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

Inquest finds ‘gross’ failures in care of UK student who died after rugby injury

The family of a student who died after hospital staff missed that she had developed sepsis despite a string of warning signs have claimed she was the victim of a “lack of care”, as a coroner ruled there were “gross” failures in her treatment.
Staff at Southmead hospital in Bristol failed to carry out the sepsis screening and observations needed to keep 20-year-old Maddy Lawrence safe after she was taken to hospital with a dislocated hip sustained in a rugby tackle.
Outside court, the student’s mother, Karen Lawrence, said: “It has been a constant struggle to understand how a healthy, strong and fit 20-year-old could lose her life to sepsis which was allowed to develop under the care of professionals.
“Her screams of pain and our pleas for help were merely managed, temporarily quietened with painkillers while the infection progressed unnoticed by hospital staff.
“Our daughter was failed by a number of nurses and medical staff; symptoms were ignored, observations were not taken, on one occasion for 16 hours. There was no curiosity, basic tests were not completed even when hospital policy required them.
“Maddy herself expressed concern on multiple occasions but her pain was not being taken seriously. As well as failing to fulfil their duty, those nurses and medical staff offered no sympathy, no compassion and little attention.
“This failure meant Maddy was not given the chance to beat sepsis. Significant delays in its discovery meant the crucial window for treatment was missed. Maddy did not die due to under-staffing or a lack of money. Her death was the result of a lack of care.”
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Source: The Independent, 8 September 2023
Sam

Woman accused of faking symptoms of debilitating illness dies aged 33

A 33-year-old New Zealand woman who was accused of faking debilitating symptoms has died of Ehlers-Danlos Syndrome (EDS).
Stephanie Aston became an advocate for patients' rights after doctors refused to take her EDS symptoms seriously and blamed them on mental illness. She was just 25 when those symptoms began in October 2015. At the time, she did not know she had inherited the health condition.
EDS refers to a group of inherited disorders caused by gene mutations that weaken the connective tissues. There are at least 13 different types of EDS, and the conditions range from mild to life-threatening. EDS is extremely rare.
Aston sought medical help after her symptoms—which included severe migraines, abdominal pain, joint dislocations, easy bruising, iron deficiency, fainting, tachycardia, and multiple injuries—began in 2015, per the New Zealand Herald. She was referred to Auckland Hospital, where a doctor accused her of causing her own illness.
Because of his accusations, Aston was placed on psychiatric watch. She had to undergo rectal examinations and was accused of practising self-harming behaviours. She was suspected of faking fainting spells, fevers, and coughing fits, and there were also suggestions that her mother was physically harming her.
There was no basis for the doctor’s accusations that her illness was caused by psychiatric issues, Aston told the New Zealand Herald. “There was no evaluation prior to this, no psych consultation, nothing,” she said.
She eventually complained to the Auckland District Health Board and the Health and Disability Commissioner of New Zealand. “I feel like I have had my dignity stripped and my rights seriously breached,” she said.
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Source: The Independent, 6 September 2023
Sam

The BMJ Investigates U.S. defunding virus detection programme

Two years after launching what officials hailed as a five-year flagship project for hunting viruses among wildlife to prevent human pandemics, the US Agency for International Development is shutting down the enterprise.
Hear the update from the Editor-in-Chief of The BMJ, Kamran Abbasi.
Source: BMJ, 7 September 2023
Patient Safety Learning

Public inquiry to be held into disgraced brain surgeon

A public inquiry will be held into the disgraced brain surgeon Sam Eljamel, the Scottish government has confirmed.
Eljamel harmed dozens of patients at NHS Tayside, leaving some with life-changing injuries.
He was head of neurosurgery at Ninewells Hospital in Dundee until December 2013, when he was suspended.
Health Secretary Michael Matheson said he was persuaded of the need for the inquiry after reading a damning due diligence review into NHS Tayside.
It follows a long-running campaign which saw almost 150 former patients of the surgeon calling for the inquiry.
Mr Matheson said he had concluded that a public inquiry was "the only route to get to the bottom of who knew what and when, and what contributed to the failures described by NHS Tayside".
The health secretary said he also wanted to see individual cases reviewed independently of NHS Tayside in a "person-centred, trauma-informed" manner.
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Source: BBC News, 7 September 2023
 
