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Good morning and welcome to the latest edition of my patient safety weekly update. Impossible not to start with the remarkable news that the UK has become the first country to approve a Covid vaccine which is not just great for patient safety but great for…well everything . So this week I look at what is in store between now and the magic moment when everyone who needs it gets vaccinated, alongside issues for people with learning disabilities (a forgotten scandal), the shocking Elizabeth Dixon case, maternity safety setbacks and WHO plans for patient safety next year. One more heave The government got its tier system through on Tuesday night despite 54 Conservative MPs (including many Boris loyalists) voting against. I supported the government on the basis it would be crazy to take our foot off the pedal at this stage, but judging by my constituency inbox it is fair to say the rebels were reflecting widespread frustration in the country at large. Thank goodness for the vaccine news with the Pfizer vaccine being deemed safe to start roll out, the government officially asking for regulatory approval of the Oxford/Astra vaccine and LAMP test trials showing they are pretty accurate - all of which should take the heat out of the issue. Lockdowns do work from an epidemiological point of view, as can be seen in this Imperial paper which shows cases falling by nearly one third in November having been rising the month before. But the big question is whether we could have avoided a second lockdown altogether if Test and Trace had worked better as I asked Dido Harding at the Select Committee. My own view is we over-focused on hitting testing targets and under-focused on key metrics such as the fact that compliance rates with requests to isolate remained at just 20% for much of the summer. Hidden scandal We’ve heard a lot about care homes, but not enough about the issues facing people with learning disabilities, something we looked at this week in the joint select committee inquiry into lessons learned from the pandemic. This group of people are often the least able to articulate their own concerns, particularly as adults when they may not have parents who can advocate for them, and many of them found themselves suddenly cut off from all family contact as we heard on Tuesday at a powerful evidence session. Issues included guidance not arriving promptly for people in supported living, lack of consultation with service users and staff not understanding the rights of residents under the Mental Capacity Act. For a flavour of what it was like at the sharp end we heard from the Chief Executive of a learning disability charity about receiving 100 pieces of guidance in the first 100 days. Not so hidden scandal The Select Committees also heard about the impact of the virus on people from minority ethnic groups. Iain Bell from the ONS explained that even if you take into account the fact that BAME people are more likely to be in higher risk occupations, multi-generational homes, and high density and deprived areas, certain groups were still more than twice as likely to die from COVID-19. Professor Kevin Fenton, the co-author of the Public Health England paper on disparities in the risk and outcomes of COVID-19, was careful with his words (as a PHE employee) but did say he would like to see better data. General theme from all was that the pandemic shone a light on existing health inequalities. Hugging allowed for Christmas New guidance has been issued to care home providers that will allow indoor visitors and hugging to recommence in care homes but how depressing this should end up being ‘good news’ - particularly as people will have to wear PPE to partake. I had pressed the Health Secretary on this issue earlier in the week. It is being made possible with one million lateral flow tests and free PPE. NHS workforce latest Following the pretty weak response from NHSE&I to the Select Committee’s report on delivering core services during the pandemic and beyond, which I wrote about last, I’ve written back to the Secretary of State, Sir Simon Stevens and Prerana Issar asking for better answers. I particularly want to find out if we are ever going to get 10 year workforce projections which the government are currently sitting on. Baby safety shocker 1 Last week the government published Bill Kirkup’s independent investigation into the life and tragic death of Elizabeth Dixon. Elizabeth died nearly 20 years ago just before her first birthday following a series of avoidable mistakes - but what makes this report a tough read is the extraordinary amount of covering up that happened right from the outset. Bill writes starkly in his foreword that “Elizabeth’s profound disability and death could have been avoided had basic clinical principles been followed” and worryingly that “the attitudes, behaviours and systemic problems that have been exposed have not disappeared.” He hits the nail on the head by concluding that “clinical error, openly disclosed, investigated and learned from, should not result in blame or censure; equally, conscious choices to cover up or to be dishonest should not be tolerated.” Maternity safety campaigner and Patient Safety Watch Trustee James Titcombe sets out his sensible response to all of this here. Baby safety shocker 2 Totally depressing news that Nottingham University Hospitals has had its maternity services rated inadequate by the CQC where inspectors found women were being left at risk of harm because of a shortage of midwives and failures by staff to properly assess high-risk pregnancies. It shows just how much work remains to be done five years after the original Kirkup inquiry into Morecambe Bay. More welcome news buried in last week’s Comprehensive Spending Review was £9.4m allocated to improve maternity safety. This money will include “pilots aimed at reducing incidence of birth-related brain injuries.” The government also stated that they will be publishing a consultation next year on improving patient safety and tackling the rising costs of clinical negligence. The consultation appears to be about a new claims handling process for clinical negligence claims of up to £25,000 mentioned here which I am hoping will be the long-awaited Rapid Redress and Resolution scheme I announced as Health Secretary. NICE annual patient safety update NICE has published its first annual patient safety update which was considered by their Board last month. This covers the period September 2019 to September 2020 and actions were focused largely on work related to the Independent Medicines and Medical Devices Safety (IMMDS) review. Great to see NICE throwing its weight behind the agenda. World Patient Safety Day update 105 countries marked the day back in September and monuments or landmarks in more than 80 cities were light up. This year’s theme was health worker safety. I co-chair the steering committee for World Patient Safety Day and we met yesterday to discuss potential themes for next year. Themes under consideration at the moment are medication error, maternity safety or paediatric safety. Jeremy Hunt
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