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Isle of Wight NHS Trust 'no longer inadequate or unsafe'

An NHS Trust, rated inadequate for more than two years, has been awarded an improved grade by inspectors.

Isle of Wight NHS Trust has made "improvements in most areas" and is no longer unsafe overall, the Care Quality Commission (CQC) said. Although it recommended the trust should remain in special measures, the CQC gave the trust a rating of "requires improvement".

The trust said it welcomed the change and was committed to improving further.

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Source: BBC News, 4 September 2019

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Is WHO’s surgical safety checklist being hyped?

In a recent BMJ 'Head to head', the authors argue whether the World Health Organization's (WHO) surgery safety checklist saves lives.

Studies show that the WHO's surgery checklist saves lives around the world, say Alex Haynes and Atul Gawande. But David Urbach and Justin Dimick argue that there’s not enough evidence to say for sure.

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Source: BMJ, 5 August 2019

 

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Is the system letting down people who were harmed by Covid vaccines?

There is nothing in life that is free of risk. That includes vaccines. But the evidence is compelling that the benefits of getting immunised with those vaccines recommended in the UK far outweigh the possibility of serious side effects.

The level of benefit from Covid vaccines is well documented. And the Oxford/AstraZeneca vaccine is credited with saving more lives, external in the first year of its use than any other - 6.3m globally compared to 5.9m for Pfizer/BioNTech’s jab.

However, we need to discuss not just the huge positives that Covid vaccines brought, but also the small minority left injured or bereaved by the AstraZeneca vaccine.

Around 50 families affected by rare blood clots have begun a group legal action for compensation under the Consumer Protection Act, arguing that the vaccine was not as safe as the public were entitled to expect.

They are a tiny fraction of all those vaccinated, but that is no comfort to the families affected, who feel like they have been airbrushed out of the pandemic and that their pleas for support have been ignored.

Those families include Jane and Ian Wrigley from Buckinghamshire. Jane, 62, used to run, ski and climb mountains. Now she can barely walk due to extreme weakness down her left-hand side.

Two weeks after receiving the AstraZeneca vaccine in March 2021, Jane was admitted to hospital. She suffered blood clots in her brain and required emergency surgery to remove part of her skull. Jane’s medical records clearly state that she suffered these blood clots as a direct side effect of the vaccine.

Her husband Ian is now her full-time carer. Jane told me: “Before I had the vaccine I was a very independent, active woman doing half marathons and enjoying my life. Now I’ve lost every bit of independence.”

Her case, and those of others affected by blood clots, raises serious questions about whether the system is letting down those who have suffered serious harm as a result of taking Covid vaccines.

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Source: BBC News, 23 October 2024

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Is the NHS in a position to handle the Covid Omicron variant?

How much of a threat does the emergence of Omicron pose to the NHS? Among hospital bosses there is a curious combination of apprehension that the new variant could lead to a surge in infections but also a battle-weary belief, born of negotiating the previous waves of Covid-19, that they can handle a potentially major rise in people seriously ill with the disease.

“Trusts are already making contingency plans for what would happen if there were to be a significant spread of this variant and it turned out that the symptoms and disease produced as a result is as serious as with the Delta variant,” said Chris Hopson, the chief executive of NHS Providers, which represents health service trusts in England.

He added: “If it turns out that this variant does evade vaccines then clearly the NHS will see a significantly higher caseload than it has at the moment.” Hopson pointed out that when the second wave was at its worst in January, hospitals in England were treating 34,000 people with Covid. On Monday, it was far, far fewer – just 6,094.

He said: “The chief executive of a district general hospital told me today that they were going through plans for how they would expand critical care capacity, and their general respiratory support capacity, because that’s exactly what they needed to do last January when we had over 34,000 cases.

A return to that number of hospital beds taken up with Covid patients would again force hospitals to cancel planned operations, he said. “If we get anywhere near the 34,000 cases we saw in January, then something would have to give. Elective surgery could be cancelled. As we saw last January, we would need to prioritise [care] on the basis of clinical need.”

