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East Kent maternity inquiry to examine failings spanning more than a decade

An inquiry into dozens of baby deaths at an NHS trust will examine failings from “ward to board” covering a period of more than a decade, it has emerged.

The independent inquiry into poor maternity care at East Kent Hospitals University Trust published its terms of reference and scope for how it will carry out its work on Thursday.

The probe, led by Dr Bill Kirkup, was commissioned by the government after The Independent revealed more than 130 infants suffered brain injuries during birth at the trust over several years.

The scandal was exposed by the family of baby Harry Richford who died after a catalogue of errors by maternity staff in November 2017. A coroner ruled his death was the result of neglect and “wholly avoidable”.

Several other families have also spoken out over the deaths of their babies, with evidence emerging the trust’s managers were warned about safety concerns but failed to take action.

In October, the Care Quality Commission (CQC) said it intended to prosecute the trust over the death of Harry Richford.

It is understood that since the inquiry was launched, a significant number of families have come forward with concerns but the inquiry has refused to say what the total number of cases is.

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Source: The Independent, 11 March 2021

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East Kent maternity deaths: Trust has lost confidence of patients

A boss at a trust which was heavily criticised in a damning report says patients have lost confidence in the care they provide.

Raymond Anakwe, executive director of East Kent Hospitals Trust, said regaining patient trust would be "possibly the largest challenge".

He was speaking at a board meeting two weeks after a review found a "clear pattern" of "sub-optimal" care.

Mr Anakwe said: "The reality is we have lost the confidence of our patients."

He also said the trust has lost the confidence "of our local community and sadly also many staff".

The trust's chief executive, Tracey Fletcher, told the meeting that she believed many staff thought "enough is enough", and that the trust has to be "brave" if it's to move forward.

Stewart Baird, a non-executive director, said: "I think it's clear the buck stops here with the people sat round this table, and where there are bad behaviours in the trust, it's because we have allowed it.

"Where people don't feel able to speak up, it's because we have not provided an environment for them to do that."

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Source: BBC News, 3 November 2022

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East Kent hospitals: Maternity concerns at baby death NHS trust

Hospital inspectors have raised safety concerns over maternity care at an NHS trust where dozens of babies died unnecessarily.

The Care Quality Commission (CQC) is threatening the East Kent Hospitals trust with enforcement action to ensure patients are protected.

An independent review in October found that at least 45 babies might have survived with better care at the trust.

The East Kent Hospitals trust has been approached for comment.

Inspectors carried out an unannounced inspection of the trust's maternity services over two days last week.

Following the visit, the CQC has now written to the trust "to request evidence of the steps it is taking to ensure people are safe and protected from risk."

In a statement to the BBC, Deanna Westwood, a director of operations with the CQC, said they would "review the trust's response to determine whether the use of our enforcement powers is required."

The warning comes just four months after the trust was severely criticised for its maternity care between 2009 and 2020.

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Source: BBC News, 18 January 2023

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East Kent hospitals: Care watchdog inspects trust after baby death apology

England's care watchdog has carried out a no-notice inspection of an NHS trust at the centre of concerns over the possible preventable deaths of babies. The Care Quality Commission (CQC) is investigating East Kent Hospitals NHS Trust but has not yet decided whether to prosecute.

It comes as the trust is likely to be heavily criticised at an inquest into the death of baby Harry Richford.

On Thursday, the BBC revealed significant concerns have been raised about maternity services at the trust, and a series of preventable baby deaths may have occurred there. On Wednesday and Thursday this week, the trust's maternity services were subject to an unannounced inspection from the CQC.

On Thursday night, East Kent Hospitals University NHS Foundation Trust said in a statement: "We are truly sorry for the death of baby Harry and our thoughts and deepest sympathies go out to Harry's family. We accept that Harry's care fell short of the standard that we expect to offer every mother giving birth in our hospital and we are fully cooperating with the CQC's investigation into Harry Richford's death."

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Source: BBC News, 24 January 2020

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East Kent hospitals: Baby deaths 'could have been prevented'

At least seven preventable baby deaths may have occurred at one of the largest groups of hospitals in England since 2016, a BBC investigation has found.

