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

Bullying and toxic culture at one of England's largest NHS trusts

Repeated cases of bullying and a toxic environment at one of England's largest NHS trusts have been found in a review.
The Bewick report was ordered after a BBC Newsnight investigation heard from staff at University Hospitals Birmingham (UHB) saying a climate of fear had put patients at risk.
A first phase of the rapid review, headed by independent consultants IQ4U and led by Prof Mike Bewick, was published Tuesday.
It is one of three major reviews into the trust, commissioned following a series of reports by Newsnight and BBC West Midlands in which current and former staff raised concerns.
Summarising the findings, Prof Bewick, a former NHS England deputy medical director, said: "Our overall view is that the trust is a safe place to receive care.
"But any continuance of a culture that is corrosively affecting morale and in particular threatens long-term staff recruitment and retention will put at risk the care of patients across the organisation - particularly in the current nationwide NHS staffing crisis.
"Because these concerns cover such a wide range of issues, from management organisation through to leadership and confidence, we believe there is much more work to be done in the next phases of review to assist the trust on its journey to recovery."
The West Midlands trust said it fully accepted the report's recommendations.
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Source: BBC News, 28 March 2023
Patient Safety Learning

Hospital at centre of rape and death inquiries to close after investigation by The Independent

A scandal-hit children’s mental health hospital will close months after an investigation by The Independent uncovered claims of poor care and systemic abuse.
Taplow Manor hospital, in Maidenhead, was threatened with closure by the NHS safety watchdog, the Care Quality Commission, only last week if it failed to make improvements following a damning report.
Active Care Group, which runs the hospital, confirmed it would close by the end of May, saying a decision by the NHS to stop admitting patients had rendered its “service untenable”.
The move comes after an investigation by The Independent and Sky News heard from more than 50 patients who alleged “systemic abuse” by the provider, while Taplow Manor is facing two police probes – one into a patient death and a second into the alleged rape of a child involving staff.
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Source: The Independent, 29 March 2023
Patient Safety Learning

Mothers and babies being put at risk due to unsafe NHS maternity services, report says

Mothers and babies are being put at risk because maternity services are still providing unsafe care, despite a series of scandals that have cost lives, the NHS ombudsman has warned.
More tragedies will occur unless the health service takes decisive action to put an end to repeated and deeply ingrained problems which lead to “the same mistakes over and over again”, he said.
Rob Behrens, the NHS ombudsman for England, voiced his concerns when he launched a report on Tuesday which details the failings several women experienced while giving birth. It also sets out the lessons the NHS needs to learn, but Behrens claimed that too many trusts were not doing so.
Behrens voiced alarm that, although efforts have been made to improve the care mothers and their children receive, progress is too slow – and that means patients remain in danger.
His report says that: “We recognise that people working in maternity services want to provide high-quality care. Culture, systems and processes can get in the way of achieving that goal.
“But improvements are not happening quickly enough, and we have not seen sustainable change. We must do more to make services safer for everyone.”
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Source: The Guardian, 28 March 2023
Further reading on the hub:
Patient Safety Learning - Mind the implementation gap: The persistence of avoidable harm in the NHS  
Patient Safety Learning

Assisted dying inquiry hears people in UK face ‘unbearable suffering’

People dying in the UK face “uncontrollable” pain and “unbearable suffering”, which palliative care alone cannot fix, according to the first evidence to a major new parliamentary inquiry asking if assisted dying should finally be legalised.
In a shocking submission in favour of a law change, Molly Meacher told the Commons health and social care committee that the reality of end of life could include vomiting faeces, endless nausea and decaying tumours that smelled so bad they drove people out of hospital wards.
People “are existing, they’re not living”, the crossbench peer and chair of the charity Dignity in Dying told the committee inquiry, which comes eight years after the House of Commons last considered changing legislation in 2015.
Arguing strongly against any law change, Ilora Finlay, a crossbench peer and palliative care physician warned of the risk of “elder abuse” being worsened by a law change and said wider availability of palliative care, which remains patchy in the UK, must instead be a priority.
Charles Falconer, a Labour peer and former Lord Chancellor, described the current situation, where dying people sometimes withdraw their own treatment rather than taking drugs to end their life, as “a mess”. He proposed that assisted dying should be available only to terminally ill people and not those facing “unbearable suffering”, as others have suggested. A diagnosis would be needed from two doctors plus approval from high court judge.
“The bills that have been proposed [previously but defeated] say the person who decides to have an assisted death must have the capacity to make that decision,” he said.
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Source: The Guardian, 28 March 2023
Patient Safety Learning

Febrile seizures: Health bodies called to take action to prevent child deaths

An inquest report into the death of a young boy who died at home in his sleep has called for health bodies to take action to prevent further deaths.
Louis Rogers' death was initially categorised as Sudden Unexplained Death in Childhood (SUDC) but the report recorded febrile seizures contributed.
The recommendations include:
A greater emphasis on medical education, research and public information for sudden unexpected deaths associated with febrile seizures Referrals for assessment of febrile seizures should be undertaken earlier to exclude more severe underlying illnesses The NHS website and pamphlet given to parents and guardians following a child's febrile seizure should be updated to help assist them in picking up potential early indicators of a more severe illness "Robust national guidance" and education should be given to GPs so that timely referrals could be made A checklist should be provided for health practitioners so that a child was not given a misdiagnosis of a febrile seizure Records of all contact with health practitioners - including GPs and paramedics - should be available for all The recommendations were made to six health authorities: Royal College of Paediatricians, Joint Royal Colleges Ambulance Liaison Committee, National Institute for Health and Care Excellence (NICE), Royal College of General Practice, Royal College of Emergency Medicine and NHS England.
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Source: BBC News, 29 March 2023
 
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