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Healthcare providers failed to inform most victims of medical error in Oregon, report says

Close to one-third of Oregonians have experience with medical errors like incorrectly prescribed medication or botched surgeries, but providers often failed to adequately inform them of their errors, according to a new report.  

The Oregon Patient Safety Commission released the findings this week in a 16-page state report on medical harm in the past five years, calling it “the first comprehensive review of post-pandemic patient safety data in Oregon.”

The Oregon Legislature created the agency in 2003 with the goal of providing an advocate for patient safety while incorporating the perspectives of medical providers, insurers and consumers.

The survey found that 30% of Oregonians have reported experiencing some form of medical harm in the past few years, whether that involved their own care or “someone close to them.” Medical harm is a broad category that can encompass a wide variety of improper practices or mistakes by doctors and medical providers, which may spiral into further inaccurate treatment plans.

The findings say that victims want to be informed about errors and receive an apology promptly, but that only about one in three receive such redress. When an error results in what the commission calls “serious health consequences,” researchers found Oregonians were less likely to get an apology.

 “The combination of transparency and apology after medical harm is what patients want and expect,” said TJ Sheehy, director of programs for the Oregon Patient Safety Commission, in a statement. “And while this can be challenging in practice, other studies show that providers do want to disclose when harm has occurred.”

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Source: Oregon Capital Insider, 22 September 2025

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Healthcare providers are failing to protect the privacy of people living with HIV, watchdog warns

Healthcare providers are failing to protect the privacy of people living with HIV, the UK’s data watchdog has warned.

The Information Commissioner’s Office said it has been forced to hand fines worth thousands to organisations which have released the details of those living with HIV.

Speaking with The Independent, Information Commissioner John Edwards, said: “It is a huge problem [within healthcare] and it’s a disproportionate amount of our business. “That’s partly because of the seriousness and the sensitivity of health information, the huge scale of the health sector and very many moving parts, with many opportunities for information to slip out as it moves from one place to another, and frankly, they’re just not doing well enough.”

In a warning on Tuesday the watchdog highlighted specific concerns over HIV patients’ data being breached through the use of bulk emails in which staff have not used the blind copy function.

The Information Commissioner said: “People living with HIV are being failed across the board when it comes to their privacy and urgent improvements are needed across the UK. We have seen repeated basic failures to keep their personal information safe - mistakes that are clear and easy to avoid."

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Source: Independent, 30 April 2024

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Healthcare professional is referred to regulator for delaying seeing a patient because of lack of PPE

A healthcare professional is facing a fitness to practise investigation for delaying attending to a COVID-19 positive patient because of inadequate personal protective equipment (PPE), in what may be the first case of its kind.

The revelation came from a healthcare regulatory solicitor, Andrea James, who tweeted, “Was expecting it, but still disgusted to have received first #FitnessToPractise case arising from NHS trust disciplining healthcare professional who expressed concern about/delayed attending to a Covid+ patient without PPE (NHS Trust having failed to provide said PPE). For shame.”

Doctors and nurses reacted with outrage to the tweet, and the Medical Protection Society issued a strong statement condemning the move. But James said that her client wanted to remain anonymous and declined to identify the profession or the regulator involved. She said that the treatment in question was expected to be an aerosol generating procedure.

Rob Hendry, medical director at the Medical Protection Society (MPS), said, “It is appalling enough that healthcare professionals are placed in the position of having to choose between treating patients and keeping themselves and their other patients safe. The stress should not be compounded by the prospect of being brought before a regulatory or disciplinary tribunal.

“MPS members who are faced with regulatory or employment action arising from a decision to not see a patient due to lack of PPE can come to us for advice and representation. However, it should not come to this: healthcare workers should not be held personally accountable for decisions or adverse outcomes that are ultimately the result of poor PPE provision.”

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Source: BMJ, 12 August 2020

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Healthcare professional arrested on suspicion of murdering stroke patient

A healthcare professional at Blackpool Teaching Hospital Foundation Trust has been arrested on suspicion of murdering a stroke patient.

Lancashire Police released a statement this evening which says the man has also been arrested on suspicion of two offences of rape and one offence of sexual assault. The suspect is currently in custody. He has also been suspended by the trust.

It comes after a police investigation was launched in November 2018 into allegations of mistreatment and neglect on the stroke unit at Blackpool Victoria Hospital.

