Skip to content

News

Keep up to date with the latest news, research and activity in patient safety.

Trust reviewing bed capacity after three patient deaths

A coroner has warned a trust in the West Midlands for the third time about bed shortages, after three patient deaths which he believes are linked.
In his report on the death in July of Philip Malone, area coroner for Birmingham and Solihull James Bennett told Birmingham and Solihull Mental Health Foundation Trust that its psychiatric bed capacity “remains inadequate”.
Mr Malone – who was diagnosed with treatment-resistant schizophrenia in the 1980s and adult autism in May this year – died by suicide while awaiting an inpatient psychiatric bed at BSMHFT after a deterioration in his symptoms of anxiety, thought disorder, and hallucinations.
Clinicians decided on 28 June that Mr Malone should be detained under the Mental Health Act, but as no inpatient psychiatric bed was available, he remained in the supported accommodation. Mr Malone died on 3 July.
In a public report warning of the risks which may cause future deaths, issued last week, Mr Bennett said he had issued two previous “prevention of future death” reports which focused on a “chronic lack” of mental health resources in Birmingham and Solihull.
Mr Bennett said: “The issue of adequately funding psychiatric beds is local and national. Locally, BSMHFT requires its commissioners to provide the necessary funding.
“Whilst some action may have been taken it is insufficient to resolve the problem. It follows there is a genuine risk of future deaths directly connected to a shortage of psychiatric bed spaces in Birmingham and Solihull unless further action is taken.”
Read full story (paywalled)
Source: HSJ, 5 November 2023
Patient Safety Learning

Urgent investment for Long Covid: Call to action for Prime Minister Rishi Sunak

Former Prime Minister Boris Johnson is scheduled to provide evidence at the Covid Inquiry on the 6 and 7 of December. Long Covid is one of the most catastrophic consequences of the pandemic and it deserves a prominent place in the discussions during this critical phase of the inquiry.
The Long Covid Groups will be delivering a letter to No.10 Downing Street today, urging attention to the unique challenges faced by those with Long Covid. 
Read the letter and sign the petition
Sam

Doctor suspended for sterilising woman without permission

A consultant gynaecologist who admitted sterilising a woman without her permission has been suspended from practising for 12 months.
The woman - known as Patient A - was sterilised by Dr David Sim following an emergency caesarean section.
Dr Sim previously admitted that the sterilisation was not necessary to save the woman's life or prevent harm to her health.
The procedure took place at Daisy Hill Hospital in Newry in September 2021.
On 1 December, the Medical Practitioners Tribunal Service (MPTS) found his fitness to practice was impaired.
The tribunal previously heard Dr Sim and the patient had discussed sterilisation twice over a period of years, but the patient had never consented or expressed any wish to undergo sterilisation.
When she required the emergency caesarean section, Dr Sim delivered the baby and blocked the patient's fallopian tubes to permanently impair their normal function.
Dr Sim previously admitted to the tribunal that this was in violation of the woman's reproductive rights.
Read full story
Source: BBC News, 5 December 2023
Patient Safety Learning

"I'm begging for help for endometriosis"

Living with seizures and crippling pain, Zara Corbett says she's "begging for help" as she copes with endometriosis.
The 21-year-old told BBC News NI that if she had any other condition she would be receiving help.
"With gynae problems, particularly endometriosis, you are left waiting for years."
"Women should not be left suffering this pain, it's not good enough," the beautician said.
Zara has been put into early menopause - which is one potential treatment for endometriosis.
The County Down woman said Northern Ireland needed a dedicated centre to provide specialist support.
"I am begging for help from medical professionals including support from a multi-agency network because we are at our wits end - life cannot go on like this," she said.
Endometriosis UK, an organisation that helps women with the condition, said it was shocked and saddened that it does not see "good, prompt care" in Northern Ireland.
Its chief executive, Emma Cox, who visited Belfast in May, said services in Northern Ireland were "lagging behind" the rest of the UK.
"We hear of the very long waiting lists to access gynaecologists to get a diagnosis but also waiting lists to access surgeons, it's about the disease being taken seriously," Ms Cox said.
Read full story
Source: BBC News, 6 December 2023
Patient Safety Learning

Experts call for fewer antidepressants to be prescribed in UK

Open letter to government from experts and politicians says rising usage ‘is a clear example of over-medicalisation’.
Medical experts and politicians have called for the amount of antidepressants being prescribed to people across the UK to be reduced in an open letter to the government.
The letter coincides with the launch of the all-party parliamentary group Beyond Pills, which aims to reduce what it calls the UK healthcare system’s over-reliance on prescription medication.
Read full story
Source: Guardian, 5 December 2023
Patient_Safety_Learning