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Source: The Guardian, 29 November 2021

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Is the CQC giving the NHS an easy ride?

The purpose of Care Quality Commission (CQC) ratings has been a hotly contested question since the creation of the four category classifications in the last decade.

The original idea was to give the public a sense of how good their local hospital was, as well as providing commissioners, system managers and government with an idea of whether the local, regional or national health services they had responsibility for were getting better or worse.

The practicality of the first aim was always questionable given the public’s inability and unwillingness, in most cases, to take their custom elsewhere. The second ran into the lack of desire and/or courage on behalf of most commissioners to challenge their local provider, but it did seem to have traction at the top of the shop.

Jeremy Hunt, told HSJ, once they had been dished out across the sector, that their CQC classification now mattered much more then whether or not it had achieved foundation status or not.

Another function, whether intended or not, was that by splashing “inadequate” and unsafe care on the front pages, in the wake of the Francis report, CQC ratings fuelled a drive to put more staff on the wards (forcing the Treasury to pay for the consequent agency bills and deficits, and curtailing Simon Stevens’ transformation funds).

Whatever your take on their purpose, however, they only make sense if they accurately reflect the state of the service. And the latest data suggests that may not be the case.

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Source: HSJ, 17 March 2022

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Is nitrous oxide a climate risk? Yes, but doctors say effective pain relief in childbirth should be the priority

Greenpeace and obstetricians have questioned a scientific report warning pregnant women to consider alternatives to nitrous oxide as pain relief during childbirth because of the environmental impact of its emissions.

A report in Australasian Anaesthesia notes that while nitrous oxide – known as laughing gas when used as an anaesthetic – is an effective method of pain relief during labour, the gas represents 7% of global emissions, according to the World Meteorological Organization. 

Using nitrous oxide as pain relief during a four-hour labour creates a carbon footprint equivalent to driving an average car for 1,500km, the report’s authors found, whereas an epidural is equivalent to driving 6km.

The report explores methods to capture and destroy waste from the nitrous oxide, and suggests that pregnant women consider alternatives, such as epidurals, as well as acupuncture, massaging and hypnobirthing to manage their pain during labour.

“While it may be innocuous for the pregnant woman and unborn baby, that is certainly not the case for the environment,” the report states, noting its use should ultimately continue in some capacity due to its convenience and safety.

A Greenpeace spokesperson said that the health sector accounts for about 7% of Australia’s emissions, and that while it was important for all industries to assess their climate impact, the focus should be on the worst polluters such as the energy sector.

Associate Prof Gino Pecoraro, president of Australia’s National Association of Specialist Obstetricians and Gynaecologists, said that while some pregnant women might be concerned about the environmental impact of their childbirth, alternative pain relief such as epidurals are not available at every hospital, especially outside of capital cities.

He added that nitrous oxide can be a more attractive pain relief option as it doesn’t restrict walking or movement ability to the extent epidurals do.

“If you’re in rip-roaring pain during labour, carbon footprint might not be the thing you most want to discuss,” Pecoraro said. 

Pecoraro said that ultimately it was important to offer as many different options for pain relief during labour as possible, as different methods are effective for different women.

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Source: The Guardian, 31 May 2022

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Is it time to live with COVID-19? Some scientists warn of ‘endemic delusion’

As surges of COVID-19 cases driven by the highly infectious Omicron variant recede, parts of the United States, Canada, and Europe are moving swiftly to lift constraints on a pandemic-fatigued public. Sweden, Denmark, and Norway have abolished nearly all ­COVID-19–related restrictions in recent weeks, and the United Kingdom announced it would do the same this month, dropping even the legal requirement that people quarantine after testing positive for SARS-CoV-2. In the United States, despite persistently high numbers of COVID-19–related deaths and busy hospitals, 10 governors, many known for being cautious in their pandemic response, last week announced immediate or impending ends to their states’ indoor or school mask mandates.