As part of the probe, a number of post-mortem examinations were conducted, including for Valerie Kneale, 75, from Blackpool, who died from a haemorrhage caused by a non-medical related internal injury.

Police said this led to a murder investigation, which is being treated separately to an ongoing investigation into allegations of poisoning and neglect on the stroke unit, in which a number of staff have previously been arrested.

Detective chief inspector Jill Johnston, of Lancashire Police, said: “We understand this will cause some significant concern in the community but please be reassured we have a dedicated team of officers conducting a number of enquiries."

“If you have any information or have worked on the stroke unit and can assist with our enquiries, please come forward and speak to police immediately.”

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Source: HSJ, 3 March 2021

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Healthcare execs confront safety as a purpose

Surveying the US healthcare landscape, some leaders are wondering, what if safety was valued as a purpose, rather than a priority? 

Patricia Gaffigan, senior advisor on patient and workforce safety for the Institute for Healthcare Improvement (IHI), voiced this question at an IHI conference in December. She said priorities are at risk of being reduced to a set of improvement projects — like fleeting goals, or something beholden to a start and end date. 

When asked to describe the difference between safety as a priority and safety as a purpose, leaders from UCSF Health, M Health Fairview, Inova Health System and Jefferson Health told Becker's that while priorities are important, they can deprioritise other plans, or even be deprioritised themselves. 

"We, like all health systems, have a mission," said Chapy Venkatesan, chief quality and safety officer of Fairfax, Va.-based Inova. "The center component of our mission is world-class healthcare. So that is really our purpose. Safety is part of that purpose."

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Source: Becker's Clinical Leadership, 18 February 2025

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Health workers to go door-to-door under new NHS plans to tackle sickness rates across England

Health workers will be sent door-to-door under drastic new NHS plans to tackle sickness rates across England, according to reports.

A community health worker will be allocated 120 homes to visit every month to see if help is needed under plans set to be rolled out in June, The Daily Telegraph reports.

Health secretary Wes Streeting said trials of the scheme showed “encouraging signs” in slashing the number of heavy NHS users which he called “frequent flyers” of A&E departments.

A pilot scheme in Westminster, London, showed a dramatic 10% drop in hospital admissions over a year, The Daily Telegraph reports.

“We’re seeing some really encouraging signs about what can happen if you’ve got the right care in the right place at the right time,” Mr Streeting said.

The scheme, set to be rolled out in 25 parts of England, is part of Mr Streeting’s 10-year plan for the NHS, which could also see younger people directed to pharmacy care using the NHS app, leaving GPs to devote their time to sicker and older patients.

The health secretary said a modernised version of the health service’s phone app could mean the NHS could “do a much better and faster job of making sure patients get the right care at the right time in the right place”.

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Source: The Independent, 7 April 2025

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Health workers ‘shattered’, says Jeremy Farrar as more NHS strikes loom

Healthcare workers are “absolutely shattered” and unless something is done to address the crisis in morale, staffing and training then “they won’t be there when you need them”, one of the world’s leading scientists has warned.

Speaking to the Guardian, Prof Jeremy Farrar, the director of Wellcome and soon to be chief scientist of the World Health Organization, warned that healthcare workers would not be ready should another crisis hit.

“This is a global issue, which I think is hugely concerning. It’s certainly true in this country,” he said. “The resilience of healthcare workers, broadly defined from ambulance drivers to nurses to doctors, to care workers in social care, etc. They’re shattered. They are absolutely shattered."

Farrar said: “I think we have to address the morale, staffing, the training, everything from public health physicians to care workers, to doctors and nurses and physios and everybody in between because there’s very little spare capacity in any system globally. It’s particularly true in the UK. As you can see from the strikes, morale and resilience is very thin.”

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Source: The Guardian, 20 February 2023

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Health warning as common painkiller linked to kidney damage

Consumers are being urged to exercise caution when using common anti-inflammatory medications such as ibuprofen for pain relief due to potential adverse effects on kidney function.

Those with a higher risk of kidney disease, including individuals with diabetes or high blood pressure, should be especially careful, warn Kidney Care UK and the National Pharmacy Association (NPA).

Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, naproxen, and diclofenac can elevate blood pressure and damage blood vessels within the kidneys.

Olivier Picard, chair of the NPA, said: “Medicines have the power to harm as well as to heal.