Huge delays to access maternal mental health care in England called a scandal

NHS figures obtained by Labour reveal 11,507 women sought care but did not get any last year.
Almost 20,000 women a year living with mental health problems triggered by being pregnant or giving birth are being denied support by the NHS, the Guardian can reveal.
Furthermore, those who do receive mental health help for their trauma are having to wait up to 19 months to start treatment in some parts of England because specialist services are so overstretched.
The situation has been described as “an absolute scandal” and sparked warnings that “rationing” of such vital care could leave women who do not get it in a very vulnerable state and risk their children facing lifelong health problems and stop mothers bonding with their baby.
Read full story
Source: Guardian, 5 December 2023
Patient_Safety_Learning

Ministers lose infected blood vote after Tory MPs revolt

MPs have backed a move to speed up compensation for victims of the NHS infected blood scandal, delivering the prime minister his first Commons defeat.
Ministers will now have to set up a body to run the scheme within three months of a new bill becoming law.
The vote was passed by 246 votes to 242 after 22 Conservatives rebelled.
The Haemophilia Society said Rishi Sunak "should be ashamed" he had been forced "to do the right thing".
Read full story
Source: BBC News, 5 December 2023
Patient_Safety_Learning

Humiliated Covid whistleblower says boss tried to 'break' her

A senior doctor who won a record £3.2m payout says her boss tried to "break" her after she raised concerns about how Covid was being handled.
Rosalind Ranson, medical director on the Isle of Man during the pandemic, experienced months of humiliation, an employment tribunal found.
Dr Ranson has given BBC News her first interview since the hearing.
Read full story
Source: BBC News, 5 December 2023
 
Patient_Safety_Learning

GPs will not be nationally mandated to use advice and guidance, NHSE confirms

There will be no national mandate for GPs to use advice and guidance in a certain number of cases, NHS England has told Pulse. 
National medical directors for primary and secondary care said that formalised pathways should be developed ‘locally’, and decisions should be based on an area’s population.
In September, it was reported that NHS England’s upcoming outpatients strategy would further increase the use of advice and guidance (A&G) before GP referrals are accepted, with the RCGP then "voicing concerns" about this proposal. 
However, when asked about the reports that this would be mandated, Dr Stella Vig, national medical director for secondary care and clinical director for elective care, said she ‘doesn’t know’ where that came from, and ‘doesn’t recognise’ those comments.
NHS England also released guidance clarifying the medico-legal risks and clinical responsibility for clinicians using A&G or referral assessment services (RAS), which is now available on the NHS Futures website.
The guidance said that these forms of specialist advice are "expanding rapidly" as a result of improvements to digital services.
On legal issues, it said liability ‘will be determined on a case by case basis’ but that GPs could be liable if "all relevant clinical information is not provided" when sending an A&G request. 
But specialists at hospitals would be accountable if they send back advice to the GP which is ‘not clinically appropriate’ or if they ‘refuse to accept a patient’. 
On turnaround times, NHS England has said that ‘local variables will ultimately dictate the agreed response times’ for hospital teams dealing with A&G – but the guidance recommends that the response time "should not exceed 10 working days for routine requests". 
Read full story
Source: Pulse, 30 November 2023
Patient Safety Learning

NHS trust under investigation accused of hypocritical email to staff

The boss of a hospital trust being investigated by police for alleged negligence over 40 patient deaths has been accused of sending a hypocritical email urging staff to have the courage to raise concerns despite the dismissal of whistleblowing doctors.
The investigation, Operation Bramber, was sparked by two consultants who lost their jobs after raising concerns about deaths and patient harm in the general surgery and neurosurgery departments of the Royal Sussex County hospital in Brighton.
In an email to staff on Friday, the chief executive, George Findlay, said the trust was committed to learning from its mistakes. He said: “When things do go wrong, we must be open, learn and improve together. That openness is how we give people courage to raise concerns and make a positive difference to patient care.”
James Akinwunmi, a consultant neurosurgeon who was unfairly dismissed by the trust in 2014 after he raised the alarm about patient safety, said Findlay’s email was “laughable”.
He told the Guardian: “Whistleblowers, including myself, have done exactly what he is encouraging in the email and they were sacked for it, so you can draw your own conclusions. I suspect what they are doing is damage limitation. Instead, they should be dealing with surgeons who have been a problem for years.”
Another more recent whistleblower, who did not want to be named, expressed incredulity at Findlay’s claim that he wanted to encourage staff to raise concerns.
They said: “The email is hypocritical. How can staff have the ‘courage to raise concerns’ after what has happened to those who have? Those brave enough to blow the whistle about patient safety have been sanctioned, lost their job and had their lives destroyed.”
Read full story
Source: The Guardian, 3 December 2023
Patient Safety Learning

