVID-19 infections, more trouble at Great Ormond Street Hospital and the latest information on what that £9.4m for maternity safety will be spent on. But given we had Professor Whitty and Sir Patrick Vallance in front of the Select Committee yesterday we’ll start with you know what…. Select Committee Session A rather more cordial session than we have had of late, must be the good news about the vaccine. But none the less some interesting comments to my ‘what would you have done differently?’ question: the biggest unknown at the start was the extent of asymptomatic transmission, with Chris Whitty pointing out that even with SARS most transmission is symptomatic, which was why they thought Covid would be similar. They also pointed out the need for more resilience in the public health system to do things like testing, something which Germany was in a stronger position than us. Most interestingly, even though our pandemic preparations may have over-focused on flu, our vaccine preparations did not with the post-Ebola launch of the UK Vaccine Network and the international CEPI fund for developing countries. No surprises then why that side of things came up trumps. Finally, we had a rousing paean of praise for British science to warm the cockles of Gavin Williamson’s heart from Dr June Raine of the MHRA. To lateral flow or not to was another issue Chris Whitty addressed in a question from Barbara Keeley: no test is 100% perfect but all can help reduce risk. Missing half of all positives still reduces risk by 50% - but the issue of false negatives is presumably why care homes still insist on visitors wearing PPE even after their rapid test. But such tests have very low rates of false positives so using them for NHS staff in hospitals should mean low numbers wrongly sent into isolation, which is why there is no excuse that… Hospital acquired COVID is back on the rise Really worrying reports from the weekend that nosocomial COVID-19 infections rose sharply in November. According to the Sunday Times nearly one in five COVID patients in England are still thought to have caught the virus after being admitted to hospital - 7,000 such patients in total including a shocking two thirds of patients at North Staffs Trust. Although some of this can be explained by rising caseloads the variation suggests it is more about infection prevention and control at individual hospitals. The same report blamed crowded A&E departments and problems with the roll out of NHS staff testing which took too long to get going as these SAGE papers from early November show. And this study from October found that one sixth of all cases were hospital staff and their families - you can’t hang around with these decisions in a pandemic. Hospital admissions also increasing The HSJ has sounded the third wave warning bell with many more COVID-19 inpatients than at the start of the second wave. But conversely with the ONS reporting a decrease in positive cases across England there are signs that the restrictions are working. But winter is coming… Duty of Candour at GOSH Great Ormond Street Hospital was in the headlines again this week for all the wrong reasons. This time the Independent has learned that the Care Quality Commission is looking at whether the hospital broke the law in relation to its duty of candour requirements in the case of five year old Walif Yafi. Walif’s parents settled a law suit with GOSH but during that process were not told about the findings of an expert report that cast new light onto his case. As the person who introduced Duty of Candour (which has worked to an extent but not, in fairness, as much as I had hoped) I will be following with interest. Baby Loss continues to be kept on the radar by the most active all-party group I have come across and now have the pleasure of co-chairing with Cherilyn Mackrory who gave an incredibly harrowing speech to parliament about having to give birth to a baby that was not alive. This week we whittled down our potential campaigning themes for next year to continuity of care for pregnant mums, universal access to bereavement care and introducing ultrasound screening for breeches. I am sure we will push for them all, but as readers of this email know all good campaigners need to focus on one big ‘ask’ at a time. Maternity funding details Nadine Dorries has provided more details regarding the £9.4m of funding announced in the Spending Review for maternity safety. The pilots this will fund will provide “cutting-edge training and expert guidance, to improve practice and avoid harm to babies”, help learning and research from recent investigations improve clinical practice, and fund the last year of the Ockenden Review. So this isn’t a replacement for the £8m 2016 maternity safety training fund but useful nonetheless. Later this morning we will see the interim Ockenden review from Donna Ockenden’s inquiry into Shrewsbury and Telford maternity services and I will be asking Nadine Dorries a question on it in parliament at 11.30. HSIB ‘smart’ pumps report In their latest report HSIB look at some of the problems associated with implementing new smart pump medication technologies. There have been cases where these pumps administered incorrect dosages of fentanyl so HSIB wanted to highlight ways to improve the implementation of these systems. Looking at their main findings you see some of the familiar patient safety failings come up including no systematic sharing of any learnings between hospitals and no national guidance on crucial aspects of the technology. HSIB has made two recommendations to address these problems which I hope NHS Supply Chain and MEDUSA implement quickly. Research Corner Interesting read in this piece from the University of Texas about why health professionals find it so hard to speak up when something goes wrong: more than half cited fear of no change or retaliation or fear of negative feedback as reasons why they wouldn’t speak up about patient safety concerns. Things seem better here in the UK with the National Guardian’s Office 2020 Index reporting that in the NHS it is just a quarter of NHS staff who don’t feel secure speaking up about safety concerns - but that is still far too many people. Stat of the week Between 2010 and 2018 there have been 16,553 neonatal deaths in England which according to Matthew Jolly are down 23% over the decade. Stillbirths are doing even better with a 25% reduction - shows what can be achieved. Jeremy Hunt
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