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National design for ‘new hospitals’ being downsized

The national design for “new hospitals” will be reduced in size, HSJ understands, amid concerns over “unnecessary” space and cost.

The New Hospitals Programme is expected to make changes to the “Hospital 2.0” standardised design that schemes will be expected to follow.

Changes to the national design are likely to include reduced sizes for rooms and corridor areas as part of ongoing design development. It is also understood these changes will reduce costs.

The changes come amid trusts involved in the New Hospitals Programme raising concerns about the scale of the Hospital 2.0 template after the design was updated in May. They said the update would drive up the potential footprint and cost of their schemes, with the size of wards commonly cited as an issue.

The government did not comment on the expected downscaling of Hospital 2.0, but said designs continue to be “developed and refined”.

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Source: HSJ, 7 August 2024

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National Deaf Children’s Society urges NHS trusts to use clear face masks

The National Deaf Children’s Society has written to every NHS trust in England urging them to start using transparent face masks because standard ones create a “serious communication barrier” for deaf patients.

The letters, co-signed by the British Academy of Audiology, said deaf patients could “miss vital information about their health” as opaque masks make lip reading impossible and facial expressions difficult to read.

It is likely that face masks will remain widespread in the NHS, as new guidance issued at the start of June states they will still be required in a number of settings, including cancer wards and critical care units, and staff may wear them in other areas depending on personal preference and local risk assessments.

Susan Daniels, the chief executive of the National Deaf Children’s Society, said: “Transparent face masks are fully approved and they could transform the healthcare experience for deaf people. However they communicate, almost all deaf people rely on lip reading and facial expressions. Opaque face masks make these techniques much more difficult and this could seriously affect communication at a time when they might need it the most.”

Three types of transparent masks, designed not to fog up, are now approved for use as PPE in healthcare settings, and although they are not currently available on the NHS supply chain, they can be bought direct from suppliers. The government previously delivered 250,000 clear masks to frontline NHS and social care workers in September 2020.

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Source: The Guardian, 15 June 2022

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National chiefs: Ventilators will follow ‘most immediate need’

National and regional NHS chiefs will seek to share out scarce ventilators to ”areas with the most immediate need, on a fair share basis relative to patient ventilation need," they have told hospital chiefs, who are increasingly concerned about what they will receive and when.

Many are expecting demand for ventilated beds to outstrip what they have as the number of patients seriously ill with covid-19 ramps up.

Trust leaders yesterday told HSJ they were growing increasingly worried about the lack of information over when the machines would be sent to their trusts. Some are worried London, and other regions which see their demand spike first, will get more supply.

A letter from NHS England and Improvement to trust chiefs late on Wednesday told them that as “extra ventilators become available we will coordinate distribution via regional teams who will work with local health systems”.

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Source: HSJ, 27 March 2020

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National call for action as measles cases surge across UK

A “national call to action” has been made by the UK Health Security Agency (UKHSA) after a worrying surge in the spread of measles in London and the West Midlands.

Professor Dame Jenny Harries, chief executive of the health board, told BBC Radio 4’s Today programme that people have “forgotten what measles is like”, and that children can be unwell for a week or two with symptoms including a nasty rash, high fever and ear infections.

She added that the virus is highly infectious, with health officials warning that serious complications can arise that include hospitalisations and death.

This comes as official figures show uptake of the measles, mumps and rubella (MMR) vaccine is at its lowest point in more than a decade.

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Source: The Independent, 19 January 2024

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National bodies ‘failed to help staff with rationing care during covid’

Six in 10 healthcare professionals said they lacked support from national bodies like NHS England and the Department of Health and Social Care when making decisions about which patients to prioritise for higher-intensity care during the pandemic, according to research.

A similar proportion of staff said they were unable to escalate some patients to a higher level of care, when they otherwise would have, a survey carried out for the covid-19 inquiry found.

The most common reasons given for not escalating were a lack of staff and not enough beds, including for high dependency care and for invasive mechanical ventilation.