“Although NSAIDs, such as ibuprofen, are effective and safe medicines, patients should be aware of their impact – particularly if a patient is at increased risk of developing kidney disease – and consider alternative medication where appropriate.

“If a patient has concerns about their usage of NSAIDs, they should speak to their pharmacist who can advise them.

“Pharmacists are experts in medicines and are best placed to offer advice to people who may be concerned about any potential long-term effect of some medicines and can help patients effectively manage pain.”

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Source: The Independent, 13 March 2026

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Health visitors call for limits on 'impossible' 1,000-family caseloads

Limits should be introduced on the "unmanageable" caseloads of health visitors in England, with some now responsible for more than 1,000 families each, the Institute of Health Visiting (iHV) has said.

The number of health visitors - qualified nurses or midwives who support families with very young children - has almost halved in the last decade.

In January, the Health and Social Care Committee said the government would fail in its ambition to give every child the best start in life, unless it took urgent action to rebuild the workforce.

The Department of Health and Social Care (DHSC) says the government is "committed to strengthening health visiting services".

Emma Dolan, a health visitor with Humber Teaching NHS Foundation Trust in Hull, says her "top priorities" are to spot potential issues early, and offer advice to parents on things like their baby's wellbeing and sleep to prevent problems arising later.

"We want our babies to live long and happy lives [by] giving that support nice and early and making sure that families know what services are out there."

However, BBC analysis has shown the number of health visitors in England has fallen from 10,200 a decade ago, to 5,575 in January - a drop of 45%.

iHV chief Alison Morton says families are paying the price for the decline in the workforce.

"We need to set a benchmark, otherwise we're just going to continue to see this decline with hugely unmanageable, unsafe caseloads which are impossible for health visitors to work within," she says.

"Health visitors are having to prioritise, and actually prioritisation has a human cost.

"They're having to tell families: 'I'm sorry, I can't do that extra follow-up visit', when you know it would have made a massive difference to that family."

Even if England did bring in safe staffing limits, according to Morton, there aren't enough health visitors currently employed to provide that level of coverage.

"We need more health visitors so that we can have manageable caseloads," she says.

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Source: BBC News, 20 April 2026

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Health systems must tackle workplace, patient safety in tandem, IHI says

A nationwide effort in the US to improve and coordinate patient safety measures will strive to make a connection between workplace and patient safety.

The Institute for Healthcare Improvement (IHI) gave an update during its National Forum this week on the creation of a national patient safety plan intended to encourage better coordination of safety efforts. A key goal of the plan, expected to be released next year, was to emphasise the role of improving workforce safety.

“In our view, too many systems have a separation between workforce safety and patient safety and yet we know the two are connected,” said Derek Feeley, President and CEO of IHI, in a briefing with reporters Monday before the start of the forum in Orlando, Florida. “Patient safety incidents are much less likely to occur when workers feel safe.”

The steering committee developing the plan includes 27 organizations that range from patient advocates and professional societies to provider organizations and government representatives. The committee's plan hopes to target healthcare leaders and policymakers.

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Source: Fierce Healthcare, 10 December 2019

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Health strike: RCN nurses in second day's strike

About 9,000 nurses across Northern Ireland have begun a 12-hour strike today in a second wave of protests over pay and staffing levels.

More than 2,000 appointments and procedures have been cancelled, including a number of elective caesarean operations.

The Health and Social Care Board said it expects "significant disruption"

Royal College of Nursing (RCN) Director Pat Cullen told BBC Radio Ulster's Good Morning Ulster programme that nurses felt "bullied" by health officials. Her comments followed a warning by the heads of Northern Ireland's health trusts on Tuesday that this week's strikes could push the system "beyond tipping point".

Valerie Thompson, a deputy ward sister at Londonderry's Altnagelvin Hospital, said concerns over safe staffing levels and pay parity had brought her to the picket line.

"We need to have the proper amount of staff to care for our patients, give them the respects, dignity, care they deserve," she said. "We are a loyal workforce; we get on with it, and rally around. But it is difficult. We miss breaks, go home late, staff are just exhausted."

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Source: BBC new, 8 January 2020

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Health strike: Nurses start industrial action on pay and staffing

Industrial action by healthcare workers is intensifying as Northern Ireland's nurses take part in 24 hours of action. Health workers are staging industrial action in protest at pay and staffing levels which they claim are "unsafe".

