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Shrewsbury maternity scandal: Medical watchdog asks NHS for information about doctors at trust

The General Medical Council (GMC) has asked the NHS to share concerns about any doctors involved in poor care at the Shrewsbury and Telford Hospital Trust.

It comes as West Mercia Police said it was considering a range of criminal charges against the hospital including corporate manslaughter.

Anthony Omo, Director of Fitness to Practice for the GMC, said the reports of poor maternity care at the trust were “shocking” and his thoughts were with the families. He added: “We are in contact with the trust and have asked NHS England and NHS Improvement for details of any concerns about individual doctors." 

“All doctors have a responsibility to take action if they are aware that patient safety may be put at risk.”

Meanwhile, the Royal College of Obstetricians and Gynaecologists has said it will make changes to the way it inspects hospitals after criticism of the way it allowed a report into the Shrewsbury trust in 2017 to be used.

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Source: The Independent, 22 November 2019

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Dr Michael Watt: Suspended neurologist offers 'sympathy' to patients

Suspended Belfast neurologist Michael Watt has offered his "sincere sympathy" to those affected by Northern Ireland's biggest patient recall.

Dr Michael Watt worked at the Royal Victoria Hospital as a neurologist diagnosing conditions like epilepsy and Parkinson's Disease. He was suspended after 3,000 patients were given recall appointments last year.

Dr Watt said he recognised the "distress these events have caused".

On Tuesday, a BBC Spotlight investigation found that he had carried out hundreds of unnecessary procedures on patients.

The programme also obtained details of a Department of Health report, as yet unpublished, that said one-in-five patients of the consultant neurologist were misdiagnosed.

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Source: BBC News, 22 November 2019

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Concerns raised with speak-up guardians are steadily rising

The number of concerns reported to the NHS’s Freedom to Speak Up Guardians has been steadily increasing since the guardians were introduced in England in 2017. Since April that year thousands of concerns have been reported to the guardians at NHS trusts, data from the National Guardian’s Office shows.

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Source: BMJ, 19 November 2019

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The Morecombe Bay scandal took my baby’s life – history has repeated itself and the NHS must act now

In March 2015, the Morecambe Bay investigation, chaired by Dr Bill Kirkup, published its report into serious failures in care that led to the avoidable deaths of 11 babies and a mother at Furness General Hospital (FGH) between 2004 and 2012. One of the babies that died was James Titcombe's son, Joshua.

The report described a seriously dysfunctional maternity unit where certain midwives pursued an “over-zealous” approach to promoting “normal” childbirth, relationships between doctors and midwives was poor, midwifery practice fell well below acceptable standards and, unforgivably, instances of avoidable harm and death were covered up – meaning lessons were not learned and similar failures were repeated year after year. 

The report detailed how opportunities to intervene at Morecambe Bay were missed at all levels and how the families who raised concerns were treated as problems to be managed, rather than voices that needed to be heard. More than four years later, it is both tragic and distressing to read about the litany of failures identified in the leaked interim report into care at Shrewsbury and Telford Hospital Trust (SaTH). Far from events at Morecambe Bay being a “one-off”, it is now painfully clear that not only have similar failures in care occurred elsewhere, but that they have happened on an even larger scale.

James, speaking to The Independent, says "Worryingly, the reason why we are reading about these issues now isn’t because the regulatory system identified a problem and called for further scrutiny, but rather because of the extraordinary efforts of bereaved families."

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Source: The Independent, 21 November 2019

 

 

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Patient died after 'transplant surgeon error'

A transplant patient died after a surgeon failed to disclose he had spilt stomach contents on organs which went on to be used in NHS operations.

The 36-year-old died of an aneurysm caused directly by infection from a donated liver, while two other patients became ill from transplants.

The incident took place in 2015 but only came to light when one of the sick patients attended a hospital in Wales. It had involved a surgeon from Oxford University NHS Foundation Trust.

Several organs became infected with Candida albicans, a fungal infection, after the surgeon cut the stomach in a donor while retrieving organs, spilling the contents over other organs. The surgeon did not tell anyone as he should have done and the organs were transplanted into three patients.

The patient, who did not want to be named, said: "What angers me to this day is that fact that the surgeon who removed the organs from the donor wasn't honest. It was only when people who received the organs became unwell that the truth was told."

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Source: BBC News, 21 November 2019

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The Shrewsbury scandal proves what women tell me every day – NHS maternity care is in crisis

As many as one in three women in the UK are traumatised by their birth experiences, and one in 25 of those will go on to develop full-blown PTSD. 

