13th Dec 2018
2018 Annual Newsletter
Now available to download
12th Dec 2018
Annual Social Care Reception 2018
Dare to Care at the House of Commons
12th Dec 2018
NCA Announces 2018 Member of the Year
It was was wonderful to see how much passion and dedication you all have for what you do, and the thought and care that goes into your work every day to improve the lives of those you provide for.
4th Dec 2018
Dare to Care.....
National Care Association's 2019 Care Sector Briefing Paper
30th Oct 2018
PRESS RELEASE - The Budget 2018: Social Care
National Care Association welcomes the announcement of additional funding for vulnerable people being supported by social care providers and the courage of the promise of future sustained investment.
4th July 2018
Old-style Graseby syringe drivers (e.g. MS16, MS16A, MS26)
We are sending the below letter on behalf of interim National Director of Patient Safety at NHS Improvement, Celia Ingham-Clark, who has sent a similar letter to all NHS trusts following the release of the Gosport Independent Panel Inquiry on 19 June 2018. The report highlighted concerns about the ongoing availability and usage of certain models of Graseby syringe drivers, specifically the use of the older Graseby syringe drivers that worked by measuring millimetres of syringe length (e.g. MS16, MS16A, MS26). Please contact NHS Improvement directly with any queries.
Patient Safety NHS Improvement Wellington House 133-155 Waterloo Road London SE1 8UG
26 June 2018
Re: Old-style Graseby syringe drivers (e.g. MS16, MS16A, MS26)
You will be aware of the media interest over the weekend in relation to the Gosport Inquiry and specifically the use of the older Graseby syringe drivers that worked by measuring millimetres of syringe length (e.g. MS16, MS16A, MS26).
A National Patient Safety Agency (NPSA) ‘Rapid Response Report’ was issued in December 2010 requiring organisations to ‘agree an end date to complete the transition between existing ambulatory syringe drivers and ambulatory syringe drivers with additional safety features (as soon as locally feasible, and within five years of this RRR)’. This advice was given not because the Graseby syringe drivers had any mechanical faults, but because the complexities of converting doses to mm of syringe length, and confusion between models that had ‘per 24 hours’ settings and models that had ‘per hour’ settings, had continued to lead to error. By the time of the NPSA RRR, alternative models of syringe driver with enhanced safety features had become available.
The NPSA requirement applied to all providers of NHS funded care in England, including in the independent sector and third sector. Hospices should therefore have acted on the alert at the time. Whilst the NPSA’s remit did not extend to providers who only ever care for privately funded patients, we know that these providers, and the healthcare professionals who work within them, also aim to implement any relevant safety advice.
We are therefore not envisioning any of these older style syringe drivers to still be in use.
However, we would urge you to undertake local checks to ensure that none of the old-style Graseby ambulatory syringe drivers, that worked by measuring millimetres of syringe length, are still in use in your organisation (e.g. MS16, MS16A, MS26).
We are aware that large chains may hold medical device asset registers which should provide the necessary information but we know that often these syringe drivers may have been purchased directly by clinical teams using charitable donations and may not have gone through formal organisational purchasing routes. We would therefore encourage organisations to directly contact all their clinical teams and units to check if they have any old-style syringe drivers.
We would advise that if any of these types of syringe drivers are found to be in use they should be withdrawn as soon as possible; ensuring patient care is not compromised.
Thank you for undertaking this additional check to ensure past safety advice has been fully implemented.
Celia Ingham-Clark MBE, SFFMLM, MChir, FRCS, FRCA Interim National Director of Patient Safety NHS Improvement