Some of those moves came with assertions that it’s time to “live with the disease” and treat the coronavirus as endemic—a stable, enduring figure in the panoply of human pathogens, alongside cold viruses and influenza. That suggestion troubles many scientists, who warn it is eroding governments’ commitment to tracking and responding to the pandemic—which could leave countries flying blind and unprepared for any new variant.

“Endemic delusion is probably what captures it the best,” says Kristian Andersen, an infectious disease researcher at Scripps Research who has been especially critical of recent moves by his home country of Denmark, which include an announcement that as of this month COVID-19 would no longer be categorised as a “socially critical disease” even though related death and hospitalisation rates were still climbing there.

In the United States, governors cited various metrics to justify recent decisions to lift or let expire indoor mask mandates. California Governor Gavin Newsom noted stable hospitalisation rates and a 65% reduction in cases since Omicron’s peak in announcing the state’s mandate would end this week. But leaders also face political and economic pressures. States’ moves may be driven largely by the public’s impatience with restrictions, says epidemiologist Dustin Duncan of Columbia University.

“Even people who recognize the importance of masking, social distancing, all that stuff, may be more amenable to take more risk,” he says. “At the same time, to me, going maskless just seems egregious.” 

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Source: Science, 15 February 2022

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Is Heatherwood Hospital a model for the future of the NHS?

Pradeep Gill can see very little of the intense activity around him. He is leaning back in a reclining chair inside one of Heatherwood Hospital's operating theatres.

Buzzing around him is the operating team, led by consultant orthopaedic surgeon Jeremy Granville-Chapman.

For the surgeon and his team, this procedure is the very definition of routine. They have carried out more than 1,000 joint operations in the past 10 months.

Heatherwood Hospital, part of the Frimley Health NHS Foundation Trust, is a specialist elective hub where patients can come in for routine but life-changing surgery at a super-charged pace with theatres working at full tilt, six days a week.

It is busy. But it is a good-busy, not the bad-busy we have come to associate with the NHS during this winter crisis.

The site opened in March last year and Frimley's hospital executives are keen to stress the impact it has made.

"As a specialist planned care facility, Heatherwood has been able to perform surgery six days a week with four out of its six state-of-the-art theatres dedicated to orthopaedic procedures," it said in a press release.

"The hospital has also successfully reduced the length of time patients stay in hospital, with 40% of patients safely discharged within 24 hours."

This is the practice the NHS wants to adopt as it battles a record seven-million-strong waiting list.

Heatherwood can do that because the hospital is ring-fenced from acute pressures that affect other hospitals, as one its most senior orthopaedic surgeons, Mr Rakesh Kucheira, explained.

"We have now realised that winter pressures are 12 months not just three months, which means the acute sites are not going to be able to do planned activity that they planned for, so we've got to create more space," he said.

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Source: Sky News, 9 March 2023

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Irregularities in blood could pave the way for a test for long covid

A pattern in rouge antibodies has been found by Imperial College London scientists which may lead to a blood test for the condition within 6 to 18 months. 

Leading the team at Imperial College London, Professor Danny Altmann has said the 'work will lead to a test which could be done in a doctor's surgery'. However, he is concerned with the lifting of lockdown restrictions on 19th July. 

Long Covid is not yet fully understood with no current diagnostic test yet available for the illness. However, a range of symptoms have been listed which include fatigue, breathlessness, muscle pain and headaches.

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Source: BBC News, 12 July 2021

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Irish medical regulator says regulating physician associates is outside its remit

The Medical Council, the medical regulator for Ireland, has announced that it believes it is not the appropriate body to regulate physician associates (PAs)—in sharp contrast to the position in the UK where the General Medical Council takes on this role from 13 December.

The role of PA was introduced in Ireland in 2016 by the Royal College of Surgeons in Ireland’s School of Medicine which offers the only masters in physician associate studies in the Republic of Ireland.

To date, 76 PAs have graduated from the two year programme with 60% working in public hospitals and 40% employed by the private sector. The GMC estimates that there are around 5000 PAs and 200 anaesthetic associates (AAs) in the UK.