Significant concerns have been raised about maternity services at the trust.

East Kent NHS Foundation Trust has apologised, saying it has "not always provided the right standard of care".

The trust has struggled to improve maternity care for years, despite repeatedly being made aware of the problems.

In 2015, the medical director asked experts from the Royal College of Obstetricians and Gynaecologists to review maternity care, amid "concerns over the working culture". Their review, seen by the BBC, found poor team working in the unit, a number of consultants operating as they saw fit, a lack of performance management of the consultant body and out of date clinical guidelines.

It highlights consultants who:

  • failed to carry out labour ward rounds, review women, make plans of care or attend out of hours when requested
  • rarely attended CTG training
  • were reported "as doing their own thing rather than follow guidelines".

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Source: BBC News, 23 January 2020

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East Kent Hospitals Trust: COVID-19 practice failings revealed by inspection

Inspectors have demanded improvements from a hospital after a report highlighted a number of failings over COVID-19 precautions.

The Care Quality Commission (CQC) inspected the emergency department and medical wards at the William Harvey Hospital in Ashford, Kent, on 11 August.

Inspection teams visited a ward where patients showed symptoms and were awaiting test results as well as a ward caring for patients who had COVID-19. A ward for patients without the virus and a fourth ward where there had been an outbreak of COVID-19 were also inspected.

The CQC said it took urgent enforcement action, telling the trust to ensure there was an "effective system to manage the health and safety of people using the hospital".

The report revealed staff did not always wear PPE or face coverings correctly in medical wards. One member of the nursing team was seen to be wearing a mask incorrectly in the ward where there had been an outbreak of the coronavirus.

At least seven members of staff were seen entering and leaving the ward caring for people who were suspected of having COVID-19 without adhering to hand hygiene practices.

Staff did not always remove PPE upon entering a new clinical area of the emergency department. Nor did they always put on or take off their PPE when entering and leaving patient bays.

While equipment was said to have been cleaned on the day, inspectors found this was not always recorded.

The report also detailed that five members of staff were seen in one room that was too small to enable the practised social distancing in that space.

East Kent Hospitals Trust chief executive Susan Acott said: "In August, a CQC inspection team visited the William Harvey Hospital and saw examples of practice which falls short of the high standard we all want to provide for our patients."

"Keeping our patients and staff safe is our priority. We have responded to the CQC with the actions we are taking and we are committed to the care and safety of every patient in our hospitals."

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Source: BBC News, 7 October 2020

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East Kent Hospitals Trust pays out more than £4 million in compensation for negligence claims relating to medication errors since 2019

A Kent hospitals trust has paid out more in compensation for medication blunders than any other in England, new data suggests.

Since 2019, East Kent Hospitals - which runs the Kent and Canterbury Hospital, QEQM in Margate, and William Harvey in Ashford - has handed over almost £5 million to patients affected by errors in prescribing, dispensing, administering or advising on medicine.

According to figures released by NHS Resolution - the legal arm of the health service - the 10 negligence claims settled by the trust over five years cost it £4,723,658 in compensation.

This sum is the highest of any trust in the country where at least five claims have been settled, and does not include legal fees, meaning the full cost to taxpayers is even higher.

Medication errors, which the NHS defines as patient safety incidents involving mistakes with medicines, can include prescribing the wrong drug or dose, poor communication between hospitals and GPs, or failing to properly monitor patients on powerful medication.

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Source: Kent Online, 6 May 2025

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East Kent Hospitals accused of ‘cancer at the top of the organisation’ by governor

The former lead governor of East Kent Hospitals University Foundation Trust has resigned this morning, claiming there is “a cancer at the top of the organisation” and that its services won’t be safe until the government provides funding for critical estates work.

His resignation as a governor came hours before the publication of what is expected to be a “harrowing” report into maternity services at the trust from an independent review led by Sir Bill Kirkup. He is also expected to raise concerns about national progress on maternity services safety in recent years.

Alex Lister, who is chair of the council of governors’ membership engagement and communications committee, said in the letter: “I believe officials on six-figure salaries continue to mislead, obfuscate, bully and conceal vital information. I consider the way the trust communicates internally and externally to be completely unacceptable and utterly untrustworthy.

