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Deaths of 56 babies at Leeds hospitals may have been preventable

The deaths of at least 56 babies, and two mothers, at an NHS trust over the past five years may have been prevented, the BBC has found.
The two maternity units at the Leeds Teaching Hospitals (LTH) NHS Trust are rated "good" by England's healthcare regulator, but two whistleblowers have told the BBC they believe the units are unsafe.
Bereaved parents say they are concerned that the trust's chief executive during the period most of the deaths occurred is now leading the regulator, saying this could affect its independence in investigating LTH Trust.
In a statement, the trust told the BBC the vast majority of births at Leeds were safe, and deaths of mothers and babies were fortunately very rare.
It added that Leeds cares for a higher volume of babies with complex conditions as it is one of a "handful of specialist centres" in the UK.
The families describe a "tick box" and "wait and see" culture at the trust, plus a lack of compassionate care.
This has been echoed by whistleblower Lisa Elliott, who worked at the two sites in 2023. Describing the care as "appalling", she highlighted a failure to listen to patients. "That's when disasters happen, and a lot of them can be avoided," she said.
Read full story
Source: BBC News, 17 January 2025
Patient Safety Learning

My mum took her life after hospital. Yet lessons won’t be learnt

As The Times reports on how the failure to act on coroners’ recommendations costs lives, Lottie Hayton says many are not issuing Prevention of Future Deaths reports in the first place.
Lottie's mum, Carrie, was sectioned on September 16, 2022. When Carrie took her own life two months later, the inquest into her death criticised the care she received and her “rapid discharge”. But, owing to significant flaws in the inquest system in England and Wales, lessons from her care and death will not be learnt.
Four days after Carrie’s admission, on September 20, when the duty doctor came back from bank holiday leave, he “introduced” himself. The brief introductory meeting amounted, according to the medical notes, to an assessment of mum’s mental state. Thirteen minutes after he recorded the introduction, mum was discharged.
The discharge notes read: “Mrs Hayton utilised her leave well and did not present with any suicidal thoughts. It was felt the inpatient environment would be detrimental to her grieving process and her risks could be managed with home treatment and community team support.” That the risks were not able to be managed with home treatment is obvious by the fatal outcome.
The review recommends a clear solution: “Acute Inpatient Operational Policy must take place to ensure clear provision for what should happen when a rapid discharge occurs.” In Carrie’s case, there was no evidence of a policy or process being followed.
At the conclusion of an inquest a coroner can issue a Regulation 28 Prevention of Future Deaths report, or PFD, to an organisation or individual, outlining actions which could be taken by them to prevent future similar deaths.
An average of 500 PFD reports are issued every year but it is ultimately up to an individual coroner to decide whether they issue one. The facts of Carrie’s case and the serious incident investigator’s submission, would, you might assume, lead to the coroner thinking that a PFD should and could be issued with simple recommendations. But the coroner overseeing the inquest in Dorset, chose not to issue a PFD.
Read full story (paywalled)
Source: The Times, 15 January 2025
Patient Safety Learning

Nurse who drugged patients for an ‘easy life’ is struck off

A nurse who drugged patients on a hospital stroke unit for an “easy life” has been struck off the nursing register.
Catherine Hudson was jailed for seven years and two months in December 2023 for illegally sedating two patients at Blackpool Victoria Hospital and conspiring with a junior colleague to sedate a third.
Now she has been struck off by the Nursing and Midwifery Council (NMC) at a hearing held this week.
Police were alerted by hospital chiefs in November 2018 after a student nurse on a work placement said Hudson suggested administering unprescribed zopiclone, a sleeping pill, to an elderly patient, Preston Crown Court heard during her sentencing. Hudson was found guilty by a jury of three counts of ill-treating patients and she was also convicted of conspiring with her junior colleague to inappropriately sedate another patient.
The nursing misconduct panel found Hudson’s “ill-treatment of vulnerable stroke patients over a prolonged period of time particularly deplorable”, a report published this week said.
Read full story
Source: The Independent, 12 January 2025
Patient-Safety-Learning

New Jersey will stockpile abortion pills, governor says before Trump inauguration

