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Nurses' strike in Northern Ireland: RCN confirms January strike dates

Nurses in Northern Ireland have announced their plans for further strike action in the new year.

Earlier this month, more than 15,000 nurses took to the picket lines over pay and staffing levels. It was the first time in the 103-year history of the Royal College of Nursing (RCN) that its members had taken such action.

It has announced nurses will strike on 8 January and 10 January 2020, unless a resolution is reached.

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Source: BBC News, 24 December 2019

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Two dead and hundreds harmed after being given wrong drugs in North East hospitals

Two people died and hundreds of others were harmed following prescription errors in North East hospitals last year, new figures reveal.

Staff at North East health trusts reported 2,375 prescribing mistakes to an NHS watchdog in 2018, including patients being given the wrong drug, failure to prescribe medicine when needed or given the wrong dosage.

At County Durham And Darlington NHS Foundation Trust, where 359 errors were found, 103 patients were harmed by prescription mistakes while one person died.

City Hospitals Sunderland NHS Foundation Trust was the second worse in the region for patients coming to harm as a result of prescription errors. One person was killed while 56 were harmed.

An NHS spokesperson said: “NHS staff dealt with over a billion patient contacts over the last three years, while serious patient safety incidents are thankfully rare, it is vital that when they do happen organisations learn from what goes wrong - building on the NHS’ reputation as one of the safest health systems in the world."

“As part of the NHS Long Term Plan a medicines safety programme has been established, meaning more than ever before is been done to ensure safe medicine use, and nearly £80 million been invested in new technology to prescription systems.”

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Source: Chronicle Live, 22 December 2019

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Pharmacy staff are less concerned about prosecution when reporting patient safety incidents

Only 14% of pharmacy professionals are worried about criminal prosecution when reporting a patient safety incident, compared with 40% in 2016, survey results have showed.

The results of the 2019 ‘Patient safety culture survey’ of 917 pharmacy professionals, carried out by the Community Pharmacy Patient Safety Group (PSG) in April and May 2019 came after the introduction of a legal defence for dispensing errors in 2018.

The survey also showed that 22% of pharmacy professionals would not report a patient safety incident inside their organisation owing to fears of criminal prosecution. This is compared with 40% of 623 respondents saying in 2016 that they would not report a patient safety incident because of the possibility of criminal prosecution.

Janice Perkins, chair of the PSG, said the results “demonstrate that there have been significant positive improvements since 2016”.

“Nurturing an open and honest safety culture in community pharmacies is vital. It requires everyone to feel confident in openly sharing when things go wrong to learn from errors and prevent them occurring again,” she added.

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Source: The Pharmaceutical Journal. 19 December 2019

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Doctors told to use 'least unsafe' option in Norwich hospital

An NHS hospital has been so overwhelmed that it told senior doctors to make “the least unsafe decision” when treating patients.

Medical groups have voiced concern that Norfolk and Norwich hospital trust’s instruction to its consultants this week showed it was struggling so much to cope with the number of people needing care that patient safety was being put at risk.

At the time the hospital had no spare beds, a full accident and emergency department, 35 patients waiting on trolleys to be admitted, and had declared a major internal incident.

In its message, seen by the Guardian, it said: “We would like you to know that the trust will support you in making difficult decisions that may be the least unsafe decision, and we would appreciate your cooperation over the coming days with this.”

The circular from the Norwich hospital added: “We are facing our most challenging situation with our trust today,” because it was so overcrowded and unable to find a bed for the 35 patients doctors had decided needed to be admitted as emergencies.

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Source: The Guardian, 20 December 2019

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New national investigation looks at outpatient appointments after hospital stays

The Healthcare and Safety Investigation Branch (HSIB) started a new national investigation looking into a safety risk involving outpatient follow-up appointments which are intended but not booked after an inpatient hospital stay.

If a patient does not receive their intended follow-up appointment, it could lead to patient harm owing to delayed or absent clinical care and treatment.

The investigation was launched after HSIB identified an event where a patient was discharged from hospital on two separate occasions with a plan to follow-up in outpatient clinics. Neither of the outpatient appointments were made.

