List of mistakes that should never happen in NHS is extended
NHS hospitals have been warned they will not be paid if patients die or are harmed by staff blunders as a new list of ‘never events’ is drawn up.
A core list of eight ‘never events’ were issued in 2009 covering operating on the wrong part of the body, leaving a surgical instrument inside a patient and the death of a woman following a haemorrhage after a pre-planned caesarean delivery.
Now the list is being expanded to cover more instances of inexcusable mistakes by healthcare staff. The new list includes:
– Death or serious injury from giving a patient the wrong blood or an incompatible organ.
– A death or injury resulting from a patient becoming trapped in bedrails.
– Deaths resulting from an overdose of insulin when given in hospital.
– Giving a patient the wrong gas resulting in a patient dying or being seriously injured.
– Death or injury of a patient while being restrained.
– Brain damage caused by untreated jaundice in newborns.
The list of events will be closely monitored and where they do occur hospitals will not receive payment for the treatment of that patient, with the aim of ensuring lessons are learned.
In the first year there were 111 “never” events reported from the original list of eight, just over half were wrong site surgery.
The National Patient Safety Agency, which monitors errors in NHS hospitals, reported that the wrong site surgery cases occured in a variety of operations and in hospitals across the country.
The report said that full implementation of the World Health Organisation’s Safer Surgery Checklist, in which all theatre staff stop at intervals and run through a set list of checks, should prevent wrong site surgery from occuring.
Simon Burns Health Minister said: “Our recent White Paper makes clear that unsafe care is not to be tolerated. We are committed to extending the system of ‘never events’ – things that are preventable and should never happen to patients in NHS care. We will introduce clear disincentives through non-payments, just as there will be clear incentives for quality.
“Across the NHS there must be a culture of patient safety above all else. These measures will help to protect patients and give commissioners the powers to take action if unacceptable mistakes happen.”
NHS Medical Director, Professor Sir Bruce Keogh said: “Never events by their very name should never occur in a modern NHS. The proposed list includes avoidable incidents with serious adverse consequences for patients.
“No one wants these to happen, therefore we will not pay hospitals when these events occur. This will send a strong signal to leaders of the organisation to learn from their mistakes so they don’t happen again.”
British dinner lady in ‘grooming for sex’ row with education chiefs after giving pupil a BISCUIT
More bureaucratic evil
A dinner lady was warned she could be accused of ‘grooming’ a primary school pupil after she gave him a biscuit. Pat Lavery, a catering supervisor, handed the boy a biscuit after he asked for one. The child and the woman are related.
But the following day, she was warned that her action could be interpreted under child protection legislation as ‘grooming’ the child for sexual exploitation. She was so upset that she refused to return to work at St Mary’s Primary School in Co Fermanagh, Northern Ireland, until the row was sorted out. During this time, she was threatened with the sack and suffered a ‘horrendous’ two years of rumour and innuendo.
Yesterday her husband, Eoghan Lavery, said: ‘It has been a horrendous two-plus years for my wife because there was a shadow hanging over her that she’d done something wrong.’
His wife was made to attend three meetings, firstly with the acting principal then two with the school principal to discuss the biscuit incident. One of the meetings lasted more than an hour and when she was requested to attend a fourth meeting, she left her job because she was so upset after being subjected to ‘a grilling’.
The incident was reported to Northern Ireland Ombudsman Tom Frawley, who heard that during her absence the woman’s parish priest was told by the principal that she was absent from school due to a ‘serious child protection issue’.
Mr Frawley said Mrs Lavery should receive an apology for her treatment. She will also receive compensation.
The dinner lady told the ombudsman that in May 2008 she was working in the school kitchen when a child raised his hand and asked for a biscuit. She brought this to the attention of the catering assistant who was serving biscuits and gave permission that the child could be given one.
She said that the next day, the Key Stage 1 manager, who was acting principal, came to the kitchen and told her that under the Child Protection Act she could be seen to be grooming a child. The child in question is a relative of Mrs Lavery.