It comes as NHS England’s representative, Eleanor Grey KC, urged the inquiry to “bear in mind the resources that were available” and “external constraints… such as the ageing NHS estate”.

Ms Grey also argued the exercise should consider what alternative decisions could have been taken by NHSE, arguing: “Evidence of the harm caused by a measure that was adopted has to be balanced by an equally serious assessment of the anticipated harms of alternatives.”

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Source: HSJ, 11 September 2024

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National audit reveals ‘dire state’ of treatment for stroke survivors

The Stroke Association says stroke care is in a “dire state” in England with too few patients receiving timely treatment and only a third getting the recommended after care.

The charity says, as a result, thousands of stroke survivors are not getting the help they need to physically and mentally recover.

It warned that patients are also facing a “postcode lottery” when it comes to getting a clot-busting treatment, which can significantly reduce the likelihood of long-term disability.

Juliet Bouverie, chief executive of the Stroke Association, said: “Stroke changes a person’s life in an instant with far-reaching repercussions for many. It requires treatments including physiotherapy, speech and language therapy, and mental health support.

“The fact that 65% of stroke survivors don’t get this is truly shocking and demonstrates the dire state stroke treatment and ongoing care is in.

“Stroke must be prioritised by governments and the NHS from prevention to diagnosis, treatment and long-term recovery, only then will stroke patients get the treatment they need, whenever they need it, so the increasing number of UK stroke survivors can live mentally and physically well.”

While stroke patients should be given a review six months after their stroke to discuss their physical and mental health and their ongoing needs, data from the 24/25 Sentinel Stroke National Audit Programme revealed that only 35% of patients had this review – the lowest level since 2019/20.

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Source: The Independent, 29 October 2025

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National ambitions for use of NHS App undermined by plateauing performance

Take-up and usage of the NHS App in England has begun to plateau, after covid drove huge growth, figures seen by HSJ suggest.

This can be seen in the percentage of GP appointments booked or cancelled using the app; the number of records viewed; and the number of times it has been downloaded.

Rapid uptake was driven during covid restrictions, when travel and other activities often required a covid vaccination pass. Government has said it wants the growth to continue.

The number of GP appointments booked or cancelled using the app fell for a third consecutive month in March to 212,954, representing a decrease of 15% since January and 28% on October 2022, when usage peaked.

The NHS app is central to government’s plan for digital health and care, published last year, billed as the “digital front door” to the NHS which would aid the recovery of services post-pandemic.

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Source: HSJ, 19 April 2023

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National alert as ‘coronavirus-related condition may be emerging in children’

A serious coronavirus-related syndrome may be emerging in the UK, according to an “urgent alert” issued to doctors, following a rise in cases in the last two to three weeks, HSJ has learned.

An alert to GPs and seen by HSJ says that in the “last three weeks, there has been an apparent rise in the number of children of all ages presenting with a multisystem inflammatory state requiring intensive care across London and also in other regions of the UK”.

It adds: “There is a growing concern that a [covid-19] related inflammatory syndrome is emerging in children in the UK, or that there may be another, as yet unidentified, infectious pathogen associated with these cases.”

Little is known so far about the issue, nor how widespread it has been, but the absolute number of children affected is thought to be very small, according to paediatrics sources. The syndrome has the characteristics of serious COVID-19, but there have otherwise been relatively few cases of serious effects or deaths from coronavirus in children. Some of the children have tested positive for COVID-19, and some appear to have had the virus in the past, but some have not.

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Source: HSJ, 27 April 2020

Do you work in paediatrics? Have you seen similar trends emerging? What are your thoughts on the concerns raised? Join the conversation in the hub community area: 

 

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National Academies is altering pending reports to appease Trump administration, some members say

The National Academies of Science, Engineering, and Medicine is scrubbing pending reports of words such as “health equity,” “marginalized populations,” and “restorative justice” and replacing them with vaguer terms in an effort to appease the Trump administration, according to a letter protesting the actions sent to the organisation’s leaders and obtained by STAT. 

