Skip to content

News

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

Inquiry into rogue breast surgeon to call for changes to private hospital safety

An independent inquiry is expected to call for major changes in the way private hospitals supervise doctors after hundreds of women were put through unnecessary operations by a rogue breast surgeon.
Ian Paterson was jailed for 20 years in 2017 after being convicted of 13 counts of wounding with intent and three counts of unlawful wounding. But his surgical malpractice may have harmed more than 750 women over more than a decade.
He carried out unnecessary surgery for breast cancer on women who did not have the disease, and put other women who did at risk by using his own unofficial technique, which left behind partial breast tissue.
On Tuesday an inquiry chaired by the Bishop of Norwich, the Right Reverend Graham James, will be published and is expected to make recommendations about how doctors are allowed to work across both the NHS and private sector with minimal supervision and oversight.
One key area of focus is expected to be a process known as “practising privileges”, where private hospitals allow clinicians to carry out their own activities within the hospital, similar to self-employed contractors. They effectively rent the hospital space for their work.
Read full story
Source: The Independent, 2 February 2020
Patient Safety Learning

NHS Trusts spent £20 million battling whistleblowers, workplace discrimination claims and employment disputes

NHS Trusts have spent nearly £20 million in four years battling whistleblowers, defending claims of workplace discrimination and fighting employment disputes, the Sunday Telegraph can disclose.
Data obtained through Freedom of Information (FOI) has revealed that a minority of healthcare trusts, often advised by the same law firms, are repeatedly running up huge legal bills.
Former health minister Sir Norman Lamb said some of the NHS employment cases he has witnessed in the last eighteen months involved ‘scandalous’ uses of public money. “It is not all NHS trusts in the country, but there are a small number where the culture is clearly wrong,” said Sir Norman.
Commenting on the findings, Tim Farron, former leader of the Liberal Democrats, who has fought for whistleblowers in his own constituency,  said: “Millions of pounds of tax payers’ money is being spent across our health service by NHS Trusts defending their actions in employment tribunals in cases of discrimination and unfair dismissal. It is only right that questions are being asked."
Read full story
Source: The Telegraph, 1 February 2020
Patient Safety Learning

Pregnant women must be respected by medics, says regulator

Mothers-to-be must be respected and listened to by medics, regulators have said, after warnings that pleas for pain relief in labour have been ignored. The intervention by the Nursing and Midwifery Council (NMC) follows an investigation by The Sunday Telegraph.
Last week it was revealed that six NHS trusts were in breach of medical guidance which says pain relief should be provided at any point of labour if it is requested. Women said they were told “‘It’s not called labour for nothing, it’s meant to be hard work” as doctors refused their pleas.
The findings prompted the Health Secretary to order an investigation. 
Today Andrea Sutcliffe, Chief Executive of the NMC, which regulates nurses and midwives said such actions should not be tolerated. In a letter to The Telegraph she said: "As the regulator for nursing and midwifery professionals, we know that all women deserve to have their views, preferences and decisions respected during pregnancy and birth."
The watchdog recently published updated standards for midwives, which she said underlined this point. 
"Enabling women to make safe, informed decisions about the care they receive, including choices about pain relief during birth, is at the heart of our new Future Midwife Standards," the Chief Executive continued. 
Ms Sutcliffe said midwives should work "in partnership" with women in labour. "While midwives don’t administer epidurals, they do play a key role in helping women to make informed choices and advocating on their behalf to make sure those choices are understood and respected by the wider care team," she said.
Read full story
Source: The Telegraph, 2 February 2020
Patient Safety Learning

'My baby died of sepsis - we can stop more deaths'

New monitors that can detect the deadly blood condition sepsis are being fitted at a Scottish children's hospital. The equipment will be installed at the Royal Hospital for Children in Glasgow.
Charlotte Cooper, who lost her nine-month-old daughter Heidi to sepsis last year, said she had "no doubt" the monitors would help save babies' lives. She told BBC Scotland: "You don't have time to come to terms with the fact that someone you love is dying from sepsis because it happens so quickly."
Ms Cooper now wants to see the monitors installed in every paediatric ward in Scotland. "We need to do whatever we can to stop preventable deaths from sepsis in Scotland," she said.
The monitors record and track changes in heart rate, temperature and blood pressure, and can pick up early sepsis symptoms. The machines, which have been installed in a critical care area, use the  Paediatric Early Warning Scores to monitor the children for any signs of deterioration in their condition.
Sepsis Research said early warning of the changes would mean sepsis being diagnosed and treated faster.
The monitors were accepted on behalf of the hospital by senior staff nurse Sharon Pate, who said: "In a very busy paediatric word it is vital all our patients are monitored regularly and closely for signs of deterioration. The addition of these new monitors will greatly improve our ability to monitor patients and provide vital care."
Read full story
Source: BBC News, 4 February 2020
Patient Safety Learning