PAs are not yet subject to statutory regulation in Ireland but there is a managed voluntary register, which lists all fully qualified PAs who successfully fit the criteria to practise as a PA in the Republic. The register is designed to provide public protection and safety and is managed by the Irish Society of Physician Associates.

In a position statement2 published on 3 December, the Medical Council said it was not the appropriate regulatory body for PAs.

“The Medical Practitioners Act 2007 has no provision to regulate health professionals other than doctors,” said the statement. “The Medical Council’s primary purpose is to protect the public by setting high standards of professional conduct, education, training, and competence among doctors.”

The council also said there was potential for emerging patient safety risks arising from confusion for patients, as observed recently in the UK.

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Source: The BMJ, 12 December 2024

Further reading on the hub:

Physician associates: What are the patient safety issues? An interview with Asif Qasim

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Irish medical negligence legal costs among highest in world, report says

Legal costs in Irish medical negligence cases are among the highest in the world, according to a report that says the slow pace of legal actions here is damaging patients and doctors’ mental wellbeing.

The average cost of a legal claim for medical negligence in Ireland is almost three times higher than in the UK, and cases take over 50 per cent longer to resolve, the industry report says.

Patients and doctors in Ireland are dragged through what can be a brutal process, for longer than necessary, with patients having to wait longer to receive compensation, the report by the Medical Protection Society (MPS) asserts.

In the report, the society, which provides indemnity cover for 16,000 doctors and other healthcare professionals in Ireland, compared the length and cost of legal actions here with other jurisdictions in which it operates.

A medical negligence claim in Ireland takes 1,462 days on average (four years), 14% longer than in South Africa and 56% longer than in Hong Kong, the UK or Singapore, it found.

Two hundred doctors in Ireland were interviewed for the report: 88% said they were worried about the length of time the litigation process was taking and 91% were worried about their mental wellbeing while it was ongoing. Some said they needed professional help, experienced suicidal thoughts, or quit medicine as a result of the claim.

“It was horrendous. I had to leave medicine after it,” says one doctor involved in a claim who is quoted in the report. “I developed severe anxiety during the course of the claim and PTSD. I lost my career in medicine and I am devastated about that. I knew I could never go through the same again.”

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Source: The Irish Times, 31 January 2024

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Ireland: Mental heath watchdog highlights concern over administration of medications

High risks relating to the ordering, prescribing, storing and administration of medicines have been found by the Mental Health Commission in a series of inspections of mental health centres in Dublin.

The commission emphasised the need to have appropriate practices including the recording of the minimum dose interval information; where medication has been stopped, the stop date to be recorded; and the need to always have the prescriber’s signature recorded.

The inspector of mental health services Dr Susan Finnerty said it was positive to see centres maintaining high compliance rating, but spoke of concerns around the administration of medication.

“We know that medication is an important tool in treatment of mental illness. In order to reduce the risk of medication errors, we need to be sure that medication prescription and administration records are completed correctly,” Dr Finnerty said.

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Source: Independent Ireland, 18 January 2023

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Ireland: Legislation to cover non-disclosure issues that arose in cervical check controversy

More than 200 women were affected by failures in Ireland’s CervicalCheck screening system. It emerged in 2018 that 221 women and families were not told about misreported smear tests.

The Minister for Health said that non-disclosure issues which arose in the cervical check screening controversy will be legislated for to prevent it from happening again.

Stephen Donnelly said new legislation will address the negligence issues and ensure that the failure to inform the women of the clinical audit of their screening will “never happen again”.

Mr Donnelly was discussing a number of amendments at the committee stage of Ireland's Patient Safety Bill.

The new legislation will require the mandatory open disclosure of serious patient safety incidents, and sets out a list of incidents which must be reported to the health watchdog, Health Information and Quality Authority (HIQA).

Mr Donnelly said that he will introduce an amendment at the report stage of the Bill that will provide for non-disclosure and will deal with issues around delayed diagnosis and delayed screening.

