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Patient Safety Learning

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  1. Patient Safety Learning
    Tens of thousands of people infected with coronavirus were incorrectly given the all clear by England’s Lighthouse Laboratories, a High Court trial will be told next week.
    Court documents seen by The Independent show the labs are accused of unfairly selecting software that was shown in a test to produce significant numbers of errors and false negatives, samples that should have been positive or classed as needing to be re-taken.
    The two companies behind the Lighthouse Labs in England – Medicines Discovery Catapult Ltd and UK Biocentre Ltd – are accused of treating British company, Diagnostics.ai unfairly and giving preferential treatment to Belgian company UgenTec, despite the British firm’s software performing better in the test.
    The case, first revealed by The Independent in June, also includes a judicial review of the procurement decision against health secretary Matt Hancock – one of the first court hearings over the procurement processes followed by the government since the start of the pandemic.
    The Independent understands lawyers for Diagnostics.ai will accuse the laboratories of choosing a software solution that went on to produce tens of thousands of incorrect results which will have led to infected people going about their normal lives while at risk of spreading the virus.
    In June, UgenTec chief executive Steven Verhoeven told The Independent the suggestion its software had made errors was “incorrect”.
    The Department of Health refused to comment on the legal action but said in June that the UgenTec software had been used for several months and was subject to quality assurance processes, though it did not give any further details.
    Mr Justice Fraser will hear opening arguments in the case on Monday at the High Court.
    Read full story
    Source: The Independent, 25 September 2020
  2. Patient Safety Learning
    An NHS trust has been criticised for advising pregnant women to stay at home for as long as possible during labour to increase the chances of a “normal birth”. University Hospitals Bristol NHS Trust also suggested mothers should avoid having epidurals or inductions and should try to have a home birth.
    The advice has been described as “shocking” by experts, who said the guidance was contrary to evidence and could be “dangerous” for mothers and babies. Others criticised the language used by the trust which suggested women who needed medical help were somehow “abnormal”.
    Earlier this month, the Bristol trust paid out £5.8m in compensation to the family of a six-year-old boy after he was left brain damaged at birth following complications during labour.
    After being contacted by The Independent, the trust deleted the childbirth advice from its website and accepted it was “outdated”.
    Read full story
    Source: The Independent, 13 February 2020
  3. Patient Safety Learning
    The number of patients stuck in hospitals because they could not be transferred is at its highest quarterly level since 2017, reversing years of progress amid ongoing crises in health and care services.
    “Delayed transfers of care” – often known as “bed blocking” – rose in the mid-2010s as austerity hit council-run adult-care services, meaning hospitals were unable to discharge patients into the community.
    The number of “delayed days” in the NHS increased from an average of 114,000 a month in 2012 to more than 200,000 in October 2016, before extra funding and higher council taxes brought the numbers back down.
    But the latest NHS figures show the problem is returning. December 2019 saw 148,000 delayed days across England, 15% higher than the same month a year earlier. The combined figures for the last quarter of 2019 were the highest in two years.
    Read full story
    Source: The Guardian, 23 February 2020
  4. Patient Safety Learning
    The number of nurses in schools has fallen in recent years, prompting fears that pupils’ lives are being put “at risk”. 
    Teaching assistants are being asked to carry out medical interventions, such as injections, without adequate training or support, the GMB union, which represents school staff, has said. 
    Data, obtained by the GMB union through a Freedom of Information request, shows the number of school nurses has fallen by 11 per cent in four years – from 472 in 2015 to 420 in 2018.
    Karen Leonard, National Schools Officer at the GMB union, said: “The uncomfortable truth is that in too many schools children are not getting the medical support they need.”
    Ms Leonard added: “School staff should not administer medicine unless they feel fully confident in their training and lines of accountability, but often they are placed in uncomfortable situations."
    “This is a highly stressful state of affairs for children, parents, and staff, who fear they will be blamed if something goes wrong. It is not alarmist to say that lives are at risk.”
    Read full story
    Source: The Independent, 23 February 2020
  5. Patient Safety Learning
    An ambulance trust has appointed a former senior trust executive to lead an independent investigation into the circumstances surrounding the unexplained death of a staff member, HSJ  has learned.
    East of England Ambulance Service Trust also shared the terms of reference for the investigation withHSJ, which follows the trust being forced to launch a similar probe in 2020 after three young staff members died in 11 days in December 2019.
    The latest investigation is into the death of Nick Lee, 46, from Ovington in west Norfolk, who died on 3 December 2021. Mr Lee was an operations manager for the trust in the west Norfolk area and had worked for the trust for nearly 20 years. The cause of death is yet to be officially established.
    Margaret Pratt has been appointed by the trust to lead the investigation. 
    A trust statement issued to HSJ said: “The purpose of the investigation is to look at the events leading up to the death, review the circumstances of the death and consider whether there is anything that the trust can learn to contribute to improving the support provided to staff.”