The National Academies, or NASEM, are widely seen as the nation’s leading science organisation and to many, its conscience. The organisation has been responsible, over the past two decades, for creating and publishing some of the nation’s most seminal reports on health disparities, such as the 2003 report Unequal Treatment which unequivocally stated that racism within healthcare was one driver of the nation’s health disparities. 

The letter, signed by 100 of the academy’s members, said those signing the letter were “deeply disturbed” by the accommodations and said they understood the academy was “taking unilateral action to remove specific words or concepts from pending reports” and such “excessive anticipatory censoring” impacted the scientific rigor and integrity of the reports. Many NASEM reports are a year or more in the making and require the time and expertise of academy members, who are considered leaders in their fields. 

The letter specifically cited an upcoming report, “Blueprint for a National Prevention Infrastructure for Behavioral Health Disorders” that was scheduled to be released in early February but has not been released and said that authors had learned that staff have been instructed to replace words in the report including the term “health equity.” That replacement of certain words, the letter states, appears “designed to appease the current administration.”

Removing the term equity was particularly upsetting to the letter’s authors. “Equity is a core part of NAM’s mission. Our understanding is that staff are being told that these terms are being deleted because equity is not a matter of science. Yet that term alludes to a core value to which we in medicine and public health are deeply committed,” the letter read. Stripping the term, the letter said, “goes against our values as members, the published principles of NAM/NASEM, and decades of scientific work on health inequities,” it continued. 

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Source: STAT, 20 February 2025

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Nasal swab followed by antibody test may catch incorrect COVID-19 diagnoses

Testing people twice for the coronavirus, with a nasal swab followed by an antibody finger prick test, would catch most of those people who fail to get the right COVID-19 diagnosis, researchers believe.

Nose and throat swabs miss around 30% to 50% of infections, say the University of Cambridge team, as the virus can disappear from the upper respiratory tract into the lungs. But they say adding an antibody test can plug that gap. Antibodies show up from about six days after infection.

A team at Addenbrooke’s hospital in Cambridge has piloted the use of combined tests for patients arriving at the hospital. Many arrive with flu-like symptoms and need an accurate diagnosis to ensure they are put on the right wards, so that there is no risk of COVID-19 patients infecting others.

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Source: The Guardian, 2 September 2020

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Nasal decongestants safety review due to rare brain risk

Experts are assessing a very rare but potentially serious brain side effect of nasal decongestants bought on the High Street.

Ones containing pseudoephedrine are being reviewed because they may cause vessels supplying the brain to contract or spasm, reducing blood flow.

The concern is this could lead to seizures and even a stroke. However, drug regulators stress the likelihood of this happening is extremely low.

The UK-wide review for pseudoephedrine was initiated after regulators in France alerted European drugs regulator the EMA, which is also conducting a review, about some recent, rare cases.

Experts say anyone with concerns about medication should speak to a doctor or pharmacist. 

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Source: BBC News, 23 February 2023

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NASA and other innovators work to redesign ventilators for COVID-19 patients

NASA scientists as well as other innovators are busy developing alternatives to the traditional ventilator being used worldwide to treat severe cases of COVID-19.  The movement is in response to growing evidence that in some cases ventilators can cause more harm than good in some patients with low oxygen levels. Statistics tell the story: 80% of patients with the coronavirus die on such machines.

Its VITAL machine is tailored for COVID-19 patients and is focused on providing air delicately to stiff lungs — a hallmark symptom of the virus.

Eight U.S. manufacturers have been selected to make the ventilator that was made in 37 days by engineers at NASA’s Jet Propulsion Laboratory.

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Source: CNBC, 30 May 2020

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Nanotechnology could enable test for early Alzheimer’s Disease

Nanotechnology could be used to test blood for evidence of Alzheimer’s disease years before symptoms appear, researchers have said.