New Jersey will begin stockpiling supplies of a key abortion drug, Governor Phil Murphy announced, days before President-elect Donald Trump returns to office with Republican majorities in the House and Senate.
“A couple of years ago, New Jersey worked proactively to protect abortion rights,” Murphy said during his State of the State address on Tuesday, in reference to a law he signed months before the Supreme Court overturned Roe v. Wade in 2022. “And now we must further secure our reputation as a safe haven for reproductive freedom.”
In addition to urging the Democratic-held state legislature to pass a law to “scrap out-of-pocket costs for abortion procedures,” Murphy announced that New Jersey will stockpile abortion medication mifepristone “so every woman can access this crucial form of reproductive care.” The decision, he said, was prompted by “anti-choice policies supported by the current majorities in Congress.”
In November, reproductive-health organizations and companies reported that more women were seeking abortion pills in the aftermath of Trump’s election victory, while antiabortion advocates began planning aggressive legal action against people and organizations that help women get abortions, as The Washington Post reported. As states moved to restrict people’s access to abortion and abortion pills in the wake of Roe’s fall, New Jersey’s abortion protections have ensured that both remain legal there.
In 2023, Democratic governors in other states—including California and Massachusetts—also announced plans to stockpile abortion pills. Eighteen US states now have bans on all or most abortions, three have bans on abortions after 12 or 15 weeks, while courts in two others have blocked similar laws—although thousands of women in states with restrictions are turning to online providers to access abortion pills.
Read full story (paywalled)
Source: Washington Post, 16 January 2025
Patient-Safety-Learning

More than one in 10 women are taking weight-loss jabs, survey finds

More than one in 10 women are taking weight-loss jabs, research has suggested.
Some 11 per cent of women aged 30 to 75 said they were taking a weight-loss jab, a survey by Juniper, a digital weight-loss service, found. Extrapolating the results across the UK would mean that about two million of the almost 20 million women within the age group are using the drugs.
The injections, which include semaglutide, known by brand names Ozempic and Wegovy, have been made popular by famous faces including Elon Musk and Boris Johnson.
But concerns have been raised about people—and young women in particular—not eligible for them under NHS rules obtaining them privately.
Lottie Moss, the 26-year-old half-sister of Kate Moss, was taken to hospital after the jabs made her violently ill when she used them despite being a healthy weight.
And health authorities have been forced to issue safety warnings about fake pens being distributed. The Medicines and Healthcare products Regulatory Agency (MHRA) has urged people to be aware of fake pharmacy websites and social ­media posts offering the medicines without a prescription. The regulator said ­criminals would go to great lengths to make their businesses appear authentic and the products that they sell could ­contain “toxins and other ingredients that could cause real harm”.
Read full story (paywalled)
Source: The Telegraph, 15 January 2025
Patient-Safety-Learning

Families failed by Covid jabs tell inquiry of pain

Families of those harmed by Covid vaccines told the UK Covid Inquiry they were forced to support each other during the pandemic because there was no other help.
Kate Scott, who represents the group Vaccine Injured and Bereaved UK (VIBUK), said they felt they were "almost being pushed into the shadows during the pandemic."
The inquiry also heard from a victims' group in Scotland which raised concerns that the vaccine had been rolled out too quickly, and that safety had been sacrificed for speed.
This is the Inquiry's fourth module, which will consider issues relating to the development of Covid-19 vaccines and their implementation.
Mrs Scott, whose husband Jamie was left severely disabled by a vaccine, said, "We are an uncomfortable truth, but we are a truth and the truth is for everyone in our group—the vaccine caused serious harm and death."
Jamie Scott, a father of two boys, worked in a high-powered job until he was severely injured by a Covid vaccine.
He spent four weeks and five days in a coma and suffered an extremely rare, life-threatening side effect called VITT, or vaccine-induced immune thrombosis and thrombocytopenia. Jamie survived, but suffered a significant brain injury, which affected his thinking processes. He is now partially blind and his wife says he will never live independently.
Jamie has received £120,000 - the maximum payout from the government's Vaccine Damage Payment Scheme. His wife, who is clear that neither of them is against vaccines, says he will never work again and that this is not a fair or adequate amount.
Read full story
Watch an interview on the hub with Charlet Crichton, founder of UKCVFamily, a support group for patients in the UK who have had an adverse reaction to a Covid-19 vaccination.
Source: BBC News, 15 January 2025
Patient-Safety-Learning