Minister: There’s systemic racism in the NHS

A health and social care minister privately said there was ‘systemic’ racism within the NHS and called for an investigation into it.
Helen Whately told Matt Hancock of her belief in a private message which was today shown to the covid public inquiry.
An inquiry hearing with Mr Hancock – who said he agreed with the point – was shown an exchange between Ms Whately, then care minister, and Mr Hancock in June 2020.
The Guardian had reported the previous day that an internal report had found systemic racism at NHS Blood and Transplant.
Ms Whately, who is now minister of state covering social care and urgent and emergency services, said: “I think the Bame next steps proposed are important but don’t go far enough. There’s systemic racism in some parts of the NHS, as seen in NHSBT.”
She added: “Now could be a good moment to kick off a proper piece of work to investigate and tackle it.”
Read full story (paywalled)
Source: HSJ, 1 December 2023
Patient Safety Learning

Trust reports two ‘never events’ in area already under review for errors

A teaching trust has reported six ‘never events’ in less than two months, including incidents in a specialty already under review for errors.
The incidents occurred at University Hospitals Birmingham between 26 July and 10 September, including two wrong-side lesion biopsies in dermatology, two incorrect blood transfusions, one injection to the incorrect eye, and one misplaced nasogastric tube.
The two incorrect blood transfusions involved the same patient at Heartlands Hospital and were reported after a biomedical scientist carried out a retrospective investigation into the case. On both occasions, the patient was transfused with incorrect red blood cells.
It brings the total number of blood transfusion events reported at UHB to seven since 2020-21. The issue is already subject to a review by the Royal College of Physicians after Mike Bewick identified concerns in his review of patient safety at the trust.
It comes after clinicians working within the haematology specialty raised multiple concerns over patient safety in 2021 and intervention from the General Medical Council over concerns around junior doctors.
John Atherton, chair of UHB’s clinical quality and safety committee, told the board a preliminary review into never events had identified that “maybe we weren’t addressing these [incidents] seriously enough”.
Read full story (paywalled)
Source: HSJ, 1 December 2023
Patient Safety Learning

Health secretary told to intervene over ‘systemic’ ambulance deaths

Ministers must intervene over systemic failures which are “too big for hospital or ambulance trusts to fix on their own” and have led to multiple preventable deaths, a senior coroner has warned.
In a move usually considered rare for such an official, Cornwall and Isles of Scilly coroner Andrew Cox has written to the Department of Health and Social Care a second time over ongoing delays to ambulance responses and long ambulance handovers in the area.
Last year he warned the NHS was “broken” after he ruled ambulance and emergency care delays contributed to the deaths of four people. Now, he has sent a similar report on the same types of failings in the deaths of John Seagrove, Pauline Humphris, and Patricia Steggles at Royal Cornwall Hospital to new health secretary Victoria Atkins.
Mr Cox wrote: “I set out in my [prevention of future death report] last year my understanding of the reasons for the difficulties that are continuing in the Cornwall & Isles of Scilly coroner area. I do not believe those reasons will have changed significantly.
”The challenges are systemic in nature. They are too big for a single doctor, nurse or paramedic to fix. They are too big for either the hospital trust or the ambulance trust to fix on their own.”
Read full story
Source: HSJ, 1 December 2023
Patient Safety Learning