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Source: HSIB, 20 December 2019

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Coroner and friends criticise NHS treatment of 24-year-old anorexia victim

A coroner has criticised health professionals for failing to give a young woman who died after suffering severe anorexia the support and care she needed.

Maria Jakes, 24, died of multiple organ failure in September 2018 after struggling for years with the eating disorder.

Coroner Sean Horstead last week concluded that the agencies involved in the Peterborough waitress’s care missed several key opportunities to monitor her illness properly. Mr Horstead said that there had been insufficient record-keeping and a failure to notify eating disorder specialists in the weeks before her death, following treatment at Addenbrooke’s and Peterborough City Hospital.

He also criticised the lack of specialist eating disorder dieticians at Addenbrookes and Peterborough hospitals, “together with a nursing team insufficiently trained and knowledgeable of eating disorder patients”, both of which had contributed to the lack of monitoring of Maria.

Despite the criticism the father of another anorexia victim, whose death was described in a Parliamentary and Health Service Ombudsman’s report as an “avoidable tragedy”, has said the inquest failed to properly address or challenge the “lack of care” that Maria received from the NHS.

Nic Hart, whose daughter Averil died in 2012 at the age of 19, criticised the inquest as “a very one sided process”. He told The Telegraph: “No real challengers were made of the clinical evidence or indeed of the lack of care that poor Maria received.”

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Source: The Telegraph, 21 December 2019

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NHS bed occupancy beyond safe levels ahead of Christmas

Hospital wards across the country are having to look after an unsafe number of patients, with hundreds of beds closed due to an outbreak of norovirus.

NHS England has said that on average almost 900 beds were closed each day during the week to Sunday 15 December.

Hospitals have reported fewer empty beds with bed-occupancy rates reaching as high as 95 per cent, 10 per cent higher than the recommended safe level.

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Source: The Independent, 20 December 2019

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Dublin mental health centre falls short on physical restraint code

A Dublin mental health centre has failed to comply with the code of practice on physical restraint for four consecutive years, an inspection report has found.

The 39-bed Elm Mount Unit at St Vincent’s University Hospital said the issue was now high risk. 

Two episodes were recorded by the Mental Health Commission (MHC) where the staff member responsible for leading the physical restraint did not monitor the person’s head or airway, and that this went undocumented. In another case, inspectors noted, the physical restraint was not reviewed by members of the multidisciplinary team and recorded correctly.

There was also concern regarding the administration of medicine, specifically deficits in the prescription and administration record “which could potentially lead to medication errors”.

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Source: The Irish Times, 17 December 2019

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Safety fears for hundreds of ‘hidden’ children on ventilators

Experts have warned hundreds of “hidden” children who rely on machines to help them breathe at home are at significant risk of harm due to staff shortages, poor equipment and a lack of training.

The number of children who rely on long-term ventilation is rising but new research has shown the dangers they face with more than 220 safety incidents reported to the NHS between 2013 and 2017.

In more than 40% of incidents the child came to harm, with two needing CPR after their hearts stopped. Other children had to have emergency treatment or were rushed back to hospital.

Many parents reported concerns with the skills of staff looking after their children or reported paid carers falling asleep while caring for their child. Families reported having to cover multiple night shifts due to staff shortages, while also having to care for their child during the day. Other patient safety incidents including broken or faulty equipment or information on packaging that did not match the item or incorrect equipment being delivered.

Consultant Emily Harrop, who led the study, said it was “easy for the plight of individual complex children to slip down the agenda”.

She warned: “This is a very hidden group of very vulnerable children who are at risk without investment in staffing, access to training and good communication."

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Source: The Independent, 18 December 2019

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Britain's postcode lottery for newborn deaths: Mortality rates on NHS wards twice as high in some areas, reveals report

Sick newborns in some areas of the UK are dying at twice the rate of seriously ill babies in other areas, a new report has revealed.

The findings raise serious questions about the quality of care in some neonatal units, with experts warning action needs to be taken to tackle the “striking variation”.

Across the country neonatal units are also short of at least 600 nurses with four in five failing to meet required safe staffing levels for specialist nurses.