Patient Safety Learning

YouTube starts verifying health workers in the UK

YouTube has launched a verification system for healthcare workers in the UK as it battles disinformation online.
In 2022, health videos were viewed more than three billion times in the UK alone on the video-sharing platform.
Doctors, nurses and psychologists have been applying for the scheme since June and must meet rigorous criteria set by the tech giant to be eligible.
Successful applicants will have a badge under their name identifying them as a genuine, licensed healthcare worker.
But YouTubers have warned the system is only meant for education purposes, not to replace medical advice from your GP.
Vishaal Virani, who leads health content for YouTube, said it was important simply due to the sheer number of people accessing healthcare information on the video-sharing platform.
"Whether we like it or not, whether we want it or not, whether the health industry is pushing for it or not, people are accessing health information online," he told the BBC.
"We need to do as good a job as possible to bring rigour to the content that they are subsequently consuming when they do start their care journey online."
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Source: BBC News, 8 September 2023
Patient Safety Learning

Trust and manager charged with manslaughter

North East London Foundation Trust has been charged with corporate manslaughter – making it only the second NHS provider to be prosecuted for the crime.
The Crown Prosecution Service has authorised the Metropolitan Police to bring a charge of corporate manslaughter against the mental health provider in regard to the death of Alice Figueiredo at the trust’s Goodmayes Hospital on 7 July 2015.
Goodmayes ward manager Benjamin Aninakwa has also been charged with gross negligence manslaughter, and an offence under the Health and Safety at Work Act.
The trust and Mr Aninakwa will appear at Barkingside Magistrates’ Court on Wednesday, 4 October. The prosecution follows a five year investigation by Met detectives.
Read full story (paywalled)
Source: HSJ, 7 September 2023
Patient Safety Learning

Crumbling estate impacting patient care ‘day in, day out’, NHSE boss tells MPs

NHS England’s finance boss has said patient treatment areas are being closed “all the time” due to crumbling estates, fire risks and flooding.
Julian Kelly told MPsthe health service had “examples all the time where hospitals are having to shut units, decant patients into other spaces, where we are losing theatres… which limits our capacity to treat patients”.
It comes amid the national controversy around the government’s investment into public buildings, sparked by the sudden closure of dozens of school buildings with unsafe structures known as ‘reinforced autoclaved aerated concrete’.
He said: “We have hospital teams which are managing these sort of issues day in and day out. And so we have examples of managing fire risk, flooding… a lot of this is because we know we’ve seen a big increase in backlog maintenance and we know there was a pause in investment in new hospital infrastructure.”
Read full story (paywalled)
Source: HSJ, 7 September 2023
Patient Safety Learning

Police to launch inquiry into maternity unit deaths

A police investigation is to be launched into failings that led to dozens of baby deaths and injuries at a hospital trust.
The maternity units at Nottingham University Hospitals (NUH) NHS Trust are already being examined in a review by senior midwife Donna Ockenden.
The review will become the largest ever carried out in the UK, with about 1,800 families affected.
Nottinghamshire Police said its decision to investigate followed discussions with Ms Ockenden.
Her team is looking into failings that led to babies dying or being injured at Nottingham City Hospital and the Queen's Medical Centre.
Chief Constable Kate Meynell said: "On Wednesday I met with Donna Ockenden to discuss her independent review into maternity cases of potentially significant concern at Nottingham University Hospitals NHS Trust (NUH) and to build up a clearer picture of the work that is taking place.
"We want to work alongside the review but also ensure that we do not hinder its progress.
"However, I am in a position to say we are preparing to launch a police investigation.
"I have appointed the Assistant Chief Constable, Rob Griffin, to oversee the preparations and the subsequent investigation."
Read full story
Source: BBC News, 7 September 2023
Patient Safety Learning