Following the most recent scandal at Shrewsbury, Milli Hill, the founder of the Positive Birth Movement, talks to The Independent about why we need to bring human connection back into maternity services, as well as continuing to invest in the research and technology that can save the lives of those most at risk and, why, above all, we need to start listening to women. If we don’t do these things, history will only repeat itself.

Milli says: "We cannot continue to see scandals like Shrewsbury and Morecambe Bay as isolated, instead we must be brave enough to view them as symptomatic of a wider problem of a maternity system that has become completely dehumanised and unable to listen to women."

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Source: The Independent, 20 November 2019

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West Suffolk Hospital's maternity services 'needs improvements'

The Care Quality Commission (CQC) issued a warning notice to the West Suffolk Hospital in Bury St Edmunds, which must improve by 31 January.

It has not released details but the hospital said inspectors flagged up how it recorded observations and monitored women in its care.

A hospital spokeswoman said: "We have taken this feedback seriously and are acting accordingly."

She added: "Concerns have been raised about how we record patient observations after we have taken them, which are currently not in line with national guidance". "The CQC also identified that we should make changes to the way we monitor women in our care, again to bring us in line with national guidance".

"We are making the necessary changes and the CQC is satisfied with the plans we have in place to make the improvements required."

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Source: BBC News, 21 November 2019

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Australian women win landmark vaginal mesh class action against Johnson & Johnson

Hundreds of women left in debilitating pain by faulty transvaginal mesh devices have won a landmark case against multinational giant Johnson & Johnson.

The Australian class action against companies owned by Johnson & Johnson was won on behalf of 1,350 women who had mesh and tape products implanted to treat pelvic prolapse or stress urinary incontinence, both common complications of childbirth.

The devices all but ruined the lives of many. Women have been left in severe, debilitating and chronic pain, and often unable to have intercourse. The vast majority also suffered a significant psychological toll. The mesh eroded internally in many cases, has caused infections, multiple complications, and is near impossible to completely remove, Australia’s federal court has heard.

The devices were not properly tested for safety before being allowed on to the Australian market, though Johnson & Johnson and the associated companies clearly knew the potential for serious complications. 

The companies were accused of launching a “tidal wave” of aggressive promotion at doctors, marketing the devices as cheap, simple to insert, and a relatively risk-free way to boost profits. All the while, their potential dangers were minimised, downplayed or ignored, both in communications to doctors and patients, the plaintiffs alleged. When patients complained of pain, they were frequently disbelieved.

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Source: The Guardian, 21 November 2019

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Nine in 10 NHS bosses say staffing crisis endangering patients

Hospitals are so short of doctors and nurses that patients’ safety and quality of care are under threat, senior NHS leaders have warned in a dramatic intervention in the general election campaign

Nine out of 10 hospital bosses in England fear understaffing across the service has become so severe that patients’ health could be damaged. In addition, almost six in 10 (58%) believe this winter will be the toughest yet for the service.

The 131 chief executives, chairs and directors of NHS trusts in England expressed their serious concern about the deteriorating state of the service in a survey conducted by the NHS Confederation. The findings came days after the latest official figures showed that hospitals’ performance against key waiting times for A&E care, cancer treatment and planned operations had fallen to its worst ever level. However, many service chiefs told the confederation that delays will get even longer when the cold weather creates extra demand for care.

“There is real concern among NHS leaders as winter approaches and this year looks particularly challenging,” said Niall Dickson, the chief executive of the confederation, which represents most NHS bodies, including hospital trusts, in England."

 “Health leaders are deeply concerned about its ability to cope with demand, despite frontline staff treating more patients than ever."

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Source: 19 November 2019

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The NHS needs a culture change to deliver safer care

The avoidable deaths of babies and mothers in Shrewsbury and Telford Hospital Trust’s maternity services are heartbreaking. What makes them a scandal, however, is that the problems have been known about for so long, and yet the instinct of managers was to deflect and minimise. 

The Healthcare Commission, a forerunner to the Care Quality Commission, was concerned about injuries to babies in the trust’s maternity units as long ago as 2007. It was not until Rhiannon Davies and Richard Stanton insisted on answers about the death of their baby Kate in 2009 that the Parliamentary and Health Service Ombudsman concluded in 2013 that it had been the result of serious failings in care. 