NHS hospitals bring in sleep pods to help tired staff take a break

Help is arriving for overworked NHS staff as a growing number of hospitals bring in sleep pods for doctors and nurses to grab power naps during their shifts.
Pods have been installed or are being trialled by a dozen hospitals in England. Royal Wolverhampton NHS trust was the first to try them, in June 2018. “Too many staff end up exhausted because they have long, busy, sometimes stressful shifts, often with little chance to grab a break because pressure on the NHS is so intense,” said Prof Steve Field, the trust’s chair.
“We know that doctors provide better, safer care when they are fresh and alert. We have found [the pods] to be very popular with staff and also very effective in helping them get more rest,” said Field, a former GP.
Dr Mike Farquhar, a consultant in sleep medicine at the Evelina children’s hospital in London, who has persuaded NHS chiefs to take staff slumber more seriously, said hospitals were finally taking practical action.
“Air traffic controllers are only allowed to work for two hours and then they must take a 30-minute break, because if they were tired and made a mistake, bad things could happen,” he said. “But in the NHS, where the pressure is often high and sustained, the problem is that the people delivering care will usually choose to prioritise everything else – especially patients – over themselves and sacrifice things like breaks and sleep.”
Read full story
Source: The Guardian, 3 February 2020
Patient Safety Learning

Prime Minister urged to give NHS 100 new hospitals plus an extra £7bn a year

NHS leaders have urged Boris Johnson’s government to build 100 new hospitals and give the service an extra £7bn a year for new facilities and equipment. They want the Prime Minister to commit to far more than the 40 new hospitals over the next decade that the Conservatives pledged during the general election.
So many hospitals, clinics and mental health units are dilapidated after years of underinvestment in the NHS’s capital budget that a spending splurge on new buildings is needed, bosses say. Too many facilities are cramped and growing numbers are unsafe for patients and staff, they claim.
Johnson has promised £2.7bn to rebuild six existing hospitals and pledged to build 40 in total and upgrade 20 others, although has been criticised for a lack of detail on the latter two pledges.
The call has come from NHS Providers, which represents the bosses of the 240 NHS trusts in England that provide acute, mental health, ambulance and community-based services.
Read full story
Source: The Guardian, 3 February 2020
Patient Safety Learning

Doctors in row with HSE over claims children's transgender care is 'unsafe'

A number of doctors have claimed a service under which adolescents with gender dysphoria can be given puberty-suppressing hormone blockers is "unsafe" and must be immediately stopped, but their concerns were suppressed.
The service is provided in Ireland by flying in two clinicians from an NHS trust in London to run clinics at Crumlin Children's Hospital. But the Irish Independent has learned at least three doctors working in the gender area expressed grave concerns over the service provided by the Tavistock and Portman NHS Foundation Trust at Crumlin.
The concerns over standards of clinical care and governance were raised at a meeting of doctors and hospital officials in Crumlin last March. These included that children had been started on hormone treatment when they did not appear to be suitable. However, the issues raised and calls by the doctors for the service to be "terminated with immediate effect" were omitted from draft minutes of the meeting.
News of their concerns comes days after it emerged a lawsuit was being taken by a former nurse, a parent, and a former patient against the trust in the London High Court. The action is challenging the clinic's practice of prescribing hormone blockers and cross-sex hormones to children under the age of 18.
The trust has also been hit by a series of resignations by psychologists amid disquiet about the alleged "over-diagnosis" of gender dysphoria.
Read full story
Source: Irish Independent, 3 February 2020
Patient Safety Learning

Surrey hospital trust becomes first in country to appoint nurse to prevent patient falls

