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Nurse Lucy Letby guilty of murdering seven babies on neonatal unit

Nurse Lucy Letby has been found guilty of murdering seven babies on a neonatal unit, making her the UK's most prolific child serial killer in modern times.

The 33-year-old has also been convicted of trying to kill six other infants at the Countess of Chester Hospital between June 2015 and June 2016.

Letby deliberately injected babies with air, force fed others milk and poisoned two of the infants with insulin.

Commenting on the verdict, Parliamentary and Health Service Ombudsman Rob Behrens said:

“We know that, in general, people work in the health service because they want to help and that when things go wrong it is not intentional. At the same time, and too often we see the commitment to public safety in the NHS undone by a defensive leadership culture across the NHS.

“The Lucy Letby story is different and almost without parallel, because it reveals an intent to harm by one individual. As such, it is one of the darkest crimes ever committed in our health service. Our first thoughts are with the families of the children who died. 

“However, we also heard throughout the trial, evidence from clinicians that they repeatedly raised concerns and called for action. It seems that nobody listened and nothing happened. More babies were harmed and more babies were killed. Those who lost their children deserve to know whether Letby could have been stopped and how it was that doctors were not listened to and their concerns not addressed for so long. Patients and staff alike deserve an NHS that values accountability, transparency, and a willingness to learn.  

“Good leadership always listens, especially when it’s about patient safety. Poor leadership makes it difficult for people to raise concerns when things go wrong, even though complaints are vital for patient safety and to stop mistakes being repeated. We need to see significant improvements to culture and leadership across the NHS so that the voices of staff and patients can be heard, both with regard to everyday pressures and mistakes and, very exceptionally, when there are warnings of real evil.”

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NHS whistleblower tells tribunal he faced ‘brutal retaliatory victimisation’

A consultant obstetrician has claimed he was sacked from his hospital for raising whistleblowing concerns about patient safety over fears they would cause “reputational damage”.

Martyn Pitman told an employment tribunal in Southampton that managers dismissed his concerns and he was “subjected to brutal retaliatory victimisation” after he criticised senior midwife colleagues.

He said: “On a daily basis there was evidence of deteriorating standards of care. We were certain that the situation posed a direct threat to both patients’ safety and staff wellbeing. Concern was expressed that there was a genuine risk that we could start to see avoidable patient disasters.”

Rather than addressing these, Pitman said the trust had considered it “the path of least resistance to take out [the] whistleblower”.

Pitman was dismissed this year from his job at the Royal Hampshire County hospital (RHCH) in Winchester, where he had worked as a consultant for 20 years. He is claiming he suffered a detriment due to exercising rights under the Public Interest Disclosure Act.

He said he “fought against [an] absolute barrage of completely unprofessional assaults on me” after he raised concerns about foetal monitoring problems that resulted in the death of a baby and the delivery of another with severe cerebral palsy.

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Source: The Guardian, 26 September 2023

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New inquiry: NHS Leadership, performance and patient safety

The Health and Social Care Committee has launched a new inquiry to examine leadership, performance and patient safety in the NHS.

Inquiry: NHS leadership, performance and patient safety

MPs will consider the work of the Messenger review (2022) which examined the state of leadership and management in the NHS and social care, and the Kark review (2019) which assessed how effectively the fit and proper persons test prevents unsuitable staff from being redeployed or re-employed in health and social care settings.

The Committee’s inquiry will also consider how effectively leadership supports whistleblowers and what is learnt from patient safety issues.

An ongoing evaluation by the Committee’s Expert Panel on progress by government in meeting recommendations on patient safety will provide further information to the inquiry.

Health and Social Care Committee Chair Steve Brine MP said:

“The role of leadership within the NHS is crucial whether that be a driver of productivity that delivers efficient services for patients and in particular when it comes to patient safety.

Five years ago, Tom Kark QC led a review to ensure that directors in the NHS responsible for quality and safety of care are ‘fit and proper’ to be in their roles. We’ll be questioning what impact that has made.

We’ll also look at recommendations from the Messenger review to strengthen leadership and management and we will ask whether NHS leadership structures provide enough support to whistleblowers.

Our Expert Panel has already begun its work to evaluate government progress on accepted recommendations to improve patient safety so this will build on that. We owe it to those who rely on the NHS – and the tax-payers who pay for it – to know whether the service is well led and those who have been failed on patient safety need to find out whether real change has resulted from promises made.”