In an unprecedented joint statement, the five health trusts said the action was likely to result in "a significant risk to patient safety".

Last week, the Royal College of Surgeons warned NI's healthcare system was "at the point of collapse". On Tuesday, members of the Royal College of Nursing (RCN) are refusing to do any work that is not directly related to patient care.

Full details and advice on current health care services can be found on the Health and Social Care Board website.

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Source: BBC News, 3 December 2019

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Health strike: Action could delay cancer diagnoses

Patients are facing a week of disruption, with more than 10,000 outpatient appointments and surgeries cancelled in Belfast.

Some people referred by their GPs on suspicion of cancer could have their diagnosis delayed, the head of the Belfast Trust has said. The trust apologised, blaming industrial action on pay and staffing.

Martin Dillon said outpatient cancellations "could potentially lead to a delay in treatment" for cancer.

The Department of Health said the serious disruption to services was "extremely distressing".

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Source: BBC News, 2 Decmeber 2019

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Health staff 'kicked, spat at, hit and scratched'

Attacks against health and social care workers in Northern Ireland have risen sharply during the pandemic, available data suggests.

Workers have reported being bitten, spat at, hit, scratched, kicked, abused on social media and sexually assaulted.

Most of the 5,500 attacks recorded in the six months to March were physical, said a forum representing local health bodies and the Fire and Rescue Service.

It has called on politicians and the public to support their staff.

The abuse affected staff across the sector, and those targeted were often already exhausted and caring for people in difficult conditions, said the chairman of the Health and Social Care Chairs' Forum, Peter McNaney.

"This is beyond intolerable," he added.

GPs, pharmacy, dental and ophthalmology staff had all been affected, and some had resigned as a result, said Eileen Mullan, chairwoman of the Southern Health and Social Care Trust.

"Even just in the last few days, with the uptake of the vaccinations across our centres, we've seen a significant increase in the amount of verbal abuse at those centres when people are waiting," she said.

"Some are abusing our staff while they are there."

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Source: BBC News, 15 December 2021

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Health spending £5bn less than government planned

The government is spending £5.5bn less on health in England than it suggested it would be at this stage, the Institute for Fiscal Studies says.

Plans set out in the 2019 election campaign indicated the budget would increase by 3.3% a year above inflation during this Parliament, the IFS said.

But despite extra being put in to cover the high inflation seen, spending had risen by only 2.7% a year on average.

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Source. BBC News, 14 May 2024

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Health services for eating disorders overrun

Health services for Londoners with eating disorders are struggling to cope with demand, a new report warns.

Data from London's mental health trusts shows adult referrals have increased by 56% - from 3,000 to nearly 8,000 - in the last six years

Child and adolescent referrals increased by 158%, from 1,400 to 4,000, in the same time period.

The report has been compiled by the London Assembly's health committee.

It has made 12 recommendations to London Mayor Sadiq Khan and City Hall officers, which include assessing other physical and mental health indicators as well as just patients' bodyweight as per their BMI.

One consultant clinical psychologist told the committee that "almost all of the eating disorder services in London do not have the staffing levels available to safely provide the care required".

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Source: BBC News, 7 March 2024

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Health service chief critical of Covid-19 ‘Protect the NHS’ slogan

The head of NHS England was critical of the government’s slogan urging people to “protect the NHS” at the start of the Covid pandemic, amid concerns it would stop people coming forward for much-needed treatment.

Simon Stevens, who led the NHS until July 2021, was one of the slogan’s “greatest critics” and was not involved in the government discussion that led to the phrase being deployed.

“It was a tremendously powerful slogan,” writes journalist Isabel Hardman in Fighting for Life: The Twelve Battles That Made Our NHS, and the Struggle for Its Future.

“It was popular in government – but not universally so. In fact, one of its greatest critics was Simon Stevens. Stevens wasn’t on the calls where [government advisers] came up with ‘Protect the NHS’, and initially he complained in private that it gave the impression that the public was there for the health service – not the health service being there for the public.

“Either way, the focus quickly became about the importance of ‘protecting the NHS’. But there was never a clear definition of what it was being protected from.”

Later in 2020, Lord Stevens referred to his concerns about the slogan, writing: “Rather than say ‘Protect the NHS’, health service staff prefer to say: ‘Help us help you’.”