A Surrey hospital trust has become the first in the country to appoint a nurse dedicated to preventing patient falls and medication mix-ups.
The consultant nurse has been appointed by Ashford and St Peter's (ASP) Hospital NHS Foundation Trust to reduce the number of patients who are injured while being treated at its sites.
This includes looking at ways to reduce the amount of people who fall over, suffer with venous thromboembolism or experience tissue damage while in hospitals in north west Surrey.
The trust says the harms prevention nurse will be the first in the country hired for such a role and will also work with the team who look at incidents of medication mix-ups and mistakes.
Read full story
Source: Surrey Live, 4 February 2020
Patient Safety Learning

Ian Paterson: Surgeon wounded hundreds amid 'culture of denial'

A culture of "avoidance and denial" allowed a breast surgeon to perform botched and unnecessary operations on hundreds of women, an independent inquiry has found.
The independent inquiry into Ian Paterson's malpractice has recommended the recall of his 11,000 patients for their surgery to be assessed.
Paterson is serving a 20-year jail term for 17 counts of wounding with intent. One of Paterson's colleagues has been referred to police and five more to health watchdogs by the inquiry.
The disgraced breast surgeon worked with cancer patients at NHS and private hospitals in the West Midlands over 14 years.
His unregulated "cleavage-sparing" mastectomies, in which breast tissue was left behind, meant the disease returned in many of his patients. Others had surgery they did not need - some even finding out years later they did not have cancer.
Patients were let down by the healthcare system "at every level" said the inquiry chair, Bishop of Norwich the Rt Revd Graham James, who identified "multiple individual and organisational failures".
One of the key recommendations from the report is that the Government should make patient safety a the top priority, given the ineffectiveness of the system identified in this Inquiry. 
Read full story
Source: BBC News, 4 February 2020
Patient Safety Learning

The Chinese doctor who tried to warn others about coronavirus

In early January, authorities in the Chinese city of Wuhan were trying to keep news of a new coronavirus under wraps. When one doctor tried to warn fellow medics about the outbreak, police paid him a visit and told him to stop. A month later he has been hailed as a hero, after he posted his story from a hospital bed.
It's a stunning insight into the botched response by local authorities in Wuhan in the early weeks of the coronavirus outbreak.
Dr Li was working at the centre of the outbreak in December when he noticed seven cases of a virus that he thought looked like SARS - the virus that led to a global epidemic in 2003. On 30 December he sent a message to fellow doctors in a chat group warning them about the outbreak and advising they wear protective clothing to avoid infection. What Dr Li didn't know then was that the disease that had been discovered was an entirely new coronavirus.
Four days later he was summoned to the Public Security Bureau where he was told to sign a letter. In the letter he was accused of "making false comments" that had "severely disturbed the social order". "We solemnly warn you: If you keep being stubborn, with such impertinence, and continue this illegal activity, you will be brought to justice - is that understood?" 
He was one of eight people who police said were being investigated for "spreading rumours".
At the end of January, Dr Li published a copy of the letter on Weibo and explained what had happened. In the meantime, local authorities had apologised to him but that apology came too late.
For the first few weeks of January officials in Wuhan were insisting that only those who came into contact with infected animals could catch the virus. No guidance was issued to protect doctors.
"A safer public health environment… requires tens of millions of Li Wenliang," said one reader of Dr Li's post.
Read full story
Source: BBC News, 4 February 2020
Patient Safety Learning

Scotland's A&E waiting times hit record high

A&E waiting times have hit a record high, as more than 1,000 people waited at least 12 hours to be seen by a doctor for the first time since records began.
Official statistics released yesterday show the proportion of people left waiting more than eight and 12 hours in December were at the worst level for a single month since records started in 2007. Patients who were seen within the four-hour waiting time target also reached the lowest level on record.
Scottish Conservatives health spokesman Miles Briggs described the figures as "an utter disaster".
Mr Briggs said: "Patients are waiting in pain, discomfort and distress which in turn significantly affects staff."
Read full story
Source: The Telegraph, 4 February 2020
Patient Safety Learning

Paterson scandal: Is the NHS learning from mistakes?