Mrs Lavery then endured a meeting at which the matter was considered resolved. But when the permanent principal returned to work, she told of the potential child protection problems.
She told the ombudsman: ‘I left the meeting very upset and confused… I felt that I had been subjected to a grilling and a “wrist-slapping exercise”.’ She also told the inquiry that she gave no preferential treatment and any child approaching the serving hatch would have been treated in the same manner.
A further 40-minute meeting took place and when the principal sought a further meeting with her she decided to leave her job. She was informed that if she did not return to St Mary’s by February this year she would lose her job.
She said she was ‘aggrieved’ that the principal told the parish priest she was absent from school due to a ‘serious child protection issue’.
The ombudsman said the board did take the initiative to arrange temporary postings for Mrs Lavery in other schools while a resolution to her complaint was being sought. But he noted his ‘concern’ that Mrs Lavery was informed that if she did not return to St Mary’s by February 1 her employment would be terminated.
‘It is my view that the abrupt manner in which the board informed her of that development was highly insensitive to her position… it made her feel very anxious about having to return to a working environment in which there was still a lack of policy or procedure for dealing with any future grievances she may have had about her non-board co-workers,’ the ombudsman said. The threat to terminate her employment if she failed to return was ‘entirely inappropriate’.
A deal was eventually reached between the school and Mrs Lavery and she returned to work.
In a statement, the school said: ‘We understood that the issues were resolved to the satisfaction of the individuals involved using mediation through the Labour Relations Agency.’
Mervyn Storey, chairman of the Stormont Education Committee, said that while rules were there to protect children and staff, this was a case of ‘political correctness gone too far’. ‘I think it’s a sad situation that schools are so boxed in because of legislation,’ Mr Storey said.
A modern-day witch hunt in Britain
Eureka, the science magazine from The Times, is in many ways a brilliant accomplishment. Advertising is following readers in an online migration – but James Harding, the editor, personally persuaded advertisers that a new magazine, in a newspaper, devoted to science would work. And here it is: giving the New Scientist a run for its money every month.
That’s why it’s such a shame that today’s magazine opens on an anti-scientific piece denouncing those who disagree with the climate consensus. My former colleague Ben Webster, now the paper’s environment correspondent, is an energetic and original journalist – so it’s depressing to see his skills deployed in a game of hunt-the-heretic.
The magazine’s list of 100 greatest scientists is preceded by a heretic list of five ‘sceptics’ who are denounced on the flimsiest of grounds. Bjorn Lomborg is no.1. “He appears to concede that man-made global warming is a serious problem,” says Webster. Appears to? He has explicitly stated this, time and time again. His argument is that we must introduce proportion to the debate: ask what these expensive solutions actually achieve. And ask whether, if saving lives is the priority, money could be spent in better ways. Webster finds him guilty of “producing alarming statistics that suggest cutting carbon is too expensive”. Strikingly Webster does not say that his figures are wrong, or exaggerated. To dismiss studies because the conclusion is wrong is not science, but spin.
Next, Nigel Lawson and his Global Warming Policy Foundation. “This ‘think tank’ of retired grandees gives sceptic arguments a veneer of authority,” he complains. Might that be because the board’s credentials are impeccable? That they include former Cabinet Secretaries with no skin in the climate change fight – other than dismay at the anti-intellectual way the debate is conducted?
Bafflingly, Sarah Palin is next. She is credited with “exploiting the University of East Anglia emails to undermine last December’s Copenhagen summit”. Can anyone remember the part in that summit where things were going swimmingly until Palin intervened? My recollection is of a summit buckling under the weight of its own contradictions. The idea of sourcing the doubt – even the emails – to Palin is certainly novel. Webster also claims that her influence “helps to explain” why Obama ‘has shelved plans for legislation to cut back on US emissions”.
Christopher Monckton, the sceptic peer, is next – like Palin, his intellectual influence is great. “He plays to full houses in the US and Australia”. This is reminiscent of Naomi Klein’s theory in No Logo: that free market economics have no force in their own right, but emanate from Bad People (Friedman was hers).