Senior NHS figures also attempted to battle against the slogan from the spring of 2020, urging patients to come forward as normal.

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Source: The Guardian, 25 June 2023

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Health Secretary warns of long-term effects of COVID-19 as new film released

The Health Secretary is urging the public – and especially young people – to follow the rules and protect themselves and others from COVID-19, as new data and a new film released today reveal the potentially devastating long-term impact of the virus.

The symptoms of ‘long COVID’, including fatigue, protracted loss of taste or smell, respiratory and cardiovascular symptoms and mental health problems, are described in a new film being released today as part of the wider national Hands, Face, Space campaign. The film calls on the public to continue to wash their hands, cover their face and make space to control the spread of the virus.

The emotive film features the stories of Jade, 22, Jade, 32, Tom, 32 and John, 48, who explain how their lives have been affected – weeks and months after being diagnosed with COVID-19. They discuss symptoms such as breathlessness when walking up the stairs, intermittent fevers and chest pain. The film aims to raise awareness of the long-term impact of COVID-19 as we learn more about the virus.

A new study from King’s College London, using data from the COVID Symptom Study App and ZOE, shows one in 20 people with COVID-19 are likely to have symptoms for 8 weeks or more. The study suggests long COVID affects around 10% of 18 to 49 year olds who become unwell with COVID-19.

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Source: Gov.uk, 21 October 2020

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Health secretary urges patients to report ‘horrific’ sexual abuse allegations

Health secretary Victoria Atkins has said mental health patients and staff must report the “horrific” sexual abuse allegations uncovered by The Independent to the police.

Ms Atkins said victims would have her full support if they reported their claims to the police.

Her intervention comes following a joint investigation by The Independent and Sky News, which revealed almost 20,000 reports of sexual harassment and abuse on NHS mental health wards in England.

The allegations uncovered include patients claiming to have been raped by staff and other patients while being treated on mental health wards.

In response to the initial investigation, Ms Atkins said a review launched last year into mental health services would now also look into sexual assault within the sector.

Speaking on Sky News, she said: “These are horrific allegations that should not and must not happen in our care. Very, very vulnerable people have to stay in mental health inpatient facilities, and they do so because they need care, support, and treatment.

“Some of the behaviours that have come to light are criminal offences, and so I would encourage anyone who feels able to – and I appreciate it is a difficult step – to go to the police and please report them, because they are crimes and we must drive them out.”

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Source: The Independent, 21 February 2024

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Health secretary urges no strikes as ballot of UK junior doctors begins

The Secretary of State for Health and Social Care, Wes Streeting MP, has urged doctors to vote against industrial action as the British Medical Association (BMA) ballots resident doctors, formerly known as junior doctors, for strike action that could last for six months.

Resident doctors say their pay has declined by 23% in real terms since 2008. If they choose to go on strike, walkouts could begin in July and potentially last until January 2026.

The government accepted salary recommendations from pay review bodies earlier this month, resulting in an average 5.4% rise for resident doctors.

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Source: The Guardian, 29 May 2025

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Health secretary told to intervene over ‘systemic’ ambulance deaths

Ministers must intervene over systemic failures which are “too big for hospital or ambulance trusts to fix on their own” and have led to multiple preventable deaths, a senior coroner has warned.

In a move usually considered rare for such an official, Cornwall and Isles of Scilly coroner Andrew Cox has written to the Department of Health and Social Care a second time over ongoing delays to ambulance responses and long ambulance handovers in the area.

Last year he warned the NHS was “broken” after he ruled ambulance and emergency care delays contributed to the deaths of four people. Now, he has sent a similar report on the same types of failings in the deaths of John Seagrove, Pauline Humphris, and Patricia Steggles at Royal Cornwall Hospital to new health secretary Victoria Atkins.

Mr Cox wrote: “I set out in my [prevention of future death report] last year my understanding of the reasons for the difficulties that are continuing in the Cornwall & Isles of Scilly coroner area. I do not believe those reasons will have changed significantly.

”The challenges are systemic in nature. They are too big for a single doctor, nurse or paramedic to fix. They are too big for either the hospital trust or the ambulance trust to fix on their own.”

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Source: HSJ, 1 December 2023

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Health secretary to investigate allegations of women denied epidurals

Women in labour are being denied epidurals by NHS hospitals, amid concern that a “cult of natural childbirth” is leaving rising numbers in agony.