Terms of Reference

  • The Committee invites written submissions addressing any, or all, of the following points, but please note that the Committee does not investigate individual cases and will not be pursuing matters on behalf of individuals.  
  • Evidence should be submitted by Friday 8 March. Written evidence can be submitted here of no more than 3,000 words.  
  • How effectively does NHS leadership encourage a culture in which staff feel confident raising patient safety concerns, and what more could be done to support this?
  • What has been the impact of the 2019 Kark Review on leadership in the NHS as it relates to patient safety?
  • What progress has been made to date on recommendations from the 2022 Messenger Review?
  • How effectively have leadership recommendations from previous reviews of patient safety crises been implemented?
  • How could better regulation of health service managers and application of agreed professional standards support improvements in patient safety?
  • How effectively do NHS leadership structures provide a supportive and fair approach to whistleblowers, and how could this be improved?
  • How could investigations into whistleblowing complaints be improved?
  • How effectively does the NHS complaints system prevent patient safety incidents from escalating and what would be the impact of proposed measures to improve patient safety, such as Martha’s Rule?
  • What can the NHS learn from the leadership culture in other safety-critical sectors e.g. aviation, nuclear?

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Source: UK Parliament, 25 January 2024

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Valdo Calocane ‘fell off radar’ of mental health services

Campaigners have said that more lives would be lost unless mental health services were reformed. Figures show 120 people each year are killed by people with mental illnesses.

Julian Hendy, whose father was killed by a psychotic man with a long history of mental ill health 17 years ago, said health professionals must be “more assertive” and work better with other agencies such as the police.

Valdo Calocane, who was sentenced on Thursday to an indefinite hospital order after being convicted of manslaughter of three people in Nottingham, had fallen off the radar of mental health services, which allowed him to avoid taking his medicine.

Hendy accused Nottinghamshire Healthcare NHS Foundation Trust, which was responsible for Calocane’s care, of “washing their hands” of him.

He said: “It’s not responsible and it’s not safe. It doesn’t look after people properly … That hasn’t helped him at all, or protected his rights at all, because he has now committed this terrible offence.”

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Source: The Times, 26 January 2024

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Cancer patient went year without check-up, inquest told

A prostate cancer patient went a year without a check-up because his referral to a consultant was lost.

An inquest into the death of Thomas Ithell also heard that when the error was spotted it was not recorded because staff at Wrexham Maelor Hospital were too busy.

The 77-year-old from Wrexham died in November 2022 after being admitted to hospital with shortness of breath.

Assistant Coroner for North Wales East and Central, Kate Robertson, has submitted a Prevention of Future Deaths report to the health board in relation to Mr Ithell's case.

As well as concerns over the lack of an investigation, she also questioned how the patient's follow-up appointment was missed.

"There have been no assurances as to what, if any, changes and learning have been identified other than a tracking system for PSA monitoring," she wrote, referring to a type of blood test that helps diagnose prostate cancer.

She was also concerned to learn that the hospital's Datix system - used for reporting incidents such as Mr Ithell's - had been described as "not user-friendly".

Time constraints also sometimes prevented staff from completing these reports, thereby failing to trigger subsequent investigations by the board, the assistant coroner added.

"I remain incredibly concerned that where matters are not raised in accordance with internal health board processes that assurances given to me in previous Prevention of Future Deaths reports cannot be supported," Ms Robertson added.

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Source: BBC News, 27 January 2024

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NHS accused of “burying” damning child cancer report

NHS bosses have been accused of “burying” a damning report into child cancer services commissioned following complaints that patients were “dying in agony”. Completed in 2015, the document highlights failings at the Royal Marsden NHS Foundation Trust, one of the UK’s flagship cancer organisations. It found that, despite being supposedly a centre of excellence, children admitted for cancer treatment were routinely transferred between hospitals to get the care they needed.

Compiled by Professor Mike Stephens, the report was commissioned after a coroner found “astonishing” failures in the care of a two-year-old girl, Alice Mason, leading to her suffering irreversible brain damage and dying in 2011. It recommended a radical shake-up of the Marsden’s services. The document was never made public, however, and former NHS medical director for London, Dr Andy Mitchell, accused the head of NHS England, Simon Stevens, and Cally Palmer, England’s National Cancer Director and Chief Executive of the Royal Marsden, of suppressing its publication.