Shipman, Mid Staffordshire, Morecambe Bay, and now Ian Paterson, the breast surgeon that performed botched and unnecessary operations on hundreds of women. The list of NHS-related scandals has got longer. It's tempting to say the health service has not learned lessons even after a string of revelations and reviews. But is that fair? asks BBC Health Editor Hugh Pym.
The inquiry, chaired by Bishop Graham James, makes clear there were failings at every level of a dysfunctional health system when it came to patient safety.
The public and private health systems did not compare notes about suspicious behaviour by a consultant. Staff working with Paterson thought that his surgical methods were unusual but, perhaps cowed by being ignored after raising concerns, kept their heads down. Add to that the power and status of a surgeon in the medical world and, in the words of the report, Paterson was "hiding in plain sight".
So could it happen again?
James says it's clearly impossible to eliminate the activities of determined criminals in any profession. He acknowledges that some improvements have been made on policing. But he says that a decade on from the Paterson scandal, he is not convinced that medical regulators, with a combined budget of half a billion pounds a year, are doing enough collectively or collaboratively to make the system safe for patients.
The review chair notes tellingly that while regulators spoke of major improvements which should identify another Paterson, some doctors and nurses had told the inquiry that it was "entirely possible that something similar could happen now".
Read full story
Source: BBC News, 4 February 2020
Patient Safety Learning

Coronavirus: Every hospital in England must create secure zones for patients

All NHS hospitals in England have been ordered to create secure areas for coronavirus testing to “avoid a surge in emergency departments”, according to a leaked NHS letter.
Hospitals have been told to create “coronavirus priority assessment pods”, where people will be checked for the virus, which will need to be decontaminated each time they are used.
The letter, seen by The Independent and dated 31 January, instructs all chief executives and medical directors to have the pods up and running no later than Friday 7 February.
It comes as the global death toll from the virus has reached 565 with around 28,000 infected.
One hospital chief executive told The Independent he believed the requirement was “an overreaction”, adding: “I think we should be sending teams out to swab in patients homes as the advice is to stay at home and self-manage as with any other flu".
In the letter, Professor Keith Willett, who is leading the NHS’s response to coronavirus, told NHS bosses: “Plans have been developed to avoid a surge in emergency departments due to coronavirus. “Although the risk level in this country remains moderate, and so far there have been only two confirmed cases, the NHS is putting in place appropriate measures to ensure business as usual services remain unaffected by any further cases or tests of coronavirus.”
Read full story
Source: 5 February 2020
Sam

Hospital whistleblower raised alarm over doctor seen injecting himself

A whistleblower raised the alarm over patient safety at West Suffolk Hospital because of concerns about the behaviour of a doctor who had been seen injecting himself with drugs, the Guardian has revealed.
The incident had already prompted internal complaints from senior staff at West Suffolk hospital, but the whistleblower decided to take matters a step further when the same doctor was later involved in a potentially botched operation. The whistleblower then wrote to relatives of a dead patient and urged them to ask questions about the conduct of the doctor and his background.
When they did this, the hospital launched a widely criticised “witch-hunt” in an attempt to find out the identity of the leaker.
The doctor’s drug use, which the trust has never acknowledged until now, helps explain why it demanded fingerprint and handwriting samples from staff – tactics which the NHS regulator roundly condemned in a hard-hitting report last week.
Read full story
Source: Guardian, 5 February 2020
Sam

Mental health: 'Urgent action needed over epidemic'

The new executive must act urgently if it is to "divert the current mental health epidemic among young people", Northern Ireland's children's commissioner has said.
Koulla Yiasouma said progress in implementing recommendations in a report on children and young people's mental health services, produced 12 months ago, had been "too slow". 
The stark read captured the scale of youth mental health problems in Northern Ireland. The report found that young people are waiting too long to ask for help and even longer to access the right support.
Health Minister Robin Swann said his aim was that young people do not wait longer than nine weeks to see a CAMHS (child and adolescent mental health services) professional."I take the mental health and wellbeing of our children and young people very seriously and I am committed to working with my colleagues in a new executive working group on mental well-being, resilience and suicide prevention," he said.
Read full story
Source: 6 February 2020
Sam

‘Culture of blame’ found at troubled health trust

The former police chief who investigated mental health services in a crisis-hit health board was “shocked” by the poor working relationships and “blame shifting” he uncovered.
David Strang, who led the independent inquiry into the issues in NHS Tayside, said staff felt isolated and unsupported and people complained about each other’s practices without coming together to sort the issues out.
He described asking staff questions based on information he had received and being met with the response: “Who told you?” He added: “A lot of staff felt there was a real blame culture and that risk and blame fell to the front line.”
Read full story (paywalled)
Source: 6 February 2020, The Times
Sam
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.