Hospital patients dying undiscovered in corridors, report on NHS reveals

Patients are dying in hospital corridors and going undiscovered for hours, while others who suffer heart attacks cannot be given CPR because of overcrowding in walkways, a bombshell report from the Royal College of Nursing (RCN) on the state of the NHS has revealed.
So many patients are being cared for in hospital corridors across the UK that in some cases pregnant women are having miscarriages outside wards while other patients are unable to call for help because they have no call bell and are subjected to “animal-like conditions”, said the RCN.
The RCN warned that patients were “routinely coming to harm” and in some cases dying because vital equipment was not available and staff were too busy to give everyone adequate care.
Dr Adrian Boyle, the leader of Britain’s A&E doctors, said the nurses’ testimonies on which the report was based were so horrendous that it “must be a watershed moment, a line in the sand” and must prompt the government to redouble its efforts to get the NHS working properly again.
Boyle, the president of the Royal College of Emergency Medicine, said: “I am shocked, appalled and so saddened that this is the level of care we as clinicians are being forced to provide to our patients – people who turn to the NHS and its staff when they are most vulnerable and in need.”
The RCN’s 460-page report, based on “harrowing” descriptions given by 5,400 UK nurses of their experience of working in hospitals, sets out how:
Patients have died on trolleys and chairs in corridors and waiting rooms in settings where “all the fundamentals of care have broken down.” One nurse had seen “cardiac arrests in the corridor with no crash bell, crash trolley, oxygen, defibrillator … straddling a patient doing CPR while everyone watches on.” Patients are being given drugs, intravenous infusions and, in one case, a blood transfusion in corridors which are cold, noisy and too cramped to allow them to have loved ones present. One nurse had to tell a patient he was dying as other patients were wheeled past and orders were shouted across the unit. They said, “How is it fair to tell someone they are dying in a corridor?” Lack of space means patients also being treated in storerooms, car parks, offices and even toilets. The report came as Wes Streeting, the health and social care secretary, was forced to defend the government’s record on the NHS in an urgent Commons debate about the intense pressures this winter that have left many hospitals overwhelmed in recent weeks.
Streeting responded to Conservative attacks by telling MPs that corridor care “became normalised in NHS hospitals under the previous government. It is unsafe, undignified, a cruel consequence of 14 years of failure on the NHS and I am determined to consign it to the history books.”
But, he added, while ending corridor care was the government’s ambition, “I cannot and will not promise that there will not be patients treated in corridors next year. It will take time to undo the damage that has been done to our NHS.”
Read the RCN report: On the frontline of the UK’s corridor care crisis
Read full story
Source: The Guardian, 16 January 2025
Patient-Safety-Learning

500 CQC reports ‘stuck in IT system’

Around 500 draft inspection reports are “stuck” in the Care Quality Commission’s IT system and cannot currently be retrieved, its leaders admitted today.
Outgoing chair Ian Dilks told the Commons health and social care committee hearing: “We have reports that go back for some months that are stuck in the system. People can’t get them back out… [The inspectors] have started their work, they have started their draft report… There is probably more information required, it has to go for quality assurance, [but] they can’t get it back out of the system. I can’t actually tell you exactly how that happened, I’m just giving you an illustration of the difficulties.”
CQC chief executive Sir Julian Hartley—who took up the post last month—told the MPs around 500 reports were involved.
HSJ asked the CQC for more details of which providers’ reports have been lost. It indicated the “majority” were of adult social care providers, but has not yet given further details. 
The regulator said the delays caused “falls far short of what people using services and providers should be able to expect and we have apologised for this”, but that “any immediate action [we] needed to take to protect people… has not been affected”.
Read full story (paywalled)
Source: HSJ, 15 January 2025
Patient-Safety-Learning

Call to overhaul obesity diagnoses amid fears of over-reliance on BMI

Doctors are proposing a “radical overhaul” of how obesity is diagnosed worldwide amid concerns that a reliance on body mass index may be causing millions of people to be misdiagnosed.
More than 1 billion people are thought to be living with the condition that for decades has been diagnosed by measuring a person’s BMI (their ratio of height to weight) to estimate the amount of excess body fat they have.
However, there are fears BMI on its own is not a “reliable measure” of an individual’s health and may be resulting in both under- and over-diagnosis of obesity, with “negative consequences” for those affected and wider society.
Dozens of the world’s leading experts across a broad range of medical specialisms – including endocrinology, internal medicine, surgery, biology, nutrition and public health – are now calling for a “reframing” of the condition that is causing major harm on every continent and costing countries billions.
Prof Francesco Rubino, the chair of the Lancet commission which produced the report, said the changes would provide an opportunity for health systems globally to adopt a universal, clinically relevant definition of obesity and a more accurate method for its diagnosis.
He said: “The question of whether obesity is a disease is flawed because it presumes an implausible all-or-nothing scenario where obesity is either always a disease or never a disease. Evidence, however, shows a more nuanced reality. Some individuals with obesity can maintain normal organs’ function and overall health, even long term, whereas others display signs and symptoms of severe illness here and now."
Read full story
Source: The Guardian, 14 January 2024
Patient-Safety-Learning