Mr Donnelly said: “I’ve had lengthy discussions with the department on this and it doesn’t fit neatly with this Bill because the serious patient safety issues which result in death or serious harm, they are very clear and binary.

“Legislating around delayed diagnosis and delayed screening, it is really complex and doesn’t fit neatly in this Bill, however my view is that the non-disclosure that happened in cervical check, even though it doesn’t neatly fit here, should still be legislated for."

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Source: The Independent, 11 March 2022

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Ireland: Hospital complaints include patient turned away from A&E despite risk of self-harm

More than one fifth of complaints about Irish hospitals were deemed ‘high severity' including one from a person who claimed their mother should not have died and another who alleged a patient was turned away from an A&E even though she was at risk of self-harming.

An analysis of 641 complaints about HSE hospitals between October and December 2019 by NUI Galway and the HSE separated them into high severity (22%), medium severity (56%) and low severity (also 22%).

Among those complaints highlighted as potentially linked to ‘catastrophic harm’ was this: “My mother would still be alive if this had not happened."

However the largest number were about hospital systems at 392 — including complaints about waiting lists.

“I was left on a waiting list for surgery for years,” at least one person wrote.

The analysis also found 322 complaints centred around patients’ arrival into hospitals including emergency departments (ED).

“She was turned away instead of admitted even though she was at risk of self-harming,” one person wrote.

Some 92 complaints related to staff not listening to patients, including new parents who said: "While our newborn son was on the ward they took too long to notice his difficulty breathing and transfer him to the NICU (neonatal intensive care unit)."

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Source: Irish Examiner, 11 July 2022

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Ireland tackled tainted blood scandal decades ago - and it has cost €800m so far

Ireland’s blood scandals have caused human suffering and cost the State around €800m in compensation so far.

A damning inquiry report in the UK this week found that authorities there covered up the infected blood scandal after knowingly exposing victims to unacceptable risks. More than 30,000 people in the UK were infected from 1970 to 1991 by contaminated blood products and transfusions.

Ireland moved decades faster to address the contamination tragedy.

The tribunal set up to compensate people infected by contaminated blood transfusions or blood products in the Republic of Ireland has paid out around €800m since 1996.

In Ireland a compensation tribunal, which is still sitting and will continue to do so for years to come, was set up by the government in 1995 first to compensate women infected with hepatitis C as a result of the use of contaminated human immunoglobulin anti-D. This blood product was given to women with the rhesus-positive blood type to protect future pregnancies.

The Finlay inquiry in the mid 1990s looked at the rules that were broken by the then blood transfusion service in producing anti-D.

The Lindsay tribunal set up in 2000 examined the contamination of Factor 8 products used by men with haemophilia which were contaminated with HIV and hepatitis C.

The tribunal heard how home-produced blood clotting agent caused infection in seven haemophiliacs despite earlier claims that it was safe.

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Source: Irish Independent, 21 May 2024

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Ireland launches digital strategy to increase mental health support

The Republic of Ireland has launched a digital strategy to increase access to mental health services through technology and improve digital health literacy.

The ‘Sharing the Vision Digital Mental Health Strategy 2026-2030’, published by the Health Service Executive (HSE) and Department of Health in Ireland on 20 February, aims to enhance mental health through digital technologies that improve infrastructure and provide “safe, effective, and accessible mental health information, tools, and services”.

As part of te 2026 Budget, €1 million (£873,455) funding was secured to implement the strategy, bringing investment in digital services such as online cognitive-behavioural therapy and text-based supports to more than €7m (£6.1m).

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Source: Digital Health, 24 February 2026

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Iran-linked attack hits trusts’ supplies

At least two trusts have declared incidents after a cyber attack on a key supplier, HSJ understands.

An Iran-linked group appears to have claimed responsibility for the attack on medical device supplier Stryker, saying it was a response to a bombing that killed dozens of children in the town of Minab.

