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Patient Safety Learning

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  1. Patient Safety Learning
    More than a dozen trusts have changed their maternity IT system – or are in the process of doing so – following a national patient safety alert.
    NHS England issued the alert  in December, after a fault was discovered with the Euroking maternity EPR, supplied by Magentus Software. It said information recorded in the EPR could overwrite previously recorded data, meaning the system could mislead clinicians.
    While no cases of patient harm have been reported, NHSE instructed trusts using the system to “consider if Euroking meets their maternity service’s needs” and “ensure their local configuration is safe” by June.
    A spokesperson for Euroking said: “We have identified a solution to the issues raised in the NPSA [alert], which has been shared with NHSE and with our customers. We’re now meeting each customer and are working with them individually to support the changes that need to be made based on their local configurations. We will continue working with the trusts to support them meeting the deadline outlined in the NPSA.
    “As the NPSA outlined, it has been issued as a precautionary measure and there is no evidence of harm being caused to patients.”
    Read full story (paywalled)
    Source: HSJ, 12 April 2024
    Related reading on the hub:
    NHS England warns electronic patient record could pose ‘serious risks to patient safety’: what can we learn?  
  2. Patient Safety Learning
    A man who suffered a psychotic episode which lasted for weeks was not fully informed about potential extreme side-effects of taking steroids medication, England’s health service Ombudsman has found.
    Andrew Holland was prescribed steroids in early January 2022 by Manchester Royal Eye Hospital after losing vision in his left eye and suffering a severe infection in his right eye.
    The 61-year-old from Manchester was given the medication as treatment for eye inflammation, but soon began suffering from disrupted sleep and severe headaches.
    These side-effects developed into more serious ones, including becoming aggressive, psychotic, and inexplicably wandering the street at different times of the day and night.
    After several hospital visits due to his symptoms, Andrew attended Manchester University NHS Foundation Trust’s emergency department in mid-January with a severe headache and later became an inpatient.
    He was diagnosed with steroid induced psychosis, with symptoms including hallucinations, insomnia and behaviour changes.
    Though no failings were found with Manchester University NHS Foundation Trust in prescribing Andrew with steroids for the eye condition, the Ombudsman discovered a missed opportunity to fully inform him of potential extreme side-effects. He was therefore unable to make a fully informed decision about whether to take them or not.
    The Trust apologised for an ‘unsatisfactory experience’. However, the Ombudsman found relevant guidelines were not followed. Moreover, there had been no acknowledgement of mistakes in communication about the side-effects. Nor was any attempt made to correct them.
    Read full story
    Source: PSHO, 10 April 2024
  3. Patient Safety Learning
    There is huge regional variation in the rate at which health systems are preventing patients joining the elective waiting list through “advice and guidance” to GPs, according to analysis by HSJ.
    Some systems – including Northamptonshire – have managed to ramp up these “diverts” to such an extent that they now report around one A&G case to every 3.5 cases cleared from the waiting list through treatment or seeing a consultant.
    This contrasts with others, such as Lancashire and South Cumbria, which only reports one A&G case for every 16 cleared from the waiting list.
    Advice and guidance involves GPs consulting specialists before making direct referrals and around half the time this results in a referral being avoided. The model is set to be a cornerstone of NHS England’s new outpatient transformation strategy, which is due imminently.
    Victoria Tzortziou-Brown, vice chair of the Royal College of GPs, said the analysis “confirms reports we’ve heard from our members – that there is too much regional variation in the use of the ‘advice and guidance’”.
    She added: “Some GPs report that when advice and guidance is properly resourced and well implemented, it can be a helpful tool for improving communications with their colleagues in secondary care.
    “[But] it is clear that more time, funding and capacity needs to be dedicated to allow clinicians to communicate efficiently and effectively whilst respecting professionalism.”
    Read full story (paywalled)
    Source: HSJ, 9 April 2024
    Related reading on the hub:
    Rejected outpatient referrals are putting patients at risk and increasing workload pressure on GPs 
  4. Patient Safety Learning
    Thousands of vulnerable children questioning their gender identity have been let down by the NHS providing unproven treatments and by the “toxicity” of the trans debate, a landmark report has found.
    The UK’s only NHS gender identity development service used puberty blockers and cross-sex hormones, which masculinise or feminise people’s appearances, despite “remarkably weak evidence” that they improve the wellbeing of young people and concern they may harm health, Dr Hilary Cass said.