New dementia cases in US projected to double to 1 million by 2060: Study

New cases of dementia in the United States are projected to double in the next three decades, a new study suggests.
The study, published this week in the journal Nature Medicine, looked at more than 15,000 people and estimated the lifetime risk of dementia from ages 55 to 95.
The team—including researchers from Johns Hopkins University, Mayo Clinic and New York University—projected new US dementia cases would double from more than 500,000 in 2020 to approximately one million by 2060. The authors said this increase is directly tied to the ageing of the US population.
The study also showed that the risk of developing dementia after age 55 is 42%, more than double the risk seen by older studies. After age 75, the lifetime risk increases to more than 50%, according to the study.
"Our study results forecast a dramatic rise in the burden from dementia in the United States over the coming decades, with one in two Americans expected to experience cognitive difficulties after age 55," Dr Josef Coresh, a study senior investigator, epidemiologist and founding director of the Optimal Aging Institute at NYU Langone, said.
Read full story
Source: ABC News, 14 January 2025
Patient-Safety-Learning

Elective recovery scheme ‘wide open to gaming’

Plans to pay trusts to validate and sometimes remove patients from their waiting lists could be “wide open to gaming” and create a public perception problem, senior NHS figures have told HSJ.
The new proposals were set out in the elective reform plan, published last week, which says NHS England “will ensure validation is, for the first time, formally reflected as a form of activity within the 2025-26 NHS Payment Scheme”.
HSJ understands the plans, already piloted by 10 trusts, involve relatively modest payments being paid to providers for “clock stops”—where an entry is removed from the referral to treatment waiting list—achieved by checking whether the entry remains valid.
So-called “removals other than treatment”, known as ROTTs, from the waiting list are common, and happen for numerous reasons such as patients moving house, no longer requiring the treatment, or having been treated elsewhere.
Waiting list expert Barry Mulholland, a partner at the MBI Health consultancy, said he was in favour of paying providers for ROTTs, but understood “concerns” among some in the NHS “that it provides an increased risk that patients may be removed incorrectly”.
Further details of the scheme are expected in the delayed 2025-26 NHS planning guidance.
Read full story (paywalled)
Source: HSJ, 15 January 2025
Patient-Safety-Learning

GPs turn to AI to help with patient workload

The difficulty of getting an appointment with a GP is a familiar gripe in the UK.
Even when an appointment is secured, the rising workload faced by doctors means those meetings can be shorter than either the doctor or patient would like.
But Dr Deepali Misra-Sharp, a GP partner in Birmingham, has found that AI has alleviated a chunk of the administration from her job, meaning she can focus more on patients.
Dr Mirsa-Sharp started using Heidi Health, a free AI-assisted medical transcription tool that listens and transcribes patient appointments, about four months ago and says it has made a big difference.
“Usually when I’m with a patient, I am writing things down and it takes away from the consultation,” she says. “This now means I can spend my entire time locking eyes with the patient and actively listening. It makes for a more quality consultation."
She says the tech reduces her workflow, saving her “two to three minutes per consultation, if not more”. She reels off other benefits: “It reduces the risk of errors and omissions in my medical note taking."
With a workforce in decline while the number of patients continues to grow, GPs face immense pressure.
Read full story
Source: BBC News, 14 January 2025
Patient-Safety-Learning