“Without the valiant efforts of the brave families caught up in a tragedy of the trust’s making, the world may never have found out about the disastrous health failings at our trust.”

In the letter to chair Niall Dickson, Mr Lister says he has seen a continuation “of the same apparent policy of manipulation and discrediting dissenting voices that existed prior to the scandal”.

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Source: HSJ, 19 October 2022

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East Kent baby deaths: Scale of deaths at trust 'not clear-cut'

The boss of an NHS trust at the centre of concerns about preventable baby deaths has claimed the scale of the failings is not clearly defined.

Susan Acott, Chief Executive of East Kent Hospitals Trust, said there had only been "six or seven" avoidable deaths at the trust since 2011. However, the BBC revealed on Monday that the trust previously accepted responsibility for at least 10.

Ms Acott said some of the baby deaths were "not as clear-cut".

A series of failings came to light during the inquest of Harry Richford who died seven days after his birth at the Queen Elizabeth the Queen Mother Hospital in Margate in November 2017. A coroner ruled Harry's death was "wholly avoidable" and was contributed to by hospital neglect.

Ms Acott added she had not read a key report from 2015 drawing attention to maternity problems at the trust until December 2019.

Ms Acott claims that from 2011 to 2020 there were "about six or seven" baby deaths that were viewed as preventable. She says the other deaths were being investigated adding "these things aren't always black and white".

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Source: BBC News, 12 February 2020

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East Kent baby deaths: Four more families come forward

A BBC News investigation has uncovered more preventable baby deaths at an NHS trust that has already been criticised for its maternity services.

Four families said their babies would have survived had East Kent Hospitals NHS Trust provided better care. The NHS's Healthcare Safety Branch is investigating 25 maternity cases at the hospitals in Margate and Ashford.

The trust has apologised for the care provided in two of the cases and said they were investigating a third. It has denied any wrongdoing in the fourth case.

The government is due to receive the Healthcare Safety Branch's report into the 25 cases later, as well as a Care Quality Commission report from an inspection carried out in January.

Last month, the BBC discovered at least seven preventable deaths may have occurred at the trust since 2016. Four further families have now spoken out, saying their babies would not have died if medics had provided better care. In two of the cases, the mothers said the actions of the trust left them feeling they were to blame for their babies' deaths.

In a statement, East Kent Hospitals Trust it had set up a board sub-committee "to ensure we are complying with national safety standards and ensure we are implementing the coroner's recommendations fully and swiftly".

"We are deeply saddened by the stories of families who have suffered the death of a much-loved baby, and we are extremely sorry for their loss," it added.

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Source: BBC News, 10 February 2020

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East Kent baby deaths: "Hospital did not learn from mistakes"

The parents of a baby who nearly died after a series of failings during his birth said they were "heartbroken" mistakes continued to be made

East Kent Hospitals told Harry Halligan's parents they would learn lessons from his delivery in 2012. But similar failings recently came to light after the death of Harry Richford in 2017 and the trust is now being probed over up to 15 baby deaths.

The trust said it made "many changes to the maternity service" after 2012.

Parents Dan and Alison Halligan, from New Romney, said watching news coverage of an inquest into Harry Richford's death earlier this year, which laid bare the failings, had brought back stressful memories.

Mr Halligan said the trust "clearly haven't learned from [the] mistakes" made in his son's care, adding that it was "heartbreaking" to see "the same mistakes being repeated".

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Source: BBC News, 5 March 2020

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Early end to England’s isolation rules is a: "perilous and politicised pandemic response"

Today the Government is expected to announce the end to all Covid restrictions, including ending self-isolation and free testing in the country. However, in an open letter to the UK's Chief Medical Officer and Chief Scientific Officer, the UK science and medical communities say this is a "HUGE mistake".

The open letter expresses concern about the Government plans to end testing, surveillance surveys and legal isolation of Covid-19 cases and asks the Government to clarify the scientific advice underpinning these policy decisions as they do not believe there is a solid scientific basis for the policy.

"It is almost certain to increase the circulation of the virus and remove the visibility of emerging variants of concern." 