The regions with the highest mortality rate at 10 per cent were Staffordshire, Shropshire and the Black Country, where 107 babies died. This compared with a rate of 5 per cent in north central and northeast London. The Shropshire region includes the Shrewsbury and Telford Hospitals Trust, which is at the centre of the largest maternity scandal in the history of the NHS, with hundreds of alleged cases of poor care now under investigation.

Dr Sam Oddie, a consultant neonatologist at Bradford Teaching Hospitals Trust and who led the work for the Royal College of Paediatrics and Child Health, said he was “surprised and disappointed” by the differences in death rates between units.

“The mortality differences are very striking, with some units having a mortality rate twice that of the lowest. This variation in mortality is a basis for action by neonatal networks to ensure they are doing everything they can to make sure their mortality is as low as possible,” he said.

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Source: The Independent, 18 December 2019

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Report highlights common ‘never event’ that leaves women at risk of harm after childbirth

Women can be left in severe pain and at risk of infection if swabs and tampons used after childbirth are accidentally left in the vagina. That’s the safety risk the Healthcare Safety Investigation Branch highlight in their new report published yesterday.

Vaginal swabs and surgical tampons (larger than tampons used by women during their menstrual cycle) are used to absorb bodily fluids in a number of procedures both in delivery suites and surgical theatres on maternity wards. They are intended to be removed once a procedure is complete.

The report sets out the case of Christine, a 30-year-old woman who had a surgical tampon inserted after the birth of her first child. It was left in and not discovered until five days after leaving hospital. Whilst being in immense pain throughout, Christine saw the community midwife and GP twice before going back to hospital where the swab was found.

Sandy Lewis, HSIB’s Maternity Investigation Programme Director, said: “Although measures have been put in place to reduce the chance of swabs and tampons being left in, it continues to happen, leaving women in pain and distress when they may have already gone through a traumatic labour.

“There are numerous physical effects; pain, bleeding and possible infection, but we can’t forget about the psychological impact as there was in Christine’s case – she had to seek private counselling and felt that what happened affected her ability to bond with her baby."

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Source: Healthcare Safety Investigation Branch, 18 December 2019

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Royal Derby Hospital: Disposable sterile hijabs introduced

A hospital trust believes it is the first in the UK to introduce disposable sterile headscarves for staff to use in operating theatres.

Junior doctor Farah Roslan, who is Muslim, had the idea during her training at the Royal Derby Hospital. She said it came following infection concerns related to her hijab that she had been wearing throughout the day.

It is hoped the items can be introduced nationally but NHS England said it would be up to individual trusts.

Ms Roslan looked to Malaysia, the country of her birth, for ideas before creating a design and testing fabrics. "I'm really happy and looking forward to seeing if we can endorse this nationally," she said.

Consultant surgeon Gill Tierney, who mentored Ms Roslan, said the trust was the first to introduce the headscarves in the UK. "We know it's a quiet, silent, issue around theatres around the country and I don't think it has been formally addressed," she said.

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Source: BBC News, 19 December 2019

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Coroner criticises NHS after death of patient with broken neck who was shunted between hospitals three times

An 88-year-old woman with a broken neck died after being transferred three times between two hospitals in the space of just 48 hours, The Independent has reveal.

The death of Jean Waghorn, who died after contracting pneumonia in hospital, sparked criticism from a coroner who said the NHS trust had ignored earlier warnings over moving patients between hospitals. Senior coroner Veronica Deeley had issued two official alerts to Brighton and Sussex Hospitals Trust last year after the deaths of frail elderly patients who were wrongly shuttled between hospitals.

But despite this, in June this year Ms Waghorn, who broke her neck after falling at home, was repeatedly transferred between the Princess Royal Hospital in Sussex and Brighton’s Royal Sussex County Hospital. She caught pneumonia and died two days later.

The hospital, which is rated good by the CQC, has now apologised and said it has learned lessons from the case. A spokesperson said it did take action following the previous warnings and added that work was ongoing to ensure the changes were consistently applied.

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Source: The Independent, 17 December 2019

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Weston General A&E rated 'inadequate' after warnings

A hospital A&E department has been rated "inadequate" after warnings over urgent and emergency care.

The Care Quality Commission (CQC) reported a lack of support for staff and safety concerns in Weston General hospital's A&E department.