Steve McIntyre is perhaps my favourite. “Feared by climate scientists for his doggedness in hunting down flaws or inconsistencies,” Webster says – and this is, apparently, enough to qualify him for the “infamous five” list. Proper science invites refutation. Denouncing people for pointing out “flaws” is not science.
Webster finishes off by saying that sceptics are over 60 “so few will be alive in 20 years’ time to see the consequences of their efforts to resist global action on climate change”. But this raises another point.
At the launch of Nigel Lawson’s excellent think tank (which acknowledges that global warming is real and a problem – a point Webster didn’t make, no doubt due to lack of space), I was approached by one of its directors – someone, again, with a distinguished record in public life. “Looking around, most of us are retirement age,” he said. “That’s because if you’re young, and you raise the slightest objection, your career is over. You will be ostracised, and if you have any profile the press will destroy you. So its only my generation, with nothing to lose, who can make these arguments in this hysterical intellectual climate.”
Webster’s piece proves his point. Even journalists, whose job is normally to probe and question, have become cheerleaders for a cause. There is a mood of hysteria – and before CoffeeHousers go the other way and attack Webster, I’d like to say that he is not one of those journalists. His reporting in Copenhagen and afterwards fully reflected both sides of the debate – which is why it’s so strange to see this piece from him today. And even stranger to see it commissioned by a science supplement – when scientific progress depends on the the type of refutation and questioning which Lomborg, Lawson and McIntyre have brought to the debate.
As for Palin and Monckton – Webster wasn’t really serious. I hope.
Green Subsidies Will Have Disastrous Effect On UK Economy
Pandering to policy makers who see the future of UK energy defined by expensive “eco-bling” solutions will have disastrous effects for the government and for consumers.
That’s the warning from the incoming president of Europe’s largest engineering membership body. Dr. Nigel Burton, who formally assumes the presidency of the Institution of Engineering and Technology (IET) this Thursday, will offer credence to the coalition government’s position of reviewing the UK’s energy framework.
In a call to action for the engineering policy community, Dr. Burton will suggest that there need be no gap in time before money-saving energy policy can be introduced. This could be achieved, he says, by reducing subsidies for some current high-cost, low-saving initiatives.
In his wide ranging inaugural speech, Dr Nigel Burton says some technologies “are a serious misallocation of resources if the principal objective is cost-effective emissions reduction. Early enthusiasm for domestic wind turbines has waned as it has become clear that in general these have no economic value and in some cases consume more electricity than they produce.” The subsidies for solar photovoltaics risk repeating the expensive mistakes made in Germany.
Dr Burton argues that “Reducing carbon emissions by 80% by 2050 will require a complete redesign of UK energy production and consumption.” He goes on to say that these changes will require investment of an estimated £400 billion by 2050.
One of his key recommendations is to focus on the decarbonisation of electricity production. He also claims that widespread public “conversion to electronic vehicles should be given a high priority.” He goes on to make the wider point that “most hopes of achieving the carbon reduction targets rest on increased electrification of the economy and decarbonisation of the power sector.” However, that is no easy change as about 78% of electricity generation is currently from coal and gas.
Dr. Burton, makes his opening address at the IET’s London headquarters, with a widely anticipated discourse on energy, entitled ”Keeping the lights on – an inconvenient truth’. The lecture will be attended by IET members, policymakers and the public.
Green Jobs Utopia Goes Up In Smoke
A whine from “The Guardian” below
Plans to build three new factories to make thousands of giant offshore wind turbines that would create an estimated 60,000 jobs are set to become the latest casualty of the spending review, it has emerged.
The previous government had pledged £60m to upgrade ports, mainly in the north-east, to enable them to handle the next generation of giant turbines for installation off the UK coast.
Siemens and General Electric have announced plans to invest £180m in two new manufacturing facilities in the UK, but say this is conditional on the necessary work on nearby ports. Mitsubishi is also interested in building a third factory.