Scientists used nanotechnology to extract previously unseen blood signals of neurodegeneration in a mouse model of Alzheimer’s disease.

They say tests that capture early signs of neurodegeneration in blood offer enormous potential for those who suffer from the disease, as well as dementia patients, to receive effective treatment or manage their progressive condition before significant brain damage occurs.

Alzheimer’s disease can currently be diagnosed using brain scans only after someone has been showing behavioural symptoms, such as memory impairment. By the time symptoms emerge, it is often too late to treat patients effectively.

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Source: The Independent, 17 March 2021

 

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Naga Munchetty: I was failed and gaslit by NHS despite debilitating periods

Naga Munchetty has said she spent decades being failed, gaslit and “never taken seriously” by doctors, despite suffering debilitatingly heavy periods, repeated vomiting and pain so severe that she would lose consciousness.

The BBC presenter, newsreader and journalist told the Commons women and equalities committee on Wednesday that she was “deemed normal” and told to “suck it up” by NHS GPs and doctors during the 35 years she sought help for her symptoms.

Munchetty was finally diagnosed with adenomyosis, a condition where the lining of the womb starts growing into the muscle in its walls, in November last year.

She said she was consistently told by doctors that “everyone goes through this”.

“I was especially told this by male doctors who have never experienced a period but also by female doctors who hadn’t experienced period pain,” said Munchetty.

Munchetty’s diagnosis came after she had bled heavily for two weeks and experienced pain so severe she asked her husband to call an ambulance. Only then was she taken seriously, seeing a GP who specialised in women’s reproductive health. That GP advised her to use private healthcare to avoid lengthy NHS waiting lists.

Munchetty and Vicky Pattison, a television and media personality, were giving evidence as part of the committee’s inquiry into the challenges that women face being diagnosed and treated for gynaecological and reproductive conditions.

The committee is also considering any disparities that exist in diagnosis and treatment, and the impact of women’s experiences on their health and lives.

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Source: The Guardian, 19 October 2023

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Mysterious new long Covid symptom identified by scientists

A new symptom of long Covid has been revealed by scientists at the University of Leeds.

Though most people who contract Covid recover within a few days or weeks of experiencing initial symptoms, some people can experience longer, more persistent symptoms – termed Long Covid or post Covid-19 syndrome by the NHS.

Until now, the most commonly identified symptoms have included extreme tiredness, loss of smell, muscle aches and shortness of breath. Others include memory problems, chest pain, insomnia, heart palpitations, dizziness, joint pain, tinnitus and depression and anxiety. Now, a new study has revealed a previously unidentified symptom of long Covid.

Published in The Lancet medical journal, the research detailed a new symptom of the condition after a 33-year-old man was referred to the specialists’ clinic.

The patient had a six-month history of what the authors describe as a “rapid purple discolouration” on his legs. When standing, he remarked that they would feel progressively heavier and become “tingly, itchy and dusky” in colour. He added that a rash would occasionally appear on his feet, but that the mysterious symptoms would disappear when laying down. The disorder is known as acrocyanosis or persistent and extreme blue or cyanotic discolouration. It typically occurs in the hands and feet but can also appear across the nose and ears.

“This was a striking case of acrocyanosis in a patient who had not experienced it before his Covid-19 infection”, said co-author Dr Manoj Sivan, associate clinical professor and honorary consultant in rehabilitation medicine at the University of Leeds.

“Patients experiencing this may not be aware that it can be a symptom of Long Covid and dysautonomia, and may feel concerned about what they are seeing. Similarly, clinicians may not be aware of the link between acrocyanosis and Long Covid. We need to ensure that there is more awareness of dysautonomia [malfunctioning of the nervous system] in Long Covid so that clinicians have the tools they need to manage patients appropriately.”

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Source: The Independent, 15 August 2023

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Mysterious conditions are afflicting Americans after Covid. It could signal a looming cardiac crisis

Five months after being infected with the coronavirus, Nicole Murphy’s pulse rate is going berserk. Normally in the 70s, which is ideal, it has been jumping to 160, 170 and sometimes 210 beats per minute even when she is at rest — putting her at risk of a heart attack, heart failure or stroke.