California pharmacies are making millions of mistakes. They’re fighting to keep that secret

Sharri Shaw walked out of the CVS on Vermont Avenue in South Los Angeles in 2019 believing she had a prescription for the pain reliever acetaminophen.
Instead the bottle held a medicine to treat high blood pressure, a problem she did not have.
Shaw began taking the pills, not learning of the mistake until six days later when a CVS employee arrived at her home, according to a lawsuit she filed last year. The employee told her not to take the tablets, the lawsuit said, before leaving the correct prescription at her door. The mistake, she said, left her stunned.
Shaw’s experience is far from an isolated event. California pharmacies make an estimated 5 million errors every year, according to the state’s Board of Pharmacy.
Officials at the regulatory board say they can only estimate the number of errors because pharmacies are not required to report them.
Most of the mistakes that California officials have discovered, according to citations issued by the board and reviewed by The Times, occurred at chain pharmacies such as CVS and Walgreens, where a pharmacist may fill hundreds of prescriptions during a shift, while juggling other tasks such as giving vaccinations, calling doctors’ offices to confirm prescriptions and working the drive-through.
Christopher Adkins, a pharmacist who worked at CVS, and then at Vons pharmacies until March, said that management policies at the big chains have resulted in understaffed stores and overworked staff.
“At this point it’s completely unsafe,” he said.
Read full story
Source: Los Angeles Times, 5 September 2023
Patient Safety Learning

‘Cowboy’ Rishi Sunak hit by new concrete crisis as it threatens pledge to cut NHS backlog

Rishi Sunak’s pledge to cut the NHS waiting list backlog is being threatened by the crumbling concrete crisis as affected hospitals warn they will be forced to shut wards and theatres.
Hospitals were told they had buildings prone to collapse in 2019 but four years later they are still dealing with the issue.
In a report last year, West Suffolk NHS Foundation Trust leaders said that work to replace reinforced autoclaved aerated concrete (Raac) in its hospitals would hit general surgery, urology, gynaecology and orthopaedic care.
Wards have had to close, piling pressure on a crowded A&E as patients can’t be offloaded due to lack of beds, and threatening its ability to hit government targets to reduce waiting lists, it added.
The warning comes as Sir Keir Starmer used Prime Minister’s Questions to attack Mr Sunak over the crisis. He argued that “the cowboys are running the country” and asked the PM if he was “ashamed” of the scandal caused by 13 years of “botched jobs”.
Read full story
Source: The Independent, 6 September 2023
Patient Safety Learning

‘Deeply flawed’ CervicalCheck tribunal sees just 26 claims, with 385 taken through courts

Only 26 claims have been sent into the CervicalCheck tribunal – while 385 claims have now been taken through the courts, new figures reveal.
The 26 claims taken through the tribunal represent only 6% of the cases taken through the courts.
The CervicalCheck tribunal was set up to hear legal cases from women who developed cancer after they got wrong smear test results.
While it was designed to provide fast-track compensation without having to go to court, it has been criticised by campaigners, as most women who were affected still opted to go through the courts system instead.
Dozens of Irish women were diagnosed with cervical cancer after being incorrectly told by the State’s CervicalCheck screening programme that their smear tests were clear.
The scandal emerged when Vicky Phelan revealed she had settled her case against a US laboratory.
The new figures were set out to Aontú leader Peadar Tóibín in response to a parliamentary question to Health Minister Stephen Donnelly.
Read full story
Source: Irish Independent, 7 August 2023
Patient Safety Learning