"The emergence of new variants and a resultant wave of infections can occur very quickly, potentially within just several weeks. The ability to rapidly detect and characterise new variants and to scale up necessary responses (such as TTI and vaccinations) quickly will be very important. Considerations for future response preparedness and surveillance infrastructure should take this into account." 

"We believe humanity is in a race against the virus."

The letter goes on to say that some form of surveillance must be continued to ensure the situation is well understood and new variants of concern identified. Lack of testing is not only detrimental to controlling the spread of SARSCoV2 and detecting new variants, it also puts people who develop Long Covid at a great disadvantage by not having a confirmation of their infection, which is integral to the diagnosis, support and care they need to receive. For the 1 in 4 people in the UK who are clinically vulnerable, the current approach appears a perilous and politicised pandemic response.

The authors of the letter are asking members of the UK science and medical communities to sign the open letter.

Read the letter in full and sign here

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Early death risk grows with just three ‘slightly unhealthy mid-life traits’

Just three “slightly unhealthy traits” in mid-life increase the risk of early death by a third, research suggests.

The study found people carrying extra weight in their 40s and 50s who also had slightly raised blood pressure, cholesterol or blood sugar levels were also 35 per cent more likely to have a heart attack or stroke over the next three decades.

Researchers warned that middle-aged people with this “cluster of slightly unhealthy traits” – known as metabolic syndrome – typically had a heart attack or stroke two years earlier on average than healthier people the same age.

Dr Lena Lönnberg, of Västmanland County Hospital, Sweden, who was lead researcher for the study, said: “Many people in their 40s and 50s have a bit of fat around the middle and marginally elevated blood pressure, cholesterol or glucose but feel generally well, are unaware of the risks and do not seek medical advice. “In fact, most people live with slightly raised levels for many years before having symptoms that lead them to seek healthcare.”

She warned that because the individual “unhealthy traits” did not usually make people feel unwell, most people were unaware of the risks combined with excess weight.

An estimated one in four UK adults has metabolic syndrome, with rising obesity levels one of the main drivers.

On their own, diabetes, high blood pressure, and obesity can damage the blood vessels. 

But even if patients only have mild versions of each condition, experts warn having the three together can be particularly dangerous.

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Source: The Telegraph, 25 August 2023

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Early CT scans deliver huge fall in lung cancer deaths, study shows

Screening smokers and ex-smokers could dramatically reduce deaths from lung cancer – Britain’s biggest cancer killer – a major new study has found.

Low-dose computerised tomography (CT) scans can detect tumours in people’s lungs early and cut deaths by 16%, according to the UK Lung Cancer Screening Trial (UKLS).

The findings have prompted renewed calls from lung cancer experts for the government to bring in routine screening across the UK of all those who are at risk because of their smoking history. They say that early detection means patients can have potentially curative surgery or radiotherapy.

“Lung cancer early detection and surgical intervention saves lives,” said Professor John Field of Liverpool University, an author of the trial. 

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Source: The Guardian, 12 September 2021

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Early care scheme could prevent thousands of miscarriages a year

After going through two devastating miscarriages, Lisa Varey could not believe what she was thinking.

She knew she would have to miscarry again before she could get the help she needed. Only when you have had three miscarriages do you normally qualify for specialist NHS help in England. One in five pregnancies end in miscarriage, most before 14 weeks.

After her second miscarriage, Lisa was invited on to a pilot project at Birmingham Women and Children's Hospital, which experts believe will prevent thousands of miscarriages every year by offering earlier checks and advice.

As part of the project, women who had suffered one miscarriage were given a one-to-one consultation with a specialist nurse to discuss lifestyle changes - including reducing alcohol consumption and giving up smoking - and using the hormone progesterone, which can help prevent miscarriage.

After a second miscarriage, women were tested for anaemia and abnormal thyroid function, which can affect pregnancy outcomes. They were also offered early scans to reassure them the pregnancy was advancing normally.

Following a third miscarriage, the pathway joins up with what the NHS currently offers - including a referral to a recurrent miscarriage clinic, further blood tests and a pelvic ultrasound.