Failure to act on coroners’ advice blamed for thousands of deaths

One woman who tracks preventable deaths says the failure to take action when inquests identify threats to life is ‘mind-blowing’.
Thousands of deaths could be prevented every year if public bodies took action over concerns highlighted at inquests. Almost 82,000 deaths in 2022 were recorded by the Office for National Statistics in England and Wales as “preventable”, meaning they could have been avoided “through effective public health and primary prevention interventions”.
Analysis by the Preventable Deaths Tracker project at King’s College London revealed that 1,495 Prevention of Future Deaths reports (28 per cent of the total) have not received any responses and another 741 (14 per cent) received only partial responses. Once reports are issued there is no official monitoring of responses or whether any action follows. Coroners have no powers to ask further questions or request progress reports on reforms.
The founder of the Preventable Deaths Tracker, the epidemiologist Dr Georgia Richards, said it was “mind-blowing” there was no system to disseminate learning from inquests. “Across 5,000 reports over the last 12 years, it is impossible to know anything about what action that might or might not have been taken following a coroner’s report,” Richards said. "People think there must be a system that’s protecting us. We assume that if you were in government that you would want to know what’s happening in these death investigations. But the system doesn’t work, it’s a waste of time. There are very few PFDs that have led to meaningful change and often it’s not the PFD that triggered it. Change comes from additional factors like change in leadership of the organisation, huge media scrutiny or dedicated families.”
Peter Thornton KC, chief coroner from 2012-16, said: “First, there are not enough coroners writing these reports. Secondly, they can’t force a response. Thirdly, they can’t follow up a response. Fourthly, they can’t force action — they can only suggest that an area of action is considered. And last, there’s no national follow-up, there’s no co-ordination.” Thornton urged reform through the creation of a national coroner service. The inquest system is jointly managed by the judiciary, local councils and the police. It is poorly funded and has big backlogs: 1,685 bereaved families are waiting longer than two years for hearings.
Read full story
Source: The Times, 14 January 2025 (paywalled)
Related reading
Five recommendations to prevent future deaths: Written evidence for the Parliamentary follow-up Inquiry to The Coroner Service (Georgia Richards, 9 February 2024) Patient Safety Learning - Mind the implementation gap: The persistence of avoidable harm in the NHS (7 April 2022)
Patient-Safety-Learning

WHO comments on United States announcement of intent to withdraw

Geneva – The World Health Organization regrets the announcement that the United States of America intends to withdraw from the Organization.

WHO plays a crucial role in protecting the health and security of the world’s people, including Americans, by addressing the root causes of disease, building stronger health systems, and detecting, preventing and responding to health emergencies, including disease outbreaks, often in dangerous places where others cannot go.

The United States was a founding member of WHO in 1948 and has participated in shaping and governing WHO’s work ever since, alongside 193 other Member States, including through its active participation in the World Health Assembly and Executive Board. For over seven decades, WHO and the USA have saved countless lives and protected Americans and all people from health threats. Together, we ended smallpox, and together we have brought polio to the brink of eradication. American institutions have contributed to and benefited from membership in WHO.

With the participation of the United States and other Member States, WHO has over the past 7 years implemented the largest set of reforms in its history, to transform our accountability, cost-effectiveness, and impact in countries. This work continues.

We hope the United States will reconsider and we look forward to engaging in constructive dialogue to maintain the partnership between the USA and WHO, for the benefit of the health and well-being of millions of people around the globe.
Source: Tedros Adhanom Ghebreyesus, Director General at World Health Organization, 21 January 2025
Patient Safety Learning

Exclusive: Hospital asks patients in corridors to ‘lobby MPs’ for funding

A hospital’s leadership has put up posters in its corridors asking patients to lobby local MPs – who include Wes Streeting – for funding to expand its under-pressure A&E.
Barking, Havering and Redbridge University Hospitals Trust, which serves the Ilford North constituency represented by the health and social care secretary, says one of its two emergency departments is “not fit for purpose”.
The A&E unit at Queen’s Hospital in Romford was designed for 325 daily attendances but saw more than double that one day last month, the trust said.
The posters say: “We’re sorry you may have had a poor experience in our A&E. We want our hospitals to deliver care our staff are proud of and our patients are happy with.
“To achieve this, we need £35m to transform our A&E and improve your care.”
Patients are then urged to scan a QR code taking them to a list of local representatives to “lobby your MP”.
Read full story (paywalled)
Source: HSJ, 14 January 2025
Patient_Safety_Learning

Woman ‘suicidal’ after taking same antidepressants as Thomas Kingston issues warning over side effects

A woman who said she has become severely suicidal during a year of being prescribed the same antidepressants as royal family member Thomas Kingston has issued a warning over their side effects.
Lingling Wang, 48, told The Independent she felt she was not made adequately aware of the potential effects of taking antidepressants before she was prescribed them for insomnia and mild anxiety last January.
Read full story
Source: Independent, 11 January 2025
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