    The investigation follows a prolonged period of years in which the trust has been dogged by high-profile and deeply ingrained cultural and bullying problems.
    Read full story (paywalled)
    Source: HSJ, 29 March 2022
  7. Patient Safety Learning
    The new version of the government’s contact tracing app will give users a ‘risk score’ based on how many people they interact with and where they live.
    The news comes as the Department of Health and Social Care launches a trial for the latest model of the contact tracing app, two months after the initial version was scrapped. 
    According to the DHSC, the new app will tell users whether their risk of contracting coronavirus is unknown, low or high based on how many people they are in significant contact with. They will also be told what the coronavirus risk level is in their local authority area and will be alerted if it changes.
    Government guidance said the risk levels and alerts will be based on a local authority watchlist – which highlights areas that are of particular concern across the country, based on the number of coronavirus cases.
    People will also be able to check into venues – such as restaurants, pubs and leisure centres – using the app by scanning a QR code. If there is then an outbreak in a venue those who have checked in via the app will be alerted and told to isolate.
    The new NHS Test and Trace app trial was launched today for residents on the Isle of Wight and will expand to the London borough of Newham next week.
    Read full story (paywalled)
    Source: HSJ, 13 August 2020
  8. Patient Safety Learning
    Patient safety is at risk in “crumbling” NHS mental health hospitals starved of the money needed to improve dilapidated buildings, new data has revealed.
    Hundreds of vulnerable mentally ill patients are still being cared for in 350 old dormitory-style wards, 20 years after the NHS was told to provide all patients with en-suite rooms. A lack of funding to refurbish hospitals has also meant too many wards still have ligature points that patients can use to try to harm themselves.
    NHS leaders said the lack of cash from the government meant they could not deal with warnings issued by the Care Quality Commission (CQC), the sector’s watchdog.
    A survey of mental health trust leaders by NHS Providers has now found bosses are worried the state of psychiatric wards is undermining their ability to keep patients safe.
    Read full story
    Source: The Independent, 20 February 2020
  9. Patient Safety Learning
    A privately run mental health hospital put in special measures last year has been rated “inadequate” again following a fresh Care Quality Commission inspection.
    Inspectors raised serious concerns about unsafe ward environments and staff not managing patient risks at the Priory Hospital Arnold, which has beds commissioned by Nottinghamshire Healthcare Foundation Trust.
    Inspectors said that while the leadership team was experienced, the registered manager had been in post since April last year and the improvements they had made “had not been fully embedded”.
    The registered manager had changed after the service was placed in special measures.
    Ligature risks were found in patients’ bathrooms despite the provider making “some progress” and undertaking “substantial work” to remove them, the CQC said.
    And in one instance, a patient had tried to harm themselves with a plastic bag which was a restricted item on the ward. 
    CQC head of hospital inspection for mental health and community services Craig Howarth said staff “had not followed the patient’s risk assessment” and had not searched the patient on their return from a visit off the ward.
    He added: “It was also concerning that despite rotas showing enough staff were available across the hospital, staff gave examples of when a lack of staffing had impacted on patient care and safety.
    “Despite the measures in place, the risks to patients were not reduced and there was evidence of incidents of harm to patients.”
    Read full story (paywalled)
    Source: HSJ, 15 March 2022
  10. Patient Safety Learning
    Former patients of rogue breast surgeon Ian Paterson may have died of “unnatural deaths” two senior coroners have said.
    Senior coroner for Birmingham and Solihull, Louise Hunt, and area coroner Emma Brown have said they believe there is evidence to suspect victims of Ian Paterson, who was jailed for 17 counts of wounding with intent in 2017, died unnaturally as a result of his actions.
    They now plan to open four inquests into the deaths of patients who died from breast cancer after being treated by Paterson.
    “Following preliminary investigations, the senior and area Coroner believe there is evidence to have reason to suspect that some of those deaths may be unnatural. In accordance with the Coroners and Justice Act 2009, inquests will now be opened in relation to four former patients of Mr Paterson.”
    Deborah Douglas, a victim of Paterson who leads a support group in Solihull, told The Independent: "I have spoken to so many women over the years who have since died. This is what I have always known and fought for.
    "Paterson lied about pathology reports and people did develop secondary cancers."
    Read full story
    Source: The Independent, 4 July 2020
  11. Patient Safety Learning
    The care model run by independent sector mental health and learning disability hospitals is ‘inherently risky’, a Care Quality Commission (CQC) chief inspector has warned.
    Speaking at the NHS Providers conference, Ted Baker, chief inspector of hospitals for the Care Quality Commission, unveiled the regulator’s plans to change how it inspects health and care services.
    When asked by HSJ how its new “streamlined” approach would be applied to inpatient units run by the independent sector for people with mental health and learning disability, Professor Baker said: ”One of the things we’ve been doing during the pandemic, and will continue in our transitional approach, is target risk. And one of the risks we have been targeting is exactly this, patients with learning disability and/or autism in some of these small units that have got closed cultures."