Infected blood: Tory rebellion expected on payouts amendment

The government faces a rebellion with at least 30 Tories backing an amendment to extend interim payouts to more victims of the infected blood scandal.
Up to 30,000 people were given contaminated blood products in the 1970s and 80s. Thousands have died.
A Labour amendment will be brought on Monday calling for a new body to be set up to administer compensation. More than 100 MPs, including Tories Sir Robert Buckland, Sir Edward Leigh and David Davis, are backing the move.
In a letter sent to Chancellor Jeremy Hunt, shadow chancellor Rachel Reeves called the scandal "one of the most appalling tragedies in our country's recent history."
She added: "Blood infected with hepatitis C and HIV has stolen life, denied opportunities and harmed livelihoods."
She praised Theresa May, who set up the Infected Blood Inquiry when she was prime minister in 2017. But she warned: "For the victims, time matters. It is estimated that every four days someone affected by infected blood dies."
The chancellor, himself a former health secretary, told the inquiry in July that the government accepted the moral case for compensation. But he said no final decisions could be made before the inquiry publishes its findings - now expected in March next year.
In August 2022, the government agreed to make the first interim compensation payments of £100,000 each to about 4,000 surviving victims and bereaved widows.
But inquiry chairman Sir Brian Langstaff, said in April this year that the parents and children of victims should also receive compensation and also called for a full compensation scheme to be set up immediately.
The Commons Speaker will decide on Monday which amendments to the bill MPs will vote on. But the government has said it will not be supporting the amendment.
A Department of Health spokesperson said: "We are deeply sympathetic to the strength of feeling on this and understand the need for action. However, it would not be right to pre-empt the findings of the final report into infected blood."
Read full story
Source: BBC News, 3 December 2023
Patient Safety Learning

UK minority ethnic transplant patients face double inequity, MPs say

NHS “inaction” for more than a decade is causing unnecessary deaths of black, Asian and minority ethnic transplant patients, a report by MPs has concluded.
An inquiry into organ donation in the UK found that minority ethnic and mixed heritage people faced a “double whammy of inequity”: they are more likely to need donors, because they are disproportionately affected by conditions such as sickle cell and kidney disease, and they are less likely to find the right blood, stem cell or organ match on donor registers.
Matching tissue type is vital to the chances of successful treatment, and compatible donors who are not relations are more likely to be found among donors from a similar ethnic background.
While there are more donors than in previous years, theall-party parliamentary group (APPG) for ethnicity transplantation and transfusion’s inquiry report says just 0.1% of blood donors, 0.5% of stem cell donors and less than 5% of organ donors are of minority ethnic or mixed background. As a result, white people are nearly twice as likely to find a stem cell donor and 20% more likely to find a kidney donor.
The inquiry found a “staggering lack of consistent and detailed ethnicity data” within healthcare systems, which “undermines accountability and jeopardises the lives of those awaiting life-saving treatments”.
Responding to the findings, Habib Naqvi, the chief executive of the NHS Race and Health Observatory, said such stark ethnic disparities in organ donor participation were of “grave concern” and required “more investment from health providers and targeted campaigns to raise awareness” to build trust in the healthcare system.
Jabeer Butt, the chief executive of the Race Equality Foundation, said the inequalities were unacceptable. “Every person, regardless of ethnic background, deserves an equal chance at receiving life-saving transplants and donations when needed. This is a solvable problem, but it requires a shared commitment to action across government, health organisations and communities. Lives depend on it,” he said.
Read full story
Source: The Guardian, 4 December 2023
Patient Safety Learning

Hospital staff failed man living with HIV by unnecessarily delaying surgery

A hospital that unnecessarily delayed a man’s surgery at the last minute because he had HIV failed in their care, according to England’s Health Ombudsman.
The 48-year-old from Walsall, who does not want to be named, had been due to have prostate surgery at Walsall Manor Hospital on 10 March 2020.
His surgery was scheduled to be the first of the morning. As he was about to enter the operating room, he was told that due to his HIV status his surgery would now be moved to last on the operating list that afternoon.
The hospital claimed that this was due to the level of cleaning and infection control that would need to take place following his surgery to reduce the risk to others.
However, the Parliamentary and Health Service Ombudsman (PHSO), found that Walsall Healthcare NHS Trust acted inappropriately and failed the man.
This is because the universal precautions that apply to all patients having surgery are enough to protect and prevent infections from spreading among patients and staff. Therefore, no additional cleaning should have been necessary.  
The policy of placing a patient at the end of an operating list usually relates to patients with a high-risk bacterial infection. It should not be applied to a person who has HIV and is receiving treatment.
The Ombudsman also found that although the Trust had made some changes since this happened, they had not done enough to make sure the same mistake did not reoccur.
PHSO recommended the Trust apologise to the man and create an action plan to stop this happening again. The Trust has complied with these recommendations.
Read full story
Source: Parliamentary and Health Service Ombudsman, 1 December 2023
Patient Safety Learning
Registered address: Patient Safety Learning, China Works SB203, 100 Black Prince Road Vauxhall, London, SE1 7SJ

Account

Navigation

Search

Search

Configure browser push notifications
Chrome (Android)
  1. Tap the lock icon next to the address bar.
  2. Tap Permissions → Notifications.
  3. Adjust your preference.
Chrome (Desktop)
  1. Click the padlock icon in the address bar.
  2. Select Site settings.
  3. Find Notifications and adjust your preference.