    Cass, a leading consultant paediatrician, stressed that her findings were not intended to undermine the validity of trans identities or challenge people’s right to transition, but rather to improve the care of the fast-growing number of children and young people with gender-related distress.
    But she said this care was made even more difficult to provide by the polarised public debate, and the way in which opposing sides had “pointed to research to justify a position, regardless of the quality of the studies”.
    “There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour. This must stop.”
    Read full story
    Source: The Guardian, 10 April 2024
  5. Patient Safety Learning
    A former consultant at the Southern Health Trust has told an inquiry into urology services that waiting lists are the "greatest source of patient harm".
    The inquiry was established in 2021 and is examining the trust's handling of urology services prior to May 2020.
    Aidan O'Brien became a consultant urologist in Craigavon Area Hospital in July 1992.
    His work is at the centre of the inquiry.
    Giving evidence on Monday, he said waiting list figures highlighted what "myself and my colleagues [have said] for decades" and described it as a "grossly inadequate service".
    "If you look at four-and-a-half years for urgent surgery, it is appalling," he told the inquiry.
    "I don't have a magic solution to the current situation, which is dire."
    Read full story
    Source: BBC News, 8 April 2024
  6. Patient Safety Learning
    Almost one in three NHS employees have had to take time off work suffering poor mental health in the past year, new research suggests.
    The Unison union said its survey of 12,000 health workers shows the impact of a staffing crisis, with many suffering “burnout”.
    Panic attacks, high blood pressure, chest pains and headaches are among the physical signs of stress reported by nurses, porters, 999 call handlers and other NHS staff who completed the survey.
    The news comes as more than half of the mental health hubs launched for NHS workers after the pandemic have closed since last year, according to the British Psychological Society.
    Unison said workforce pressures are taking a huge toll as staff tackle a waiting list backlog, with many struggling to look after their wellbeing.
    Of those who were off with mental health problems, one in five said they did not tell their employer the real cause of their absence, mainly because they did not feel their manager or employer would be supportive.
    The union said staff feel undervalued and frustrated, with many quitting for less stressful jobs that pay more.
    Read full story
    Source: The Independent, 8 April 2024
  7. Patient Safety Learning
    Thousands of pests including rats, cockroaches and bedbugs have been found at NHS hospitals in England as the health service buckles under a record high repair bill.
    Hospital bosses are having to spend millions of pounds on pest control after discovering lice, flies and rodents in children’s wards, breast clinics, maternity units, A&E departments and kitchens, in the most graphic illustration yet of the dismal and dangerous state of the NHS estate.
    NHS bosses have repeatedly warned ministers of the urgent need to plough cash into fixing rundown buildings in order to protect the safety and dignity of patients and staff. The maintenance backlog now stands at £11.6bn in England.
    Figures obtained under freedom of information laws and reviewed by the Guardian suggest the NHS is struggling to cope with an army of pests plaguing decrepit hospitals.
    There were more than 18,000 pest incidents in the last three years, the NHS data reveals. There were 6,666 last year, equivalent to 18 a day. The figures also show NHS bosses are having to spend millions of pounds calling out pest control and dealing with infestations, with £3.7m spent in the last three years.
    Read full story
    Source: The Guardian, 9 April 2024
  8. Patient Safety Learning
    Black and Asian people who spot cancer symptoms are taking twice as long to be diagnosed as white people, a shocking new study shows.
    Research by Bristol Myers Squibb (BMS) and Shine Cancer Support shows that people from minority ethnic backgrounds face an average of a year’s delay between first noticing symptoms and receiving a diagnosis of cancer.
    These groups report more negative experiences of cancer care than white people, limited knowledge about the diseases and lack of awareness of support services, which all contribute to later diagnostic rates.
    “In a year that’s revealed that the UK’s cancer survival lags behind comparable countries, I am saddened but unsurprised that people from minority ethnic groups face additional hurdles that delay their diagnosis.” said Ceinwen Giles, co-ceo of Shine Cancer Support.
    “We know that catching cancer earlier saves lives, yet with year long waits for some people, collaborative efforts between health leadership, advocacy groups and the pharmaceutical industry are required.”
    Read full story
    Source: The Independent, 9 April 2024
  9. Patient Safety Learning
    NHS staff including ambulance workers, porters, nurses and cleaners have been shown pornographic images, offered money for sex, and assaulted at work, according to new research.
    The widespread incidents of sexual harassment are revealed in a wide-ranging survey published by the Unison union on the first day of its annual health conference in Brighton.
    In the study of more than 12,200 health workers, one in 10 reported unwanted incidents including being touched or kissed, demands for sex in return for favours, and derogatory comments.