Trusts need to ensure lessons stemming from failings are being implemented while patients and their families are being treated with respect and as a valuable source of feedback.

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Source: The Independent, 20 November 2019

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Shrewsbury and Telford Hospital: Babies and mums died 'amid toxic culture'

Babies and mothers died amid a "toxic" culture at a hospital trust stretching back 40 years, a report has said. The catalogue of maternity care failings at Shrewsbury and Telford Hospital NHS Trust are contained in a report leaked to The Independent.

It reveals that some children were left disabled, staff got the names of some dead babies wrong and, in one case, referred to a child as "it".

The trust apologised and said "a lot" had been done to address concerns.

In 2017, then Health Secretary Jeremy Hunt announced an investigation into avoidable baby deaths at the trust, which runs Royal Shrewsbury Hospital and Telford's Princess Royal. It is being led by maternity expert Donna Ockenden, who authored the report for NHS Improvement.

Its initial scope was to examine 23 cases but this has now grown to more than 270 , covering the period from 1979 to the present day. The cases include 22 stillbirths, three deaths during pregnancy, 17 deaths of babies after birth, three deaths of mothers, 47 cases of substandard care and 51 cases of cerebral palsy or brain damage.

The interim report said the number of cases it is now being asked to review "seems to represent a longstanding culture at this trust that is toxic to improvement effort".

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Source: BBC News, 20 November 2019

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NHS health board Cwm Taf Morgannwg 'prioritised targets over safety'

A health board criticised for severe maternity failings put too much emphasis on targets instead of patient safety, according to a new review of quality governance arrangements at Cwm Taf Morgannwg University.

It found wider failings in Cwm Taf Morgannwg health board's governance. Healthcare Inspectorate Wales (HIW) and the Wales Audit Office (WAO) also found a high level of risk to patient safety was accepted as the norm in some departments. The health board said work was under way to address the issues raised.

The report was not an assessment of frontline care, but spoke to staff about procedures for reporting and learning from problems.

It found Cwm Taf Morgannwg health board had not given enough attention to the safety of its services, in contrast to a strong focus on targets and financial controls.

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Source: BBC News, 19 November 2019

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War veteran, 99, left 'crying out in pain' on A&E trolley for 10 hours

A 99-war-old war veteran was left in agony on an A&E trolley in a hospital for almost 10 hours.

Brian Fish, a former captain in the Royal Engineers, was left “crying out in pain” as he endured the long wait at Margate’s Queen Elizabeth Queen Mother Hospital, his daughter said. Mr Fish had been urgently admitted to hospital with gall bladder problems.

Details of his ordeal emerged as figures showed the queues at NHS emergency departments are now the longest on record, with one in four patients at major A&Es waiting longer than four hours to be seen or treated in October.

His daughter Hilary Casement, who witnessed her father’s hospital ordeal, said: “It was traumatic for him. He lay for hours crying out in pain on a hard trolley. Eventually, with much pleading from me, he was transferred, actually tipped, on to a slightly more comfortable hospital bed and eventually seen by the kind, but overworked, medical team".

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Source: The Independent, 19 November 2019

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CDC: More people dying from antibiotic resistance than previously believed

More than 2.8 million antibiotic-resistant infections occur in the U.S. every year, and more than 35,000 people die as a result of those infections, according to a newly released Centers for Disease Control and Prevention (CDC) report.

The updated Antibiotic Resistance Threats in the United States (AR Threats Report) also estimates when antibiotic-resistant bacterium Clostridium difficile (or C. diff) is included, that number exceeds 3 million infections and 48,000 deaths. The report, which used data sources such as electronic health records not previously available, shows that there were nearly twice as many annual deaths from antibiotic-resistant infections as the CDC originally reported in 2013.

CDC officials called the numbers in this report "more precise, though still conservative, estimates of the human costs of antibiotic resistance.

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Source: FierceHealthcare, 13 November 2019

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World Antibiotic Awareness Week: Letter from senior NHS and health system leaders

The World Health Organization's (WHO) World Antibiotic Awareness Week (WAAW) aims to increase awareness of antibiotic resistance as a global problem, and to promote best practices among the general public, health workers and policy-makers to avoid the further emergence and spread of antibiotic resistance.

Since their discovery, antibiotics have served as the cornerstone of modern medicine. However, the persistent overuse and misuse of antibiotics in human and animal health have encouraged the emergence and spread of antibiotic resistance, which occurs when microbes, such as bacteria, become resistant to the drugs used to treat them.