Tests showed Lisa would benefit from taking the hormone progesterone to help maintain her pregnancy and a regular aspirin tablet to increase the chances of a healthy birth.

Lisa is now pregnant and in the last weeks of her second trimester. She breaks down in tears as she speaks about how much difference the project's help has made.

"There's so much support for pregnant women, but it didn't always feel like there was any support for women who were no longer pregnant. We're having to go through that journey of just feeling very sad."

Professor Arri Coomarasamy, head of miscarriage research at Tommy's, says the three miscarriage wait is an unacceptable anomaly.

"We don't do that with any other medical condition. If somebody has a heart attack, we don't say have your third heart attack and then we will see if there is anything we can do," he says.

He says the findings of the study, if rolled out across the NHS, could also save the NHS money. The pilot suggests the extra costs of staff and training are outweighed by the money saved having fewer women miscarry.

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Source: BBC News, 29 April 2026

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Early cancer diagnoses plummeted in England during Covid pandemic

The number of people being diagnosed with cancer early in England has plummeted during the Covid pandemic, sparking fears that many will only be treated when it is too late to save them.

Official figures show a third fewer cancers were detected at stage one, when the chances of survival are highest, in the early months of the pandemic than during the same months a year before.

Cancer experts fear that the figures, which have been collected by Public Health England’s National Cancer Registration and Analysis Service, mean thousands of people have the disease but have not yet started treatment because of “a shift to later diagnosis”. They urged anyone with possible symptoms of the disease to get them checked out immediately.

“While it’s fantastic that Covid rates are dropping and lockdown is easing, the knock-on impact of the pandemic on cancer care cannot be overstated,” said Steven McIntosh, the executive director of advocacy and communications at Macmillan Cancer Support. “We are likely to be dealing with Covid’s long shadow for many years to come.”

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Source: The Guardian, 5 May 2021

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Earlier recognition of aortic dissection needed to prevent deaths

Up to half of all patients who suffer an acute aortic dissection may die before reaching crucial specialist care, according to a new Healthcare Safety Investigation Branch (HSIB) report.

The report highlights the difficulty which can face hospital staff in recognising acute aortic dissection. The investigation was triggered by the case of Richard, a fit and healthy 54-year old man, who arrived at his local emergency department by ambulance after experiencing chest pain and nausea during exercise. It took four hours before the diagnosis of an acute aortic dissection was made, and he spent a further hour waiting for the results of a CT scan. Although Richard was then transferred urgently by ambulance to the nearest specialist care centre, he sadly died during the journey.

The report has identified a number of risks in the diagnostic process which might result in the condition being missed. These include aortic dissection not being suspected because patients can initially appear quite well or because symptoms might be attributed to a heart or lung condition.

It also highlighted that, once the diagnosis is suspected, an urgent CT scan is required to confirm that an acute aortic dissection is present. 

Gareth Owens, Chair of the national patient association Aortic Dissection Awareness UK & Ireland, welcomed the publication of HSIB’s report, saying: “HSIB’s investigation and report have highlighted that timely, accurate recognition of acute Aortic Dissection is a national patient safety issue. This is exactly what patients and bereaved relatives having been telling the NHS, Government and the Royal College of Emergency Medicine for several years."

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Source: HSIB, 23 January 2020

 

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Earlier diagnosis of ovarian cancer possible with medical tampon, research suggests

A specialist medical tampon could be used to help diagnose ovarian cancer earlier, researchers believe.

In the UK about 7,500 women are diagnosed with ovarian cancer each year. If the cancer is caught in the early stages a woman has a 95 per cent chance of surviving the disease.

But only around one third of women are diagnosed at the earliest stages with more than 50 per cent diagnosed when the disease is at an advanced stage when fewer treatment options are available, according to Ovarian Cancer Action.

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Source: Independent, 21 February 2026

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Earlier C-section could have saved baby

A baby who died three days after birth would have survived if her mother had been offered a caesarean section, a coroner has said.

Emmy Russo was delivered at Princess Alexandra Hospital in Harlow but died on 12 January 2024.

Mother Bryony Russo told an inquest at Essex Coroner's Court that her requests for a C-section were "laughed off" during the hours she was there in labour.