Dr Nigel Acheson, deputy chief inspector of hospitals for the South NHS , said it was "disappointing". Weston Area Health NHS Trust "fully recognises that while improvements have been made... further work is required."

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Source: BBC News, 17 December 2019

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The NHS staffing crisis is about the expanding knowledge gap – not just numbers

A lot has been written about the workforce crisis in health and social care. 43,000 registered nurse vacancies, a 48% drop in district nurses in eight years and not enough GPs to meet demand.

When we talk about workforce, the focus is always on numbers. There are campaigns for safe staffing ratios and government ministers like to tell us how many more nurses we have. But safety is not just about numbers. Recent workforce policy decisions have promoted a more-hands-for-less-money approach to staffing in healthcare. More lower-paid workers mean something in the equation has to give. In this case, it’s skill and expertise.

In this article in The Independent, Patient Safety Learning's Trustee Alison Leary  discusses how healthcare has failed to keep frontline expertise in clinical areas due to archaic attitudes to the value of the experienced workforce.

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Source: The Independent, 15 December 2019

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Pager systems used in healthcare could be exposing patient data across Canada

Paging systems used across B.C could be exposing sensitive health data of patients, and the privacy researcher who first discovered the data breach believes it’s likely happening across the country.

“I wouldn’t be surprised to find this everywhere in Canada,” said privacy researcher Sarah Jamie Lewis, in an interview with CTVNews.ca in Vancouver. Lewis first discovered and reported the breach to Vancouver Coastal Health in November 2018. Now, internal emails released this month through a Freedom of Information request show that the vulnerability is not limited to Vancouver.

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Source: CTV News, 13 December 2019

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Hospital fined over death of patient who was given five times amount of drugs needed

A hospital has been fined £45,000 after the death of a leukaemia patient who was given five times the amount of drugs she needed.

Royal Bournemouth Hospital Trust ignored repeated warnings from inspectors raising concerns about the unit where the 80-year-old patient, who was taking part in a clinical trial, was given the wrong dose on two separate occasions.

The trust was fined at Bournemouth Crown Court on Monday after pleading guilty in August to supplying a medicinal product that was not of the nature or quality demanded.

Investigations revealed that, while staff spotted the incorrect dosage, they were wrongly told it was fine, meaning the pensioner, who was terminally ill, was given five times the prescribed amount over four days rather than a lower dose over 10 days.

An investigation by the Medicines and Healthcare products Regulatory Agency (MHRA) found staff were working “beyond capacity”.

Inspections in 2012, 2013, 2015 and 2017 all found the unit was running over capacity and highlighted it as an issue that urgently needed addressing to prevent any mistakes being made.

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Source: The Independent, 12 December 2019

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Using temporary nurses can increase risk of patients dying, warns new study

Patients are more likely to die on wards staffed by a high number of temporary nurses, a study has found.

Researchers say the findings, published in the Journal of Nursing Scholarship, are a warning sign that the common practice by many hospitals of relying on agency nurses is not a risk-free option for patients.

The University of Southampton study found that risk of death increased by 12 per cent for every day a patient experienced a high level of temporary staffing – defined as 1.5 hours of agency nursing a day per patient. For an average ward, this increased risk could apply when between a third and a half of the staff on each shift are temporary staff, according to Professor Peter Griffiths, one of the study’s authors.

He told The Independent: “We know that patients are put at risk of harm when nurse staffing is lower than it should be.

“One of the responses to that is to fill the gaps with temporary nursing staff, and that is an absolutely understandable thing to do, but when using a higher number of temporary staff there is an increased risk of harm.

“It is not a solution to the problem.”

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Source: The Independent, 10 December 2019

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Doctors at West Suffolk hospital 'too scared' to report safety issues

Doctors at a hospital accused of bullying its staff have told the NHS care regulator that they are too scared to report lapses in patient safety in case they end up facing disciplinary action. 

The Guardian revealed earlier this week that West Suffolk hospital stands accused by its own medics of secrecy, bullying and intimidation after it demanded they take fingerprint tests in its effort to identify a whistleblower.