The US firm was attacked on Wednesday evening and local NHS procurement teams spent Thursday determining what the impact would be on trusts that buy orthopaedic implants, defibrillators, ambulance trolleys and other products from the company.

Sources at two acute trusts confirmed they had declared incidents due to the supply concerns, but they did not want to be identified. So far trusts have been able to obtain equipment needed urgently from elsewhere after implementing their business continuity plans.

National NHS bodies have set up an incident team to manage supply disruption, but have not declared a national critical incident.

The company, whose UK and Ireland branches turned over nearly £500m sales last year, said the incident had “caused disruptions to order processing, manufacturing and shipping”.

Stryker said the disruption stems from a cybersecurity attack targeting its Microsoft environment but that it has no indication of ransomware or malware and believes the incident has been contained.

The American Hospital Association said it has not identified any direct disruptions to U.S. hospital operations. John Riggi, the AHA’s national adviser for cybersecurity and risk, told Becker’s on the 12 March the organisation is actively exchanging information with hospitals and the federal government as the situation develops.

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Source: HSJ, 13 March 2026

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Investigations launched after Atikamekw woman records Quebec hospital staff uttering slurs before her death

As she lay dying in a Joliette, Que., hospital bed, an Atikamekw woman clicked her phone on and broadcast a Facebook Live video appearing to show her being insulted and sworn at by hospital staff.

Joyce Echaquan's death on Monday prompted an immediate outcry from her home community of Manawan, about 250 kilometres north of Montreal, and has spurred unusually quick and decisive action on the part of the provincial government.

The mother of seven's death will be the subject of a coroner's inquiry and an administrative probe, the Quebec government said today. A nurse who was involved in her treatment has been dismissed.

But that dismissal doesn't ease the pain of Echaquan's husband, Carol Dubé, whose voice trembled with emotion as he told Radio-Canada his wife went to the hospital with a stomach ache on Saturday and "two days later, she died."

Echaquan's relatives told Radio-Canada she had a history of heart problems and felt she was being given too much morphine. 

In the video viewed by CBC News, the 37-year-old is heard screaming in distress and repeatedly calling for help. Eventually, her video picks up the voices of staff members. One hospital staff member tells her, "You're stupid as hell." Another is heard saying Echaquan made bad life choices and asking her what her children would say if they saw her in that state.

Dubé said it's clear hospital staff were degrading his wife and he doesn't understand how something like this could happen in 2020.

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Source: CBC News, 29 September 2020

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Investigation of maternity deaths "too late"

Parents of babies who died at a hospital trust at the centre of a maternity inquiry say a police investigation has come "too late".

West Mercia Police said it was looking at whether there was "evidence to support a criminal case" at Shrewsbury and Telford NHS Hospital Trust. An independent review, contacted by more than 1,000 families, said it was working with police to identify relevant cases.

"It's bittersweet," one mother said. 

"It's come too late for my daughter, she should still be here," said Tasha Turner, whose baby, Esmai, died four days after she was born at Royal Shrewsbury Hospital in 2013.

Ms Turner's case is part of the Ockenden Review, an independent investigation into avoidable baby deaths at the trust, which runs Royal Shrewsbury Hospital and Telford's Princess Royal.

LaKamaljit Uppal, 50, from Telford, who is also part of the review following the death of her son Manpreet in April 2003 at Royal Shrewsbury Hospital, said she hoped the police inquiry would bring some closure.

"The trust put me through hell, someone should be held accountable," she said.

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Source: BBC News, 1 July 2020

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Investigation launched into safety of maternity equipment used in NHS

A national investigation has been launched into the equipment used by NHS staff to monitor babies heart rates during labour because of concerns they could be contributing to deaths and disabilities.

The independent Healthcare Safety Investigation Branch (HSIB), which investigates systemic safety risks in the NHS, has opened an inquiry after reviewing hundreds of maternity incidents.

It found equipment used to record cardiotocographic (CTG) traces were linked to 138 maternity investigations since 2018 with more than 238 separate findings referencing the use of CTG as a factor in the error.