No one seems to be able to pinpoint why. She’s only 44, never had heart issues, and when a cardiologist near her hometown of Wellsville, Ohio, USA, ran all of the standard tests, “he literally threw up his hands when he saw the results,” she recalled. Her blood pressure was perfect, there were no signs of clogged arteries, and her heart was expanding and contracting well.

Murphy’s boomeranging heart rate is one of a number of mysterious conditions afflicting Americans weeks or months after coronavirus infections that suggest the potential of a looming cardiac crisis.

A pivotal study that looked at health records of more than 153,000 U.S. veterans published this month in Nature Medicine found that their risk of cardiovascular disease of all types increased substantially in the year following infection, even when they had mild cases. The population studied was mostly White and male, but the patterns held even when the researchers analyzed women and people of color separately. When experts factor in the heart damage probably suffered by people who put off medical care, more sedentary lifestyles and eating changes, not to mention the stress of the pandemic, they estimate there may be millions of new onset cardiac cases related to the virus, plus a worsening of disease for many already affected.

“We are expecting a tidal wave of cardiovascular events in the coming years from direct and indirect causes of covid,” said Donald M. Lloyd-Jones, president of the American Heart Association.

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Source: Washington Post, 21 February 2022

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Mysterious ailment, mysterious relief: Vaccines help some COVID long-haulers

An estimated 10% to 30% of people who get COVID-19 suffer from lingering symptoms of the disease, or what's known as "long COVID."

Judy Dodd, who lives in New York City, is one of them. She spent nearly a year plagued by headaches, shortness of breath, extreme fatigue and problems with smell, among other symptoms.

She says she worried that this "slog through life" was going to be her new normal.

Everything changed after she got her COVID-19 vaccine.

"I was like a new person, it was the craziest thing ever," says Dodd, referring to how many of her health problems subsided significantly after her second shot.

And she's not alone. As the U.S. pushes to get people vaccinated, a curious benefit is emerging for those with this post-illness syndrome: Their symptoms are easing and, in some cases, fully resolving after they get vaccinated.

Judy Dodd suffered lingering symptoms of COVID-19 for nearly a year, until she got her vaccine.

It's the latest clue in the immunological puzzle of long COVID, a still poorly understood condition that leaves some who get infected with wide-ranging symptoms months after the initial illness.

The notion that a vaccine aimed at preventing the disease may also be a treatment has sparked optimism among patients, and scientists who study the post-illness syndrome are taking a close look at these stories.

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Source: NPR, 31 March 2021

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Myla’s mum left with ‘soul‑destroying sadness’

Mother Natalie Deviren was concerned when her two-year-old daughter Myla  awoke in the night crying with a restlessness and sickness familiar to all parents. Natalie was slightly alarmed, however, because at times her child seemed breathless.

She consulted an online NHS symptom checker. Myla had been vomiting. Her lips were not their normal colour. And her breathing was rapid. The symptom checker recommended a hospital visit, but suggested she check first with NHS 111, the helpline for urgent medical help. To her bitter regret, Natalie followed the advice.

She spoke for 40 minutes to two advisers, but they and their software failed to recognise a life-threatening situation with “red flag” symptoms, including rapid breathing and possible bile in the vomit.

Myla died from an intestinal blockage the next day and could have survived with treatment.

The two calls to NHS 111 before the referral to the out-of-hours service were audited. Both failed the required standards, but Natalie was told that the first adviser and the out-of-hours nurse had since been promoted. She discovered at Myla’s inquest that “action plans” to prevent future deaths had not been fully implemented. The coroner recommended that NHS 111 have a paediatric clinician available at all times.

In her witness statement at her daughter’s inquest in July, Natalie said: “You’re just left with soul-destroying sadness. It is existing with a never-ending ache in your heart. The pure joy she brought to our family is indescribable.”