But the Guardian has learned that the competition inviting ports to bid for the funds is likely to be scrapped. Officials at the Department of Energy and Climate Change (DECC), which is to provide half the £60m required, are still fighting for the funds. However, they have little support from the Department for Business, which would have to find the other half, or from the Treasury.
The energy secretary, Chris Huhne, is understood to be determined to set up a Green Investment Bank, which will have to take public funds for existing renewable and low-carbon schemes, such as the ports, to have sufficient capital.
The Guardian has also learned that the nuclear industry has successfully lobbied the government to safeguard the huge budget to decommission the UK’s old reactors, handled by the Nuclear Decommissioning Authority. This year, about 60% of the NDA’s budget – £1.7bn – came from taxpayers via the DECC, making up about 40% of the ministry’s entire spending.
In opposition, the Conservatives had wanted to cut about 25% of DECC’s funding to the NDA. But after the election, industry executives outlined to ministers the urgency of the clean-up of Britain’s nuclear sites, particularly Sellafield in Cumbria. One source said: “We succeeded in scaring David Cameron off.” The NDA, which is cutting its own operating budget, could even secure a slightly higher funding settlement than this year.
MPs will debate the ports programme in the House of Commons on Tuesday, with the trade body RenewableUK warning that 60,000 jobs are at stake. No final decision has been made either on the £60m ports plan or the NDA’s budget, with the funding settlement for DECC only expected to be formally agreed just before the Treasury’s publication of the spending review on 20 October. It is thought that the most that would be available would be funds to upgrade one port.
But the scrapping of the ports competition will sit uneasily with Cameron’s declaration that this “would be the greenest government ever”. It will also raise questions about the government’s commitment to help the economy grow out of recession, in particular by boosting hi-tech exporters. It has already axed an £80m government loan to the engineering firm Sheffield Forgemasters.
Huge bureaucratic waste by Britain’s Left
Labour wasted hundreds of millions of pounds on empty offices and mobile phones for the most junior civil servants, it will be revealed today.
Sir Philip Green, who has been brought in by the Tories to eradicate government waste, says taxpayers may even have paid for officials’ personal calls on their free BlackBerrys.
The owner of Topshop and BHS will today publish a report exposing how departments sometimes have no idea what they are spending public money on.
Cabinet Office minister Francis Maude, who has seen the report, said it showed that financial controls across Whitehall are ‘lamentably bad’. The Government could use the report as justification for a massive round of cuts to departments.
David Cameron caused controversy in August when he appointed Sir Philip to produce the report on how government could make better use of its assets, property and kit. His Lib Dem coalition partners – led by Chris Huhne – were annoyed because the Topshop owner is rumoured to have avoided paying UK tax.
The report will show that public sector bodies are spending £10million a year on empty offices, including space in Victoria, central London, for the Highways Agency.
The billionaire has found that thousands of officials get free BlackBerrys and other mobiles, despite working nine-to-five at their desks. And he says millions of pounds are being wasted because police authorities are paying over the odds for uniforms.
An official said: ‘Sir Philip was also amazed that different police authorities order the same uniforms separately from the same suppliers. They could be saving millions of pounds if they bought in bulk.’
His study will show that different departments are paying massively varying prices for the same furniture, office supplies and computers.Sir Philip also looked at spending on advertising, consultants and PR.
Mr Maude said he would be introducing strict limits and rules on spending. For example, every IT project worth more than £1million would have to be signed off by him.
A Downing Street source said: ‘Sir Philip has found waste on just about every item you could imagine a government department spending money on – desks, computers, pens. You name it, it’s there.’
Sir Philip and his wife are worth more than £4billion. Energy secretary Mr Huhne has said his appointment as advisor had sent the ‘wrong message’. He has said: ‘Philip Green could clearly, if he were to arrange his tax affairs in a different manner and spend rather more time in the country, be paying rather a lot more tax.’
Now it’s beetroot juice!
It appears to give elite athletes a tiny extra edge but drinking a lot of it has unpleasant side effects
When Chris Carver ran an ultra-marathon in Scotland last year, which challenges athletes to run as far as possible within 24 hours, he ran 225 kilometres.