    “I think we do recognise that model of care is an inherently risky model of care and so we have been inspecting many of those under this risk driven model and taking action against many of them.
    But there is ongoing concern about that model of care and in a few weeks’ time we will be publishing a report on our assessment of that model of care and the importance of it being changed for the benefit of the people being looked after. The model of care needs to be improved but we need to make sure we are tackling the risk.”
    The chief’s comments come ahead of the regulator’s state of care report, which is due to be published next week.
    In its report published last year the CQC highlighted a concern regarding the quality and safety of independent learning disability and autism units. In particular it warned these were at a higher risk of developing closed cultures. 
    Read full story (paywalled)
    Source: HSJ, 7 October 2020)
  12. Patient Safety Learning
    A “critical” shortage of lung specialists may leave the NHS struggling to cope with a spike in hospital admissions related to complications of pneumonia and flu this winter, the British Thoracic Society (BTS) has warned.
    At its winter meeting this week (taking place 4-6 December), the society presented results from a survey it conducted of almost 250 UK NHS respiratory specialists. Some 83% of respondents (199) thought respiratory healthcare staff shortages would impair the ability of the NHS to cope with the increase in lung disease hospital admissions this winter.
    Read full story (paywalled)
    Source: BMJ, 4 December 2019
  13. Patient Safety Learning
    Pregabalin may be associated with serious breathing problems in patients with compromised respiratory systems, according to a drug safety alert from the medicines regulator.
    Elderly patients, patients with neurological disease, renal impairment and those who are taking antidepressant medication are also at increased risk of breathing problems from the drug, the Medicines Healthcare Regulatory Agency (MHRA) said (18 February).
    Pregabalin is a medication that has increasingly been prescribed to treat chronic pain, however, it is also used to treat epilepsy, fibromyalgia, restless leg syndrome, and generalised anxiety disorder.
    The use of pregabalin combined with central nervous system depressants such as opioids has been associated with an increased risk of respiratory failure, coma, and deaths since 2018, said the MHRA. However, a recent review of the safety of the drug has found that the use of pregabalin alone can also cause ‘severe’ respiratory depression.
    "The review identified a small number of worldwide cases of respiratory depression without an alternative cause or underlying medical conditions. In these cases, respiratory depression had a temporal relationship with the initiation of pregabalin or dose increase. Other cases were noted in patients with risk factors or underlying medical history. The majority of cases reviewed were reported in elderly patients," the alert said.
    Health professionals have been advised to consider adjustments in dose or dosing regimen are necessary for patients at higher risk of respiratory depression.
    The alert also told them to report suspected adverse drug reactions associated with the use of pregabalin via the Yellow Card website.
    Existing advice asks healthcare professionals to check the patient for a history of drug abuse before prescribing pregabalin and to observe patients who have been prescribed the drug for signs of drug abuse and dependence.
    Read full story
    Source: Pulse, 23 February 2021
  14. Patient Safety Learning
    Inspectors have raised “new and ongoing” patient safety concerns at Shrewsbury and Telford Hospitals Trust, it has emerged.
    The Care Quality Commission has issued a new warning notice to the Midlands trust after an inspection of the hospital earlier this month sparked concerns for the welfare of patients on its medical wards.
    These concerns are separate from the trust’s maternity service, which, it was revealed on Tuesday, is now facing a police investigation alongside an NHS inquiry into more than 1,200 allegations of poor maternity care dating back to the 1970s.
    In October, a patient at the hospital bled to death after a device used to access his bloodstream became inexplicably disconnected while he was receiving care on the renal unit.
    The Health Service Journal reported the latest concerns related to the inappropriate use of bed rails and risks of patients falling from beds after several incidents. The CQC is also concerned about the trust’s use of powers to detain elderly or vulnerable patients on wards.
    The concerns also include patients being at risk of abuse and learning from past incidents not being shared with staff.
    Read full story
    Source: The Independent, 1 July 2020
  15. Patient Safety Learning
    The Care Quality Commission (CQC) has taken immediate enforcement action at East Kent Hospitals University Foundation Trust citing “serious concerns” over patient safety.
    The regulator confirmed it was taking action today after inspectors visited on 12 August following concerns being raised about the standard of care and risk to patients.
    The CQC confirmed the action had been taken, but it said it could not comment further due to legal restrictions and the trust’s right to appeal the decision.
    HSJ understands the enforcement action was taken due to concerns over infection prevention control and the number of patients who have contracted COVID-19 in hospital. It is believed to be the first such action against a trust.
    Read full story (paywalled)
    Source: HSJ, 27 August 2020
  16. Patient Safety Learning
    "I thought she would be safe at Chadwick Lodge,” said Natasha Darbon, recalling how she felt in April 2019 when her 19-year-old daughter, Brooke Martin, was admitted to the mental health hospital in Milton Keynes.
    Eight weeks later, Brooke took her own life.
    The jury at the inquest found that Brooke’s death could have been