Turkey surgery warning as mother-of-four dies after gastric sleeve

A father whose daughter died after travelling to Turkey for weight-loss surgery has urged people to think again before doing the same.
Shannon Meenan Browse from Londonderry was 32 when she died in August.
The mother-of-four travelled for a gastric sleeve operation 18 months ago but, according to her father, got sick almost straight away.
The family were told she died in Altnagelvin Hospital from "malnutrition due to gastric sleeve".
A BBC investigation in March found that seven British patients who travelled to Turkey for weight-loss surgery died after operations there, while others returned home with serious health issues.
One of the UK's leading bariatric surgeons, Prof David Kerrigan said people are taking a "massive risk" by travelling abroad for weight-loss surgery.
In the UK, he said, patients undergo a rigorous preparatory process that includes a psychological assessment and there is "a proper after-care programme".
Read full story
Source: BBC News, 6 September 2023
Patient Safety Learning

Misinformation preventing women from getting effective menopause treatment, study finds

Most women going through menopause are not receiving effective treatment for their symptoms, in part because of widespread misinformation, according to new research.
A comprehensive literature review led by Prof Susan Davis from Monash University in Australia calls for more personalised treatment plans that address the greatly varying physical and mental symptoms of menopause.
After adverse affects were reported from the landmark 2002 Women’s Health Initiative study into menopausal hormone therapy (MHT), Davis said there was a blanket fear that “hormones are dangerous” and as a result, “menopause [treatment] just went off the radar”.
Read full story
Source: The Guardian, 6 September 2023
Patient Safety Learning

Young autistic people still dying despite coroner warnings over care

Dozens of young autistic people have died after serious failings in their care despite repeated warnings from coroners, BBC News has found.
Their investigation found issues that were flagged a decade ago are still being warned about now.
Two bereaved mothers said lessons had not been learned by their local health authority after the deaths of their teenage sons, two years apart.
The coroner who oversaw both cases, noted a repeated failure in care.
After the first death, the coroner criticised NHS Kent and Medway for "inadequate support" and said a similar incident may happen if this continued.
Two years later, the second autistic teenager died under the care of the same authority. The same coroner found that had the victim received the recommended level of care, he might have got the therapy he needed.
In the first piece of research of its kind, the BBC combed through more than 4,000 Prevention of Future Death (PFD) notices delivered in England and Wales over the past 10 years.
Read full story
Source: BBC News, 7 September 2023
Patient Safety Learning

Execs accused of ‘bullying culture and misuse of power’

Former commissioning chiefs have been accused of presiding over a ‘culture of bullying’ at the predecessor organisation to Norfolk and Waveney Integrated Care Board, as part of a legal claim from a former employee.
The accusations, which have been made in an employment tribunal case, relate to former chief executive Melanie Craig and other former executives at what was then Norfolk and Waveney Clinical Commissioning Group. Ms Craig now leads Suffolk Community Foundation, a local voluntary sector organisation.
The claims have been made by a former long-standing assistant director for mental health services, Clive Rennie, who has claimed unfair dismissal. However, the integrated care board said it disputes the claims and is defending the case.
In a witness statement to the tribunal, which began this week, Mr Rennie alleges there was an “authoritarian and dictatorial style of management” and described a “culture of bullying and misuse of power that had emerged under the leadership of Melanie Craig and which included the executive team”.
Read full story (paywalled)
Source: HSJ, 6 September 2023
Patient Safety Learning

Steve Barclay names Lucy Letby inquiry lead amid patient safety address

Health secretary, Steve Barclay, has named Lady Justice Thirlwall as the chair of the independent inquiry into the crimes committed by former Countess of Chester Hospital nurse, Lucy Letby.
The inquiry was given statutory powers last week and will be led by one of the country’s most senior judges, who currently sits on the Court of Appeal.
The announcement came during Barclay’s speech in the House of Commons, where he also announced that the chair of the Essex mental health inquiry will be Baroness Lampard, who investigated the crimes of Jimmy Saville in a similar inquiry led by the Department of Health and Social Care (DHSC).
The rest of the health secretary’s address centred around patient safety and what the government has done, is doing and will do.
Barclay drew attention to the appointment of Dr Aidan Fowler as NHS England’s first ever national director of patient safety in 2018, and thus the following patient safety strategy in 2019.
Read full story
Source: National Health Executive, 4 September 2023
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