Determined to do better in this year’s race, Carver added something extra to his training regime: beetroot juice. For a week before the race, he drank the dark purple juice every day. Last month, Carver won it by running 238 kilometres. “The only thing I did differently this year was the beetroot juice,” said Carver, 46, a professional runner based near Leeds, in northern England.
He said more exercise would have improved his endurance, but to get the same result he attributes to the juice – an extra 13 kilometres – it would likely have taken an entire year.
Some experts say adding beetroot juice to your diet could provide a performance boost even beyond the blood, sweat and tears of more training.
In two studies conducted at Exeter University on 15 men, Stephen Bailey and colleagues found cyclists who drank a half-litre of beetroot juice several hours before setting off were able to ride up to 20 per cent longer than those who drank a placebo blackcurrant juice.
By examining the cyclists under a scanner that analyses how much energy is needed for a muscle to contract, Bailey and colleagues discovered beetroot juice allows cyclists to exercise using less oxygen than normal.
“The beetroot juice was effective even without any additional training,” Bailey said. “It reduces the energy requirements on your muscles so you can last longer.” While the beetroot juice was provided free by its manufacturer, Exeter University paid for the research.
Bailey said the high nitrate content of beetroot juice is responsible for its athletic benefits. Scientists aren’t exactly sure how it works, but suspect having more nitric oxide in your body, a byproduct of nitrate, helps you exercise with less oxygen. Bailey said the same effects might be possible if people ate more nitrate-rich foods like beetroot, lettuce or spinach.
Bailey and colleagues calculated beetroot juice could translate into a 1 to 2 per cent better race time, a tiny improvement likely only to matter to elite athletes. They are still tweaking the dosage but say athletes should consume the juice a few hours before training so their body has time to digest it. Their latest study was published in June in the Journal of Applied Physiology.
“Drinking beetroot juice is not going to turn a recreational runner into an Olympic champion, but it might make tolerating more exercise easier so you can train more,” said Dr Andy Franklyn-Miller, a sports medicine expert at the Centre for Human Performance in London. He was not connected to the research and has not received any funding from beetroot juice makers.
Franklyn-Miller said since people often reach an athletic plateau where more training doesn’t help, beetroot juice could give you an extra edge you wouldn’t get otherwise. “It’s not banned, so there’s no reason not to try it,” he said. Still, he warned drinking too much of the juice could lead to side effects like abdominal cramps, diarrhea or purple urine.
Previous studies in Britain and the US have found beetroot helps the heart by lowering blood pressure.
Other experts warned manipulating your diet can’t replace the benefits of training. “Certain foods can help you maximise the benefits from exercise, not reduce the amount you’re doing,” said Roger Fielding, director of the Nutrition, Exercise Physiology and Sarcopenia Laboratory at Tufts University. He was not connected to any research on beetroot or any other nutritional supplements.
For serious athletes, Fielding said changing your diet could help. “If a very small improvement is valuable to you, it’s possible something like beetroot juice could do that,” he said.
Other studies have shown drinking things like pickle juice or having a small carbohydrate snack during a marathon, can prevent cramps and improve performance. Scientists have also found cherry juice, which helps reduce exercise-induced swelling, could be strong enough to reduce some athletes’ use of anti-inflammatory pain medication.
Fielding said the benefits of beetroot juice and other foods and drinks could have wider benefits and might one day be used to help elderly people with muscle weakness.
Some elite athletes warned beetroot juice may not be to everybody’s taste. “A few of my friends think it’s really disgusting,” said Colin McCourt, 25, a British runner competing at the Commonwealth Games in New Delhi this month.
In April, McCourt started drinking cherry and beetroot juice, which he credits with helping him train longer and more often. “I feel like I get a benefit from it, even if it’s minimal,” he told Associated Press Television.
McCourt said he will continue to adjust his training regimen in preparation for the London 2012 Olympics, but plans to maintain his juice habit. “There will be a lot more beetroot juice if my stomach can take it.”