    Royal College of Nursing chief nurse Professor Nicola Ranger said: “These figures paint an incredibly disturbing picture."
    In the survey, sexual assault was reported by 29% of respondents who had experienced harassment, while half said they have been leered at or been the target of suggestive gestures.
    One in four who had been harassed said they have suffered unwelcome sexual advances, propositions or demands for sexual favours.
    Half the staff had not reported sexual harassment to their employer, amid concerns of being considered “over-sensitive” or feeling complaints would not be acted on.
    Read full story
    Source: BBC News, 8 April 2024
  10. Patient Safety Learning
    NHS leaders have warned that Royal Mail’s plans to cut second-class deliveries to two days a week could risk patient safety.
    The changes are part of wider measures announced by Royal Mail’s parent company, International Distributions Services (IDS), including cuts of up to 9,000 routes, which could take more than two years to implement, saving £300m a year. IDS has assured the Royal Mail workforce that there will be no compulsory redundancies and they will request only 100 voluntary redundancies.
    In a letter sent to the Telegraph, executives from the NHS, Healthwatch England, the Patients Association and National Voices said the Royal Mail proposals would increase the cost of missed appointments, which already exceeds £1bn.
    The letter said: “Provisional Healthwatch data suggest that more than 2 million people may have missed medical appointments in 2022-23 due to late delivery of letters, and this will only deteriorate under the proposed new plans.”
    Sir Julian Hartley, the chief executive of NHS Providers, said the proposed delays were “extremely unhelpful”.
    “It’s really important that patients be updated at the earliest opportunity on developments in their care and treatment,” he said.
    “An efficient, punctual postal service remains a key part of that process. At a time when far too many patients already face long delays – the last thing any trust leader wants – anything that adds to that uncertainty, and possibly the worsening of conditions, would be extremely unhelpful.”
    Jacob Lant, the chief executive of health charity National Voices, said: “The proposals being consulted on risk further delaying vital communications and worsening digital exclusion, therefore unfairly widening health inequalities. NHS mail must remain a priority service.”
    Read full story
    Source: The Guardian, 6 April 2024
  11. Patient Safety Learning
    People with long Covid have evidence of continuing inflammation in their blood, which could help understanding of the condition and how it may be treated, a UK study suggests.
    It found the presence of certain proteins increased the risk of specific symptoms, such as fatigue, in people sick enough to need hospital treatment.
    It is unclear whether milder cases of Covid have the same effect on the body.
    A test remains a long way off - but the findings may prompt future trials.
    Read full story
    Source: BBC News, 8 April 2024
    Related reading on the hub:
    Top picks: 12 research papers on Long Covid
  12. Patient Safety Learning
    The Care Quality Commission’s assessments of integrated care systems (ICSs) have been put on hold at the last minute, as the government declined to sign off on the process.
    They were due to begin this month, following pilots in Birmingham and Solihull and Dorset ICSs, but the Care Quality Commission (CQC) has put the brakes on assessments elsewhere until it receives government approval.
    Under the legislation brought in when ICSs were set up in 2022, the CQC can review and assess systems, but ministers must approve its methodology.
    Interim chief inspector of adult social care and integrated care James Bullion wrote to integrated care board chiefs this week stating that, following discussions with the Department of Health and Social Care, the CQC had agreed to a “short delay… to allow for further refinements to our approach”.
    He added: “In particular we have been working with NHS England on their strengthened approach to performance evaluation and rating of the ICB elements of the ICS which we will take into account as evidence for our scoring and reporting approach.”
    Read full story (paywalled)
    Source: HSJ, 8 April 2024
  13. Patient Safety Learning
    Eight hospitals in England have fire safety warnings attached to them, with half in place since 2022 or earlier, HSJ can reveal.
    All are enforcement notices issued by fire brigades when serious risks are not being managed. Issues raised include risk assessments, maintenance, and emergency routes.
    There were more than 1,300 fires across the NHS trust estate in 2022-23, according to official estates data, which was an increase of 18% on the year before.
    NHS Providers deputy chief executive Saffron Cordery said the figures highlighted the “urgent need” to address maintenance backlog – which includes fire safety – across the NHS estate. The overall backlog figure has been growing yearly and is approaching £12bn.
    Ms Cordery said: “Greater capital investment is essential to enabling a safe environment for patients and staff.”
    Rory Deighton from NHS Confederation said more than a decade of underinvestment was behind the “dilapidated” state of the NHS estate.