Dr Mitchell told the Health Service Journal (HJS): “I can’t imagine any other individuals having the power and influence to be able to stop this report moving forward.”

NHS England has denied that its then Medical Director, Sir Bruce Keogh, was improperly leaned on and said the report remained unpublished because it made “implausible suggestions” which would have forced children with cancer to travel further for care. But Gareth Mason, Alice’s father, said: “To write a report, shelve it and not debate it, that is a cover-up [and] it has left children since Alice and danger, and the Marsden won’t acknowledge that.”

The controversy surrounds the performance of a so-called “shared care system”, with the Marsden’s Sutton site forming part of a network for South London, Surrey, Sussex and Kent.

Critics say the format meant children were transferred between sites more regularly than they should have been and were put in danger because information was not properly shared.

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Source: The Telegraph, 19 June 2019  

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Inquest finally delivers the truth about how Claire Roberts died

The parents of Claire Roberts said those responsible for their daughter's care should "hang their heads in shame". Alan and Jennifer Roberts were speaking after an inquest found that the nine-year-old's death in October 1996 was caused by the treatment she received in hospital. Outside Laganside courthouse, Mr and Mrs Roberts welcomed the coroner's findings but said the public can have "no confidence in patient safety" in Northern Ireland. 

Mr Roberts said that after a two decade wait the inquest had finally delivered the truth about how their daughter died. "We would like to thank the coroner for reaching a verdict after 22 years of cover-up that finally identifies the truth. The coroner has confirmed an unnatural cause of death. We have known as a family since 2004 the true cause of death - this has not been news to us but the coroner reaffirming what we have always known."

Mr Roberts also issued a demand to health officials for accountability, saying those responsible for failings in his daughter's care should "hang your heads in shame."

Source: Belfast Telegraph

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Chief Medical Officer to lead the fight against AMR

Public Health Minister, Seema Kennedy, has confirmed that Professor Dame Sally Davies will take on the role of UK Special Envoy on antimicrobial resistance (AMR) later this year. Dame Sally will be working across all sectors to deliver a ‘One Health’ response to AMR, which includes health, agriculture and the environment.

The appointment of Dame Sally follows the government’s 20-year vision and 5-year national action plan published earlier this year, setting out how the UK will contribute to containing and controlling AMR by 2040.

Professor Dame Sally Davies said: “AMR is a complex challenge which needs local, national and global action. The UK should be proud of its world-leading work on AMR. We have made tangible progress but it is essential we maintain momentum. I am honoured to have been asked to continue this vital work on behalf of the UK government.”

Last year the government committed £32 million funding to accelerate the UK’s work in the global fight against AMR. The awarded funding will support the development of a state-of-the-art, virtual ‘open access’ centre that will link health outcomes and prescribing data. This technology, led by Public Health England (PHE), will gather real-time patient data on resistant infections, helping clinicians to make more targeted choices about when to use antibiotics and cutting unnecessary prescriptions.

PHE will use £5 million in funding to develop a fully functional model ward, the first of its kind in the UK, to better understand how hospital facilities can be designed to improve infection control and reduce the transmission of antibiotic-resistant infections.

Other successful funds include £4.4 million to Manchester University to test ‘individualised’ approaches to antibiotic prescribing by bringing together patient care and clinical research, and £3.5 million to the University of Liverpool to apply innovative genome sequencing to enable more personalised antibiotic prescribing.

Public Health Minister Seema Kennedy said: “Antibiotic resistance poses an enormous risk to our NHS – we are already seeing the harmful effect resistant bugs can have on patient safety in our hospitals. It is vital that we retain the irreplaceable expertise of Professor Dame Sally Davies – an international expert in AMR – and continue to invest in research.”

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Confidence and trust in hospital staff high but no improvement in inpatient experience

Findings from the Care Quality Commission's (CQC’s) latest annual survey of people who stayed as an inpatient in hospital show that most people had confidence in the doctors and nurses treating them and felt that staff answered their questions clearly. However, just over a third (40%) of patients surveyed left hospital without written information telling them how to look after themselves after discharge (up from 38% in 2017), and of those who were given medication to take home, 44% were not told about the possible side effects to watch out for. 