Senior staff have privately passed on serious concerns to the Care Quality Commission (CQC) about the behaviour of the trust’s leadership. They used confidential meetings with CQC inspectors, who visited twice in the autumn, to explain why they lack confidence in Steve Dunn, the trust’s chief executive, Dr Nick Jenkins, its medical director, and Sheila Childerhouse, who chairs the hospital’s board.

The CQC is due to publish its report into the trust, including the performance of its leadership, in January.

 “Staff are scared that they’ll face disciplinary action [if they raise concerns about patient safety],” said one doctor, who declined to be named.

“As a result of recent events I can’t imagine that anyone at the trust will feel comfortable to speak out or whistleblow in the future. I fear that any future patient safety concerns will not be expressed and will simply be brushed under the carpet.”

The trust demanded fingerprints and handwriting samples after a staff member wrote anonymously to the family of Susan Warby, who died in August 2018 after undergoing treatment at the hospital, which was investigated as a “serious incident”.

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Source: The Guardian, 11 December 2019

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The NHS robots performing major surgery

How would you feel about a robot performing major surgery on you?

2019 has seen a boom in the use of cutting edge robotic technology and there is more to come. Evidence suggests robotic surgery can be less invasive and improve recovery time for patients.

That could be good news with ever growing demand on health services. But how do patients feel? BBC News speaks to a patient as he prepares to put his trust in robotic assisted surgery, hoping it would mean he could get back to work more quickly.

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Source: BBC News, 12 December 2019

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Australia: ‘Medicine safety is a priority for us all.’

Stakeholders from across various sectors in Australia attended a medicine safety forum convened in Canberra on Monday.

Held by the Consumers Health Forum of Australia (CHF), Pharmaceutical Society of Australia (PSA), the Society of Hospital Pharmacists of Australia (SHPA), NPS MedicineWise and academic partners Monash University and University of Sydney, the forum challenged participants to ‘think differently’ on the safe use of medicines in Australia.

This included brainstorming on what success in improving medicine safety would look like in 10 years.

“Medicine safety is a priority for us all and we each have a role to play,” PSA National President Associate Professor Chris Freeman said. “It was inspiring to see the sector work together today to proactively identify those measures we can cooperatively pursue to make a real difference and protect patients.”

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Source: AJP.com.au

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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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Patient has recurring nightmares of having skin cut after not properly anaesthetised

An NHS hospital has admitted it failed to properly anaesthetise a patient who was operated on while conscious – leaving her with post-traumatic stress disorder (PTSD) and recurring nightmares.

The woman, who has chosen to remain anonymous, said she screamed out as the gynaecological surgery at Yeovil District Hospital began to operate, but could not be heard through her oxygen mask as the surgeon cut into her belly button.

Medical negligence lawyers said she was given a spinal rather than general anaesthetic during the procedure at the hospital in Somerset last year. She remained conscious while a laparoscope – a long camera tube – was placed inside her, and her abdomen was filled with gas. Her law firm Irwin Mitchell said that an increase in blood pressure had alerted staff to her discomfort, but that the procedure was continued.

The woman, who is in her 30s, said: “While nothing will change what has happened to me, I just hope that lessons can be learned so no one else faces similar problems in the future."

A spokeswoman for Yeovil Hospital said the incident was the result of “a breakdown of communication” which “led to the use of a different anaesthetic to that normally required for such an operation”.

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Source: The Independent, 10 December 2019

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GP Manish Shah guilty of sex assaults on 23 female patients

Manish Shah preyed on cancer concerns to carry out invasive intimate examinations for his own sexual gratification, the Old Bailey heard.

He convinced his victims to have unnecessary checks between May 2009 and June 2013. He was convicted of 25 counts of sexual assault and assault by penetration. Jurors acquitted 50-year-old Shah, of Romford, of five other charges.

They were told afterwards he had already been found guilty of similar allegations relating to 17 other women, bringing the total number of victims to 23.

Prosecutor Kate Bex QC told the trial: "He took advantage of his position to persuade women to have invasive vaginal examinations, breast examinations and rectal examinations when there was absolutely no medical need for them to be conducted."

The NHS in London said it "extended sympathies" to the victims and added: "As soon as the allegations came to light, swift action was taken and we have supported the police throughout their investigation."

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Source: BBC News, 11 December 2019

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