As part of preparations for the 2019 Awareness Week this November, a group of senior leaders from across the health system, including NHS England and Improvement, have co-signed a letter, coordinated by Public Health England, that reminds commissioners and providers alike of their responsibility to contribute to this important agenda. The letter also reminds colleagues that this year’s WAAW campaign is the first of a new five-year UK National Action Plan for antimicrobial resistance, which contains stretching ambitions for reducing inappropriate prescriptions; as well as controlling and preventing infections.

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Insurers overrule consultants on best treatment for patients

Patients are being left in pain and having operations delayed or denied because insurers are overruling consultants’ decisions on treatment.

Policy holders with breast cancer, heart conditions, arthritis and knee problems are among those who have been unfairly denied procedures, The Times has found.

Analysis of Financial Ombudsman Service reports shows that complaints about private medical insurers have risen sharply.

Richard Packard, chairman of the Federation of Independent Practitioner Organisations, estimates that hundreds of patients a year are denied recommended treatments. “Consultants have reported that their expert decisions for the benefit of the patient are being overturned,” he said. “This is being done by insurance administrators at the end of a telephone. Some would seem to lack medical knowledge and [make] decisions based on computer algorithms, which can result in delayed treatment and patients suffering pain for longer than necessary.”

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Source: The Times, 18 November 2019

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NHS staff shortages put 'cancer survival rates at risk'

Progress on treating cancer has stalled in Scotland because of staff shortages and a lack of funding, according to a parliamentary report.

The Scottish Parliament's Cross-Party Group on Cancer found that 18% of cancer patients in June were not seen within the six-week target. Their report, which will be published later, has been described as "deeply concerning" by Cancer Research UK.

The Scottish government said its £100m strategy would improve survival rates.

Cancer Research UK Chief Executive Michelle Mitchell said the Scottish government must "publish a long-term cancer workforce plan" to enable the NHS to prepare for rising demand in the future. She said: "The findings of this inquiry are deeply concerning".

"Diagnosing cancer early can make all the difference, but there are major shortages in the staff trained to carry out the tests that diagnose cancer. Cancer services in Scotland are already struggling. Without urgent action, this will only worsen as demand increases."

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Source: BBC News, 18 November 2019

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Bradford Teaching Hospitals Command Centre officially opens

At a launch event last week, Bradford Teaching Hospitals NHS Foundation Trust has officially opened its new Command Centre.

The Command Centre, using technology from GE Healthcare Partners, went live earlier this year and was recently awarded Tech Project of the Year in the innovative Health Tech Awards 2019.

The Trust said it helps staff to optimise patient flow and allow real-time co-ordination of care for each and every patient. Using advanced analytics and machine learning, the new system provides staff with real-time information to help them make speedy and informed decisions on managing patient flow across the Trust’s hospitals.

Sandra Shannon, Chief Operating Officer and Deputy Chief Executive at the Trust “Demand for services is growing at Bradford Teaching Hospitals every year, with up to 400 patients coming through our A&E every day, and we have to get smarter at how we manage the needs of patients with the resources we have.”

“The Command Centre is a major investment in how we, as a very busy acute Trust, can improve our performance, maintain and improve patients’ experience of coming into hospital and support our staff to do their jobs more efficiently, so they can concentrate on delivering excellent patient care.”

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Source: Health Tech Newspaper, 12 November 2019

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A&E waiting times in England at their worst on record

A&E waiting times are at their worst on record as the NHS comes under intense pressure before what doctors and hospital bosses fear will be a very tough winter for the service.

Less than three-quarters (74.5%) of people who sought care at A&E unit in England in October were treated and then discharged, admitted or transferred within four hours – the smallest proportion since the target was introduced in 2004.

That is far below the 95% of patients that ministers and NHS chiefs say should be dealt with by A&E staff within four hours.

“As political parties vie to prove their NHS credentials, today’s figures highlight that the NHS is desperately struggling to stay afloat,” said Dr Rebecca Fisher, a GP and senior policy fellow at the Health Foundation.

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Source: The Guardian, 14 November 2019

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Child's hospital death 'linked to contaminated water'

A whistleblower claimed a cancer patient died as a result of contaminated water at Scotland's largest hospital. The whistleblower raised concerns about the findings of a review into infections in child cancer patients.

Jeane Freeman, the health secretary, says she knew in September a child had died after contracting an infection possibly linked to water at the Queen Elizabeth University Hospital, but did not make it public. She told BBC Scotland she acted on the information but chose to maintain patient confidentiality.