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Source: The Times, 5 January 2020

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My treatment was delayed so long I got cancer – and there are tens of thousands like me

Delays in NHS care have led to almost 40,000 compensation claims since 2010, costing more than £8bn

Sharni Marks endured multiple rounds of chemotherapy, leaving her weak and sick. She has lost her hair and her nails and suffers painful mouth ulcers. Now doctors have told her that her cancer treatment has probably made her infertile and she might need a hysterectomy.

All this was avoidable.

Marks, 31, was diagnosed with cancer last March after waiting more than a year and a half for the double mastectomy meant to reduce her risk of getting the disease.

The NHS has now accepted in a letter to her GP that her cancer developed during her long time on the waiting list. She is not alone.

Since 2010, there have been almost 40,000 compensation claims for injury and deaths caused by delays in care, costing more than £8.3 billion — enough to build 15 hospitals the size of the Queen Elizabeth Hospital in Birmingham.

The data comes from NHS Resolution, which handles compensation claims against the health service, and includes routine surgery and emergency care. The 39,686 successful compensation claims over the past 15 years are attributed to one of eight categories of delay such as surgery or diagnosis. Delay in treatment was the single largest category, costing the NHS £3.9 billion for 19,199 cases. Delays in diagnosis was the next biggest group at 16,164 claims, worth a total of £3.4 billion.

The government has been repeatedly warned about patients coming to harm from long waits. Coroners in England and Wales sent at least 192 warnings about the issue by the end of 2024, up from 62 in 2013.

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Source: The Times, 19 January 2025

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My surgeon experimented on me and ruined my life

Leann Sutherland was 21 and suffering from chronic migraines when one of Scotland's top surgeons offered to operate.

She was told she would be in hospital for a few days and had a 60% chance of improvement. Instead she was in for months while Sam Eljamel operated on her seven times.

"He had free rein on my body. He was playing god with my body and the NHS handed him the scalpel, seven times," says Leann.

When Leann tried to raise concerns with staff she was told that Mr Eljamel had saved her life. She was not told that he was under investigation, nor that he had been later forced to step down.

It was only after seeing recent BBC coverage she realised she was not alone.

The BBC can reveal her surgeon - the former head of neurosurgery at NHS Tayside - was harming patients and putting them at risk for years but the health board let him carry on regardless.

BBC Scotland has spoken to three surgeons who worked under Mr Eljamel at Tayside. All three said he was a bully who was allowed to get away with harming patients.

All three said there was a lack of accountability in the department and that Mr Eljamel was allowed to behave as if he were a "god" - partly because of the research funding he brought to the department.

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Source: BBC News, 16 June 2023

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My son took his life. Why did the NHS ignore the warning signs?

Chris Nichols was one of 2,000 mental health inpatients who died in Essex between 2000 and 2023. The Lampard Inquiry is tasked with finding out why

In one of his final conversations with his mother, Chris Nichols was upbeat and hopeful despite a period of turbulence and poor mental health.

He had phoned Linda Lindsay from Colchester Hospital, in Essex, where he had sought help after the latest in a series of suicide attempts. Despite complaining of voices in his head and acknowledging he had hurt himself, there was a note of optimism as he told her things were going to change.

“He told me ‘it’s all right, Mum, you don’t need to worry. I’m going to get help’,” says Lindsay, 70, recounting the phone call in May 2022. “If only that happened.”

Shortly afterwards, in the early hours of May 30, Nichols was discharged and took a cab home, his right wrist bandaged from the self-inflicted wounds. On June 3 he took his own life at his home in Clacton-on-Sea, aged 44.

Nichols’s mother and stepfather Iain Lindsay, 72, believe his suicide was preventable. He had a long history of mental health issues and alcohol dependency, and had been at A&E on May 24 after overdosing on the anxiety drug Clonazepam.

His relatives cannot understand why, given his risk factors, he was released so quickly, discharged to his GP and advised to self-refer to alcohol related services. They say he was not given a clear care plan or proper support.