    Read full story (paywalled)
    Source: HSJ, 5 April 2024
  14. Patient Safety Learning
    Healthcare workers' perceptions of safety at their organisations is improving, though a gap still remains between senior leaders and front-line workers, according to a Press Ganey report.
    Press Ganey surveyed more than 1 million employees from 200 health systems in the USA in 2023. The poll included 19 questions related to safety culture across three domains: prevention and reporting, pride and reputation, and resources and teamwork.
    Three takeaways:
    Staff safety culture scores have risen from an all-time low of 3.96 (out of 5) in 2021 to 4.01 in 2023. This increase was largely driven by improvements around staff members' perceptions of resources and teamwork, including views on adequate unit staffing. "While these improvements are encouraging, there's still a lot of work to do," Press Ganey said. "Pre-pandemic rates were never the desired end state, and it’s important to note that nearly half (48.5%) of employees still have a low perception of safety culture."  Senior management reported the highest perceptions of safety culture at 4.53, while registered nurses and advanced practice providers reported the second- and third-lowest at 3.95 and 3.92, respectively. Security team members had the lowest perceptions of safety at 3.91. large gap was also seen between senior leaders and registered nurses regarding perceptions of workplace violence protections. Senior management gave their organizations a 4.30 out of 5 for having strong security measures in place to prevent violence, compared to just 3.36 for nurses.  Read full story
    Source: Becker's Hospital Review, 3 April 2024
  15. Patient Safety Learning
    Climate change presents one of the most significant global health challenges and is already negatively affecting communities worldwide. Communicating the health risks of climate change and the health benefits of climate solutions is both necessary and helpful. To support this, the World Health Organization (WHO) in collaboration with partners has developed a new toolkit designed to equip health and care workers with the knowledge and confidence to effectively communicate about climate change and health.
    The toolkit aims to fill the gaps in knowledge and action among health and care workers – all those who are engaged in actions with the primary intent of enhancing health, as well as those occupations in academic, management and scientific roles. Despite their recognized trustworthiness and efficacy as health communicators, many health and care workers might not be fully equipped to discuss climate change and its health implications. This toolkit seeks to change that narrative.
    “Health and care workers play a key role in addressing climate change as a health crisis. Their unique position enables them to raise awareness, advocate for policy changes, and empower communities to mitigate and adapt to climate change,” said  Dr Maria Neira, Director, Department of Environment, Climate Change and Health. “By engaging in dialogue and action, health and care workers can catalyse efforts to safeguard human health as well as ensuring a resilient and sustainable future for all.”
    Read full story
    Source: WHO, 22 March 2024
  16. Patient Safety Learning
    A trust has appointed a chair to lead an independent review into dozens of suicides that was sparked by allegations of record tampering.
    Following questions from HSJ about the review’s chair and terms of reference, Cambridgeshire and Peterborough Foundation Trust said Ellen Wilkinson, a former medical director at Cornwall Partnership FT and its current chief clinical information officer, would chair the review. 
    The trust, which is looking for a substantive CEO following Anna Hills’ departure earlier this year, said the review “will not examine individual patient deaths but will take a thematic approach and look at the learnings we can take from these tragic incidents”.
    The trust told HSJ the terms of reference for the review of more than 60 cases of patients who died by suicide since 2017 were still being finalised.
    The decision not to investigate individual cases has been criticised by the whistleblower whose concerns prompted the review in the first place, as HSJ reported in October.
    While an employee of the trust, Des McVey, a consultant nurse and psychotherapist, carried out an investigation in July 2021 into the case of 33-year-old Charles Ndhlovu, who died by suicide in 2017.
    Mr McVey told HSJ his review found Mr Ndhlovu’s patient record had been tampered with and “his care plans were created on the day after his death” – a conclusion he stands by.
    Read full story (paywalled)
    Source: HSJ, 3 April 2024
  17. Patient Safety Learning
    Patient safety in the Accident & Emergency unit at the Queen Elizabeth University Hospital in Glasgow will be reviewed by an NHS watchdog.
    Healthcare Improvement Scotland (HIS) was first contacted by 29 A&E doctors in May 2023 warning that safety was being "seriously compromised".
    HIS last month apologised for not fully investigating their concerns.
    The review will consider leadership and operational issues and how they may have impacted on safety and care.
    In the letter to HIS, the 29 consultants highlighted treatment delays, "inadequate" staffing levels and patients being left unassessed in unsuitable waiting areas.
    They claimed this resulted in "preventable patient harm and sub-standard levels of basic patient care".