Last night, Matt Hancock, the Health Secretary, promised an investigation, and action to ensure women’s choices were respected, pledging to make the NHS maternity services the world-leader.

An investigation by The Sunday Telegraph found hospitals refusing clear requests from mothers-to-be, in breach of official guidelines from the National Institute for Health and Care Excellence (NICE).

Mr Hancock said all expectant mothers should be able to make an informed choice, knowing their choice would be fully respected.

“Clinical guidance clearly state that you can ask for pain relief at any time – before and during labour – and as long as it is safe to do so this should never be refused. I’m concerned by evidence that such requests are being denied for anything other than a clinical reason,” he said.

“It's vital this guidance is being followed right across our NHS, as part of making it the best place in the world to give birth. Women being denied pain relief is wrong, and we will be investigating.”

One mother, describing her experience at one NHS Hospital said: "It made me feel unsafe psychologically - I couldn't speak up, I couldn’t say what I wanted to say, I couldn’t advocate for myself medically because people were ignoring or belittling me. It feels that in childbirth, it’s a given that the doctor is taking their personal beliefs with them to the table, whereas in any other area of healthcare that would be unacceptable."

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Source: The Telegraph, 26 January 2020

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Health secretary to act on racial bias in effectiveness of medical devices

Sajid Javid has said medical device manufacturers should check their products work well for people of all ethnic backgrounds, citing problems that those with dark skin have experienced when using pulse oximeters.

Several studies have found oximeters are not as good at identifying hypoxia in people with darker skin. The devices have been widely used during the covid pandemic to monitor people at risk of deteriorating at home. They are meant to trigger a response when needed. Official guidance was updated this summer to encourage caution in their use. 

The health and social care secretary has identified health inequalities as one of his priorities. He gave the issue as an example of racial bias in healthcare when speaking at the Conservative party conference on Tuesday evening.

He said: “It turned out that pulse oximeters, all of them that exist in the world, were giving often the wrong reading for people with dark skin, because they were designed by companies where basically all they were thinking about were white people. Why is that? Because the companies, their market was white countries with a majority of white people.”

Mr Javid, who has a British Pakistani background, continued: “They just weren’t thinking whether these things could work on people with a skin colour like mine or just darker skin, and that’s not right.

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Source: HSJ, 6 October 2021

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Health secretary tells striking NHS nurses: Take the money and patients will pay the price

Patients will suffer if ministers bow to nurses’ demands for pay rises, the health secretary has warned as tens of thousands of NHS staff walk out on today.

Steve Barclay told the Independent said any boost to wages would “take billions of pounds away from where we need it most”.

He wrote: “Unaffordable pay hikes will mean cutting patient care and stoking the inflation that would make us all poorer.”

Today tens of thousands of nurses will strike across 55 trusts. NHS data shows 4,567 operations and 25,009 outpatient appointments were cancelled during the nurse’s strikes on 15 and 20 December.

The NHS also faces further ambulance strikes next Monday, which sources indicate will go ahead, and new strikes are to be announced for February by union GMB.

The Royal College of Nursing (RCN) criticised Mr Barclay for “pitting nurses against patients”, branding the comments “a new low for the health secretary”.

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Source: The Guardian, 18 January 2023

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Health secretary sets up £500m fund to discharge medically fit NHS patients

Ministers are setting up a £500m emergency fund to get thousands of medically fit patients out of hospital as soon as possible in an attempt to prevent the NHS becoming overwhelmed this winter.

Thérèse Coffey, the new health secretary, unveiled the move in the Commons on Thursday as part of her plans to tackle the growing crisis in the health service, especially patients’ long delays for care.

The newly created adult social care discharge fund is intended to relieve the pressure on overstretched hospitals in England by ensuring that patients whom doctors have judged well enough to leave can be safely discharged either to their home or into a care home.

In her first speech since becoming the health secretary 16 days ago, Coffey told MPs: “I can announce today that we are launching a £500m adult social care discharge fund for this winter.

“The local NHS will be working with councils with targeted plans on specific care packages to support people being either in their own home or in the wider community. This £500m acts as the downpayment in the rebalancing of funding across health and social care as we develop our longer-term plan.”

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Source: The Guardian, 22 September 2022

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