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Launch of Patient Safety Learning’s 'the hub'

After many months of development and several user workshops, we are delighted and proud to present the hub at Patient Safety Congress 2019.

the hub is one of the actions proposed by Patient Safety Learning's A Blueprint for Action. The report identifies six foundations of safe care: shared learning, leadership, professionalising patient safety, patient engagement, data and insight, and culture, and proposes a range of actions to address these foundations. the hub is Patient Safety Learning's share online learning platform, which encourages and facilitates knowledge sharing, collaboration and conversation in patient safety across the whole of health and social care. It is a platform for health and social professionals, patients and their families to share and learn from one another.

the hub is free for everyone to use. Have a browse and you will find the latest news, research, resources and events in patient safety, and lively conversations and debates. Members can share content, comment on posts and start conversations in our communities. Please use the hub, share content and let us know what you think and how we can continue to develop it.

We would like to take the opportunity to thank everyone who has contributed this far in the development of the hub. Your thoughts, ideas and critique have been invaluable. the hub is still in development and we continue to seek out user testing and feedback. Please contact us at feedback@pslhub.org with your ideas or if you would like to be a part of our user testing group.  

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Global white paper urges leaders to invest in safe nurse staffing

The Nursing Times has just broken a story about the importance of safe nurse staffing levels, which has been underlined in an international white paper that calls on countries around the world to take action to ensure they have enough nurses.

The paper – launched at the International Council of Nurses’ annual conference – states evidence for a clear link between nurse staffing levels, patient safety and the quality of care is now “overwhelming and compelling”.

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The NHS Patient Safety Strategy

NHS Improvement and NHS England have published their NHS Patient Safety Strategy. The publication out today describes how the NHS will continuously improve patient safety, building on the foundations of a safer culture and safer systems. The strategy sets out what the NHS will do to achieve its vision to continuously improve patient safety. 

 

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Blame culture forcing Northern Ireland doctors to consider quitting

Doctors in Northern Ireland feel increasingly "vulnerable" to criminal proceedings in the workplace, forcing them to consider abandoning the profession, senior medic, Dr Tom Black, warns. Dr Black, chairperson of the British Medical Association Northern Ireland, says that consultants in Northern Ireland are operating in a "hostile working culture" as a result of the situation. He explains that medics are increasingly fearful of the professional repercussions if they make a medical error amid pressured case loads: "Doctors feel vulnerable to criminal and regulatory proceedings, and this creates a hostile training environment for our medical students, young doctors... This blame and sanction culture creates disrespect and mistrust. This has a price - it encourages risk avoidance behaviours in professionals, inefficient and ineffective management, increased cost for the system and deteriorating services for patients."

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Source: Belfast Telegraph, 25 June 2019

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Can we change the culture around breaks in the NHS?

The culture of working without breaks is dangerous to doctors’ and patients’ wellbeing and only a cultural shift can change things, argues Heidi Edmundson. 

Heidi, Consultant for Emergency Medicine at Whittington Health NHS Trust, discusses in BMJ Opinion how it has become impossible to ignore the huge cost of burnout to both individual doctors and the medical workforce. Breaks are no longer being viewed as a luxury, but as an integral part of physician wellbeing, patient safety, and workforce sustainability. However exceptional reporting and the costs associated with recruitment and retention issues mean that they are becoming a financial issue as well. Heidi ran her own departmental “public health” campaign entitled “take a break” to see if she could change this culture. 

"I started this project with a desire to try and change culture and I have come to realize that changing the culture around taking breaks is really just the tip of the iceberg. What we really need is a huge cultural shift in our attitudes and behaviours towards staff wellness. This will require imagination, innovation, and investment at all levels."

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Source: BMJ Opinion, 28 June 2019

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Rude surgeons may have worse patient outcomes

Traditionally, as a group, surgeons are not well known for their bedside manner. While poor manners aren't commonly accepted in most professional circles, representations of surgeons in popular culture often link technical prowess with rude behavior, and some surgeons have even argued that insensitivity can be helpful in such an emotionally strenuous profession. However, a study published in JAMA Surgery challenges these ideas. The study, which looked at interactions between surgeons and their teams, found that patients of surgeons who behaved unprofessionally around their colleagues tended to have more complications after surgery. Surgeons who model unprofessional behavior can undermine the performance of their teams, the authors write, potentially threatening patients' safety.

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Source: NPR, 19 June 2019

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Tackling bullying in the NHS

The Social Partnership Forum (SPF)’s collective call to action tasks employers and trade unions in all NHS organisations to work in partnership to create positive workplace cultures and tackle bullying. To support this work, the SPF is publicising the views of NHS leaders and experts on this topic and signposting information, tools and resources and case studies which can help partnership initiatives.