    The doctors also said critical events had occurred including potentially avoidable deaths.
    The consultants said repeated efforts to raise the issues with health board bosses "failed to elicit any significant response".
    Read full story
    Source: BBC News, 4 April 2024
  18. Patient Safety Learning
    The General Medical Council (GMC) has relaxed its fitness to practise (FTP) processes for doctors so that ‘minor’ concerns such as ‘pushing a colleague’ are not taken to tribunal. 
    In an update to its guidance, the regulator has given FTP decision makers and case examiners ‘more discretion’ to throw out complaints if they represent a lower risk to public protection. 
    Concerns which are ‘minor in nature and did not impact patient care’ will fall under this guidance.
    This is part of the GMC’s efforts to carry out ‘more efficient and proportionate investigations’ and to ‘minimise’ stress for doctors during the FTP process. 
    Two examples of concerns which will no longer need to be investigated, if there are ‘no aggravating factors’,  are:
    A doctor giving false details to a market research company, in order qualify for free products. A doctor pushing a colleague out the way following a heated argument.  The regulator has said: "Decision makers will now be able to weigh the full circumstances of a concern earlier in the fitness to practise process to assess the overall risk to public protection including to public confidence in the profession– meaning some concerns may not need to be investigated or referred to a tribunal."
    However, the guidance, which covers concerns relating to violence and dishonesty, emphasises that allegations which raise a risk to public protection will continue to be investigated. 
    Read full story
    Source: Pulse, 4 April 2024
  19. Patient Safety Learning
    A new private ambulance service will offer faster travel to A&E for those caught out by half-day waits for NHS ambulances, The Independent can reveal, in a sign of a growing “two-tier” health service.
    MET Medical ambulance service will begin by charging £99 for a call-out, and could serve thousands of people a week, its chief executive Dave Hawkins has said.
    Mr Hawkins, who is a paramedic himself, said he launched the service after seeing his elderly relatives wait too long for NHS ambulance services following falls.
    It comes as waiting times for ambulance service reached a crisis point in the last year, with frail and vulnerable people waiting hours for an ambulance.
    Ambulance response times hit record highs over 2022-23, with people who should have an ambulance within 20 minutes waiting an hour and 30 minutes in December 2023.
    According to estimates from the Association of Ambulance Chief Executives, 34,000 patients were likely to have suffered harm due to these delays – this hit a high of more than 60,000 in December 2022.
    MET Medical will still have to wait to deliver patients if they are seen as a priority, but it said its patients are likely to be lower priority and can be dropped at A&E without waiting for a handover.
    Mr Hawkins said vulnerable patients waiting for an ambulance can wait up to 12 hours.
    “It’s that moment when you’re out of options, it’s really a horrible place to be, particularly if it’s a loved one … It is a shame, like we’ve seen from the stats and everything, that the health service is failing us."
    Read full story
    Source: The Independent, 3 April 2024
  20. Patient Safety Learning
    Almost 10 million people across England could be waiting for an NHS appointment or treatment, 2 million more than previously estimated, according to a survey by the Office for National Statistics (ONS).
    The ONS survey of about 90,000 adults found that 21% of patients were waiting for a hospital appointment or to start receiving treatment on the NHS.
    When extrapolated, this equates to 9.7 million people. In January, the waiting list stood at 7.6 million, according to official NHS statistics.
    The survey found that the delays were most prominent among 16-24-year-olds, one in five of whom said they had experienced waiting times of more than a year.
    Conducted in January and February, the survey was part of the annual winter coronavirus infection study of adults aged 16 and over.
    The ONS said the survey was the first of its kind to assess the experiences of adults awaiting hospital appointments, tests or medical treatments. It said the data was experimental, based on self-reported data, and may differ from other statistics on waiting lists.
    Read full story
    Source: The Guardian, 3 April 2024
  21. Patient Safety Learning
    The NHS is experiencing an “avalanche of need” over autism and attention deficit hyperactivity disorder (ADHD), but the system in place to cope with surging demand for assessments and treatments is “obsolete”, a health thinktank has warned.
    There must be a “radical rethink” of how people with the conditions are cared for in England if the health service is to meet the rapidly expanding need for services, according to the Nuffield Trust.
    The thinktank is calling for a “whole-system approach” across education, society and the NHS, amid changing social attitudes and better awareness of the conditions. It comes days after the NHS announced a major review of ADHD services.