Ms Freeman said she felt for the child's parents. She said: "I deeply regret not only the death of their child. In any circumstance that has to cause a pain that I can't possibly imagine, but I also deeply regret that they feel they haven't been given the information that they have a perfect right to receive and are entitled to. They have my commitment to act to ensure that situation does not happen to parents in the future".

"I don't regret honouring patient confidentiality. But upholding patient confidentiality does not mean I don't act on the information I am given."

Labour MSP Anas Sarwar had raised the issue - which was brought to light by an NHS whistleblower - during First Minister's Questions on Thursday. He  described the situation as a "cover-up".

The MSP said he had seen information which showed that senior managers were repeatedly alerted to the fact a previous review failed to include cases of infection related to the water supply in 2017. He said the parents of the child had never been told the true cause of their child's death.

Greater Glasgow Health Board say a link between the infection and the hospital cannot be proven because regulations at the time did not require water testing.

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Source: BBC News, 14 November 2019

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NIH grant to study unstructured data that can improve patient safety

Reports that medical errors are the third leading cause of death in the US have led the Institute of Medicine and several state legislatures to suggest that data from patient safety event reporting systems could help health care providers better understand safety hazards and, ultimately, improve patient care.

"Tens of thousands of these safety report databases provide a free text field that does not constrain the reporter to fixed, predefined categories," said Srijan Sengupta, Assistant Professor of Statistics in the College of Science and a faculty member at the Discovery Analytics Center.

Sengupta has received an $815,218 Research Project Grant (R01) from the National Institutes of Health (NIH) to develop novel statistical methods to analyze such unstructured data in safety reports.

"Detailed information that spans multiple categories can be more valuable than identifying an event by just checking off a category," he said.

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Source: EurekAlert, 13 November 2019

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Little evidence that locum GPs pose greater risk to patient safety, study finds

Existing claims that locum GPs present a greater risk of harming patients are unfounded, according to new research published in the Journal of the Royal Society of Medicine. It found that there is little evidence that locum doctors, including GPs, have a 'detrimental' impact on patient care delivery.

Researchers from the University of Manchester looked at 42 international papers, including 24 from the UK, on the impact of locum doctors working in various healthcare settings to determine whether this group is more likely to harm patients than permanent doctors. 

Previous reports highlight longstanding and growing concerns about the quality, safety and cost of locum doctors among a range of stakeholders such as policymakers, employers, regulators and professional bodies. These include locum GPs being less aware of local policies and less familiar with the patient's healthcare history and lacking commitment. 

However, the researchers found there is 'very limited evidence' to support claims that these healthcare professionals deliver lower quality of care than their permanent counterparts. 

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Source: Pulse, 12 November 2019

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Hospital deploys new £700,000 computer system to improve patient safety in intensive care unit

A new £700,000 computer system has been deployed in an intensive care unit at Aberdeen Royal Infirmary. The new Philips system will replace bedside charts, freeing up clinical time and improving patient safety at the NHS Grampian hospital.

ICU clinical director Dr Iain MacLeod said: “At the heart of this change is patient safety. The system records physical measurements like blood pressure and heart rate as well as blood results and parameters from the various machines used in ICU, such as dialysis machines and ventilators."

“It will also save on staff time. Currently medical staff members waste lots of time transcribing blood results from a computer onto sheets of paper. The new system allows this to happen automatically. That’s great from a timesaving point of view but more importantly there will be a reduction of errors that can happen when writing something down.”

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Source: FutureScot, 11 November 2019

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Thousands of bowel cancer cases missed due to ‘unacceptable’ testing failures

Thousands of bowel cancer cases are being missed due to “unacceptable” testing failures, research in the BMJ shows. 

The UK research found that some providers carrying out colonoscopies were three times as likely as others not to spot signs of disease. At the worst units, almost one in ten cases which turned out to be bowel cancer were not picked up during the tests, the study led by the University of Leeds found. 

Researchers said that almost 4,000 more cases could have been prevented or treated sooner had there been better screening over a nine year period tracked. 

Researcher Roland Valori, Consultant Gastroenterologist from Gloucestershire Hospitals NHS Foundation Trust, said: “We are seeing unacceptable variation in post colonoscopy bowel cancers between providers in the English NHS and this variation in quality needs to be addressed urgently.” 

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Source: The Telegraph, 2019

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