Creating positive workplace cultures and tackling bullying in the NHS - a collective call to action

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NHSX: giving patients and staff the technology they need

NHSX has just completed a major review of NHS tech spending. They have agreed to reducing the burden on clinicians and staff, so they can focus on patients; giving people the tools to access information and services directly; ensuring clinical information can be safely accessed, wherever it is needed; aiding the improvement of patient safety across the NHS; and improving NHS productivity with digital technology.

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'One in a million’ matron is crowned RCN Nurse of the Year

Royal College of Nursing (RCN) member Tara Matare has won the coveted title of RCN Nurse of the Year 2019. She scooped the leadership category at the RCNi Nurse Awards before being crowned the overall winner. Tara has tackled short staffing, improved workplace culture and enhanced patient care at her ophthalmology unit at Whipps Cross Hospital in London. Over a 14-year mission to overhaul the unit, there have been a steady stream of challenges, including fighting ophthalmology’s corner to ensure it wasn’t overlooked in favour of higher-profile inpatient services and tackling an ingrained culture of bullying.  

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Source: Royal College of Nursing, 4 July 2019

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Sepsis: How good are hospitals at treating 'hidden killer'?

Patients' lives are being put at risk because of delays giving them treatment for sepsis, experts are warning. Hospitals are meant to put patients on an antibiotic drip within an hour when sepsis is suspected, but research by BBC News suggests a quarter of patients in England wait longer. However, NHS England said there were signs performance was improving and that hospitals were getting better at spotting those at risk sooner. 

Dr Ron Daniels, of the UK Sepsis Trust, said the "concerning" figures showed patients were being put at risk. In some hospitals, over half of patients face delays. Dr Daniels said the one-hour window was "essential to increase the chances of surviving". "There is no reason really why it should take longer," he added.

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Source: BBC News, 4 July 2019

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'Crumbling hospitals’ are putting patient safety and care at risk

Hospitals throughout the NHS are in such a poor state of repair that patient safety and care is being put at risk, according to an investigation by the Labour Party. A freedom of information requests sent to every hospital trust in England highlighted problems such as sewage and water leaking on to hospital wards, broken lifts and ceilings collapsing. The incidents have affected patient care, often leading to the cancellation of appointments and leaving people waiting longer for vital treatment. It is speculated that these issues are not just confined to secondary care.

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Source: Nursing Notes, 5 July 2019

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New guidance calls on NHS to embed a learning and just culture to support staff, patients and carers

Challenging the NHS’ workplace culture is key to improving patient safety says NHS Resolution in their latest guidance: Being fair: supporting a just and learning culture for staff and patients following incidents in the NHS. The paper draws on NHS Resolution’s unique dataset to explore best practice in response to incidents resulting from claims from across the system. The guidance aims to help the NHS to create an environment to better support staff when things go wrong and to encourage learning from incidents.

 

 

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Bereaved families could be forced to turn to ambulance-chasing claims firms, in fight for justice

Plans to cap legal costs for NHS mistakes that lead to deaths of newborns could leave the bereaved at the mercy of 'ambulance-chasing' claims firms, a former Lord Chancellor has warned. Health officials have drawn up plans to limit spending in cases where damages are worth less than £25,000. This covers around eight in ten medical negligence claims, including the deaths of newborns, and stillbirths - where Britain’s record is among the worst in the developed world. Ministers have said the changes will stop “unscrupulous law firms” receiving excessive legal costs that dwarf the damages received by victims. However, Lord Falconer, Lord Chancellor under Tony Blair, raised fears that the measures could see established law firms leave the market  and be replaced by unregulated claim management companies. 

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Source: The Telegraph, 6 July 2019

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Hancock hopes NHSX will "transform technology use" across healthcare

Matt Hancock, Secretary of State for Health and Social Care, has said he hopes NHSX will "provide the leadership to transform the use of digital technology" across the health service. Speaking exclusively to Digital Health News at the launch of NHSX in London on 3 July, Matt Hancock added that he ultimately hopes NHSX “will save clinician’s time and patient’s lives”.

NHSX, which will oversee technology across health and social care, was confirmed by Digital Health News in February 2019 and brings together teams from the Department of Health and Social Care, NHS England and NHS Improvement.

Source: Digital Health News, 4 July 2019

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