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Source: The Times, 25 April 2025

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My schizophrenic son killed his father. We speak every day

Dan Harrison, who had schizophrenia and psychotic delusions about his parents, had been sectioned ten days before he attacked his father. He was detained at Neath Port Talbot Hospital, run by the Swansea Bay University Health Board.

During those ten days he received no treatment or medication. He escaped through a door being held open by a member of staff who was talking to someone else and immediately headed for the family home where he killed his father.

The attack came after Dan's mother, Jane, and her husband repeatedly asked for help from mental health services as their son’s state of mind and behaviour deteriorated. They were refused.

Last month Kirsten Heaven, assistant coroner for Swansea, recorded in a narrative verdict that there had been repeated failings by the Swansea University Health Board and local council. She said multiple system failures had contributed to Kim’s death and warned of more deaths if they were not addressed.

Jane is speaking out now, with her son’s permission, after a Sunday Times investigation highlighted the scale of mental health-related killings in Britain. There have been at least 233 reported since 2020 and there have been repeated warnings about NHS services failing to provide crisis care.

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Source: The Times, 1 June 2024

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My mum's 40-hour wait to get to A&E with hip break

When 85-year-old Koulla fell at home, her family immediately rang for an ambulance. She was in agonising pain - she had broken her hip.

It was around 8pm. It took another 14 hours for an ambulance to get to her, leaving her pregnant granddaughter to care for her through the night.

When they arrived the crews were able to give her pain relief and quickly transported her to the Royal Cornwall Hospital.

But there the wait continued - there were around 30 ambulances queuing to handover patients to A&E staff.

It was another 26 hours before she was taken inside to A&E.

She then faced many hours in A&E before being taken for surgery.

Koulla's daughter, Marianna Flint, 53, said: "It was awful. You feel helpless because you're giving your trust over to them to look after a family member who's in agony and who needs surgery."

She has since received a written apology from the Royal Cornwall for the care provided to her mother in August.

Ms Flint said: "I almost feel sorry for those looking after her. It's not down to them. There was no room inside to accept her in."

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Source: BBC News, 1 December 2022

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My mum took her life after hospital. Yet lessons won’t be learnt

As The Times reports on how the failure to act on coroners’ recommendations costs lives, Lottie Hayton says many are not issuing Prevention of Future Deaths reports in the first place.

Lottie's mum, Carrie, was sectioned on September 16, 2022. When Carrie took her own life two months later, the inquest into her death criticised the care she received and her “rapid discharge”. But, owing to significant flaws in the inquest system in England and Wales, lessons from her care and death will not be learnt.

Four days after Carrie’s admission, on September 20, when the duty doctor came back from bank holiday leave, he “introduced” himself. The brief introductory meeting amounted, according to the medical notes, to an assessment of mum’s mental state. Thirteen minutes after he recorded the introduction, mum was discharged.

The discharge notes read: “Mrs Hayton utilised her leave well and did not present with any suicidal thoughts. It was felt the inpatient environment would be detrimental to her grieving process and her risks could be managed with home treatment and community team support.” That the risks were not able to be managed with home treatment is obvious by the fatal outcome.

The review recommends a clear solution: “Acute Inpatient Operational Policy must take place to ensure clear provision for what should happen when a rapid discharge occurs.” In Carrie’s case, there was no evidence of a policy or process being followed.

At the conclusion of an inquest a coroner can issue a Regulation 28 Prevention of Future Deaths report, or PFD, to an organisation or individual, outlining actions which could be taken by them to prevent future similar deaths.

An average of 500 PFD reports are issued every year but it is ultimately up to an individual coroner to decide whether they issue one. The facts of Carrie’s case and the serious incident investigator’s submission, would, you might assume, lead to the coroner thinking that a PFD should and could be issued with simple recommendations. But the coroner overseeing the inquest in Dorset, chose not to issue a PFD.

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Source: The Times, 15 January 2025

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