Assistant coroner for Essex, Thea Wilson, said there were five missed opportunities to offer Ms Russo a C-section, and that Emmy's chances would have been different had she been born an hour earlier.

"She would have been born in a better condition and on the balance of probabilities she would have survived," she said.

"There was a failure to respond adequately to the request for a C-section"

Independent expert obstetrician Teresa Kelly had told the coroner there was enough evidence "this baby wasn't coping with labour" and staff should have acted sooner.

Giving evidence, midwife Megan Fletcher defended her decision not to escalate concerns to a more senior doctor, saying she was trying to avoid any further "invasive procedures".

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Source: BBC News, 7 May 2025

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Dying patients living longer than expected lose NHS funds

More than 1,300 patients a year are having NHS funding for their palliative care withdrawn after living longer than expected, BBC analysis shows.

Terminally ill or rapidly-declining patients are given fast-track support, allowing them to live outside hospital.

From 2018 to 2021, a total of 9,037 people had this funding reviewed in England and Wales, with 47% of them losing all support.

A further 15% of patients had their continuing healthcare support replaced with the more limited NHS-funded nursing care.

Sandra Hanson was referred to the fast-track pathway of the NHS continuing healthcare scheme in mid-2020, after her needs were judged by a clinician to be "end of life".

She was diagnosed with end-stage dementia, and had been in hospital eight times in the previous year following multiple falls and bouts of pneumonia.

The funding covered the costs of a nursing home, where she suffered fewer falls. But in March 2021, this funding was reviewed by her local Clinical Commissioning Group (CCG).

These assessments, usually undertaken by a multi-disciplinary team including health and social care professionals, consider the severity of a person's needs in areas such as mobility, cognition and behaviour.

Sandra's daughter, Charlotte Gurney, said the family was represented by a social worker they had not previously met, and describes the meeting as "traumatic" as she tried to explain her mum's needs.

"We just felt not listened to... we were treated as if we were trying to swindle the system.

Sandra's support was withdrawn, and she had to be moved to a new nursing home, financed by her husband Malcolm.

Shortly afterwards, she broke her wrist following a fall and injured her face. The family believe had the review correctly identified Sandra's needs and risks, this could have been avoided.

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Source: BBC News, 17 March 2022

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Dying patients go without care as community nurses ‘on their knees’

Dying patients are going without care in their own homes because of a collapse in community nursing services, new data shared with The Independent reveals.

Across England a third of district nurses say they are now being forced to delay visits to end of life care patients because of surging demand and a lack of staff. This is up from just 2% in 2015. The situation means some patients may have to wait for essential care and pain medication to keep them comfortable.

Other care being delayed includes patients with pressure ulcers, wounds which need treating and patients needing blocked catheters replaced.

More than half of district nurses said they no longer have the capacity to do patient assessments and psychological care, in an investigation into the service.

Professor Alison Leary, director of the International Community Nursing Observatory, said her study showed the country was “sleepwalking into a disaster,” with patients at real risk of harm.

She said the situation was now so bad that nurses were being driven out of their jobs by what she called the “moral distress” they were suffering at not being able to provide the care they knew they should.

“People are at the end of their tether. District nurses are reporting having to defer work much more often than they did two years ago. What they are telling us is that the workload is too high. This is care that people don’t have time to do.”

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Source: The Independent, 29 November 2021

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Dying patient should have been seen in person

NHS officials ruled a man who died after his ear infection was not picked up in GP telephone consultations should have been seen face to face, a BBC Newsnight investigation has found.

David Nash, 26, had four remote consultations over three weeks during Covid restrictions but was never offered an in-person appointment. His infection led to a fatal abscess on his brainstem.

David first spoke to the practice on 14 October 2020, after finding lumps on his neck. He sent a photograph but was never examined.

With David worried the lumps might be cancerous, the GP asked a series of questions about his health and reassured him that while she could not rule it out completely, she was not worried about cancer.

She suggested he booked a blood test for two to three weeks' time.

In those three weeks, David would go on to speak to another GP and two advanced nurse practitioners but never face to face or via video call.

He was actually due to be seen in person at the GP surgery that day, for the blood tests booked some 19 days earlier, when he had presented with neck lumps. But - fearing he could have coronavirus, despite a negative PCR test - the nurse cancelled the bloods and asked David to retest for Covid.

In its investigation, NHS England found "the overarching benefit [of this decision] was less than the risk with going ahead with blood tests".

After five calls to NHS 111, David was taken to hospital in an ambulance that day but died two days later.

NHS England, in a finding seen by Newsnight, said: "A face-to-face assessment should have been offered or organised to confirm the diagnosis and initiate definitive management."

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Source: BBC News, 29 September 2022

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Dying doctor warns of asbestos ‘hidden epidemic’ caused by NHS failures

A doctor and mother of two with just months left to live has warned of a “hidden epidemic” of asbestos-related cancers among NHS staff and patients because hospitals have failed to properly handle the toxic material.

Kate Richmond, 44, has spoken out to raise awareness after she won a legal case against the NHS for negligently exposing her to asbestos while she was working as a medical student and junior doctor.

An investigation by The Independent has learnt there have been 13 prosecutions linked to NHS breaches of regulations for the handling of asbestos since 2010, while 381 compensation claims have been made by NHS staff for work-related diseases, including exposure to asbestos, since 2013, costing the health service more than £26m.

According to data from the Health and Safety Executive, between 2011 and 2017, a total of 128 people working in health and social care roles died from mesothelioma, the same asbestos-related cancer which is killing Kate Richmond.

She described how maintenance staff removed asbestos ceiling tiles with no protective measures, allowing dust and debris to fall on to wards where patients were in their beds and staff were working. Managers at the Walsgrave Hospital in Coventry failed to heed warnings by workers that they were putting people at risk.

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Source: The Independent, 9 February 2020

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Duty of candour review announced

Patient Safety Learning sets out its response to the announcement by the Department of Health and Social Care that it will be reviewing the statutory duty of candour for health and social care providers in England.

"We welcome today's announcement by the Government that they will hold a review into the statutory duty of candour for health and social care providers.

The statutory duty of candour is intended to ensure that healthcare providers are open and transparent with the public. It sets specific requirements for organisations to follow when things go wrong with care and treatment.

Earlier this year the Parliamentary and Health Service Ombudsman highlighted concerns around the implementation of duty of candour and called for a review to assess its effectiveness in their report Broken trust: making patient safety more than just a promise. In our response to this report, we supported this recommendation.

As part of reviewing problems with compliance, we believe that there are also broader questions that also need to be addressed concerning how the implementation of this is monitored and what remediation and redress is available to patients and the families when these obligations are not met.

We also believe that this review should look at how the duty of candour is being implemented in light of the introduction of the new Patient Safety Incident Response Framework (PSIRF), given that this represents a significant change to the NHS’s approach to incident investigation."

Source: Patient Safety Learning, 6 December 2023

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Duty of candour a ‘tick box exercise’ for overworked leaders, says watchdog

Senior leaders are resorting to “ticking the duty of candour box” instead of developing a “just and learning” culture in their organisations because their bandwidth is full, the patient safety commissioner has said.

Speaking with HSJ as she begins the second year of her first term in the newly-established role, Henrietta Hughes said the bandwidth of senior leaders is “too full for them to make and maintain the necessary culture change”.

She warned the duty of candour — giving patients and families the right to receive open and transparent communication when care goes wrong — gets seen as a “bit of a tick box exercise, ‘doc tick’ as it’s described to me, which is a bit depressing really”.

A GP herself, she said individual doctors typically respond to concerns or they are handled by someone who knows the patient. Elsewhere, complaints are often addressed through a chief executive’s office, once all staff have provided written statements, she said.

She added: “[In general practice] it feels more compassionate and empathetic… I find it’s often quicker to have a conversation with the patient before it turns into a formal complaint and resolves it quickly.”

“What needs to change is that [NHS] trusts are currently held accountable to a very narrow set of criteria — financial and operational performance,” she said.

“This is how we will improve safety and experience, transparency, a just and learning culture, and improve morale.”

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Source: HSJ, 30 January 2024

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Patient Safety Learning is registered as a charity with the Charity Commission Registration number 1180689.

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