Read the full article here

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Investigation launched into gel nail polish allergic reactions

The government is investigating reports that growing numbers of people are developing life-changing allergies to some gel nail products.

Dermatologists say they are treating people for allergic reactions to acrylic and gel nails "most weeks".

Dr Deirdre Buckley of the British Association of Dermatologists urged people to cut down on gel nail use and stick to "old-fashioned" polishes.

Some people have reported nails loosening or falling off, skin rashes or, in rarer cases, breathing difficulties, she said.

Although most gel polish manicures are safe and result in no problems, the British Association of Dermatologists is warning that the methacrylate chemicals - found in gel and acrylic nails - can cause allergic reactions in some people.

It often occurs when gels and polishes are applied at home, or by untrained technicians.

Dr Buckley said: "We're seeing it more and more because more people are buying DIY kits, developing an allergy and then going to a salon, and the allergy gets worse."

The allergies can leave sufferers unable to have medical treatments like white dental fillings, joint replacement surgery and some diabetes medications. This is because once a person is sensitised, the body will no longer tolerate anything containing acrylates.

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Source: BBC News, 15 April 2023

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Investigation launched after seven ‘never events’ in two years at leading trust

An external review has been launched at a leading children’s hospital after a series of “never events”.

According to local commissioners, a review by the Association for Perioperative Practitioners will look into seven incidents at Alder Hey Children’s Foundation Trust over the last two years. The probe had been delayed by the pandemic and began this month.  

Great Ormond Street Hospital for Children FT and Sheffield Children’s FT, the two other dedicated children’s trusts in England, reported one and four never events respectively, between April 2018 and July 2020, according to national data.

In a statement, Alder Hey claimed it could not provide further details of the incidents. But most have been described in its board papers over the past year. They include a 15-year-old who had the wrong tooth removed by the surgical division, a patient who had the wrong eye operated on, a swab that was left inside a patient having their adenoids and tonsils removed, and an incorrect implant being inserted into an orthopaedics patient.

Liverpool Clinical Commissioning’s group’s board papers for September said: “The trust has had a series of seven never events and there is a plan to undertake an external review that has been delayed due to the pandemic response. The trust has approached the Association for Perioperative Practitioners and have agreed the process."

“The trust also plans to work with Imperial College London on a peer review and bespoke human factors training to include simulation training and coaching. The trust also plans to produce an overarching action plan to bring together the themes and learning from the seven never events. This work is still underway and NHSE/I and CCG had requested a copy of this plan.”

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Source: HSJ, 24 September 2020

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Investigation into insulin prescribing in hospitals starts

The Healthcare Safety Investigation Branch (HSIB) has started a national investigation looking into insulin prescribing and administration in hospitals.

It was launched after a patient was administered an overdose of concentrated insulin while under the care of an acute hospital. 

The investigation will focus on factors which compromise safety when health professionals administer concentrated insulin through insulin pen devices.

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Source: HSIB, 24 September 2019

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Investigation begins into woman's childbirth death

An investigation has been launched after a woman died during childbirth at a hospital's maternity unit.

It was the third death of a mother in just over three years at Basildon University Hospital in Essex, in addition to a newborn baby's death.

The trust that runs the hospital said it could not comment on the case while it was under investigation.

Basildon University Hospital is part of Mid and South Essex NHS Foundation Trust, which also runs Southend and Broomfield hospitals.

The latest fatality follows the death of 36-year-old Gabriela Pintilie in February 2019. Ms Pintilie died after losing six litres of blood giving birth to her second child at the unit.

In separate incidents, a mother died and another woman had a stillborn baby at the unit in March 2019, while the trust was being inspected by the Care Quality Commission (CQC) following Ms Pintilie's death.

The unit at Basildon had its rating upgraded from "inadequate" to "requires improvement" in December by the CQC.

The hospital also apologised for the death of newborn Frederick Terry after he suffered a brain haemorrhage during a failed forceps delivery in November 2019.

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Source: BBC News, 27 March 2022

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