    Thea Stein, the chief executive of the Nuffield Trust, said: “The extraordinary, unpredicted and unprecedented rise in demand for autism assessments and ADHD treatments have completely overtaken the NHS’s capacity to meet them. It is frankly impossible to imagine how the system can grow fast enough to fulfil this demand.
    “We shouldn’t underestimate what this means for children in particular: many schools expect an assessment and formal diagnosis to access support – and children and their families suffer while they wait.”
    Read full story
    Source: The Guardian, 4 April 2024
  22. Patient Safety Learning
    Trusts could be exposed to increased negligence claims as a result of new NHS England guidance for a rare spinal condition, a royal college has claimed.
    The Royal College of Emergency Medicine (RCEM) has said updated national guidance on treating cauda equina syndrome could also lead to greater “inequity of access” due to issues accessing timely MRI scans at many accident and emergency departments.
    An NHS Resolution report in 2022 found delayed MRI scans were a significant factor in high-value clinical negligence claims, particularly those relating to management of spinal conditions. 
    The guidance issued by NHSE’s Getting It Right First Time programme national pathway guidance says emergency MRIs for suspected CES should be taken within four hours of requests to radiology, and where this is not possible, “standard operating procedures” involving local spinal and radiology services should be in place for urgent out-of-hours scanning. Local provision for this “must be in place by June 2024,” the guidance says.
    NHSE said the GIRFT guidance has been endorsed by 11 clinical and patient bodies, including the Royal College of Radiologists and the Spinal Injuries Association.
    But RCEM, understood to be the only clinical body not to endorse the guidance, has issued a position statement last month stating that “few EDs, outside of tertiary centres, have access to 24/7 MRI scanning”.
    Read full story (paywalled)
    Source: HSJ, 3 April 2024
  23. Patient Safety Learning
    The new NHS gender identity clinics for young people are “understaffed” and “nowhere near ready”, it was claimed on Monday as they officially started taking on patients.
    A London hub, alongside a second in the northwest, will begin to see patients this week as they replace the Gender Identity Development Service (Gids) at the Tavistock and Portman NHS Foundation Trust.
    The Gids clinic was ordered to close after a review by Dr Hilary Cass found it was “not a safe or viable long-term option”.
    However, whistleblowers described as senior staff at Gids have expressed concerns about the preparedness and expertise of the new hubs, just as they open.
    One, who spoke to the i newspaper under the condition of anonymity, said: “It’s been shoddy, disorganised, messy and unclear. And at times, it’s felt unsafe.”
    Read full story (paywalled)
    Source: The Times, 1 April 2024
  24. Patient Safety Learning
    Drugs are a cornerstone of medicine, but sometimes doctors make mistakes when prescribing them and patients don’t take them properly.
    A new AI tool developed at Oxford University aims to tackle both those problems. DrugGPT offers a safety net for clinicians when they prescribe medicines and gives them information that may help their patients better understand why and how to take them.
    Doctors and other healthcare professionals who prescribe medicines will be able to get an instant second opinion by entering a patient’s conditions into the chatbot. Prototype versions respond with a list of recommended drugs and flag up possible adverse effects and drug-drug interactions.
    “One of the great things is that it then explains why,” said Prof David Clifton, whose team at Oxford’s AI for Healthcare lab led the project.
    “It will show you the guidance – the research, flowcharts and references – and why it recommends this particular drug.”
    Read full story
    Source: The Guardian, 31 March 2024
  25. Patient Safety Learning
    Catherine O’Connor was 17 when she died, having lost 14 litres of blood during high-risk surgery on her back.
    At her inquest, the surgeon who operated on her, John Bradley Williamson, told the coroner the procedure at Salford Royal Hospital in Greater Manchester had “progressed uneventfully” and “the blood loss was perhaps a little higher than one would usually anticipate but was certainly not extreme”. The coroner recorded a verdict of death by misadventure.
    Now Greater Manchester police are examining O’Connor’s death, in February 2007, and whether Williamson misled the coroner during the inquest in September that year.
    Catherine's family are now demanding a new inquest into her death in 2007.
    This is because in the days after O’Connor’s death, Williamson sent an internal letter to the head of the hospital’s haematology department, Simon Jowitt, describing the surgery as “difficult” and having involved “a catastrophic haemorrhage”. Williamson had also ignored advice to have a second surgeon present during the operation.
    Officers led by Detective Inspector Michael Sharples have commissioned two expert reports and sought advice from the Crown Prosecution Service ahead of a meeting with the coroner, who has been asked to consider reopening O’Connor’s inquest.
    Read full story (paywalled)
    Source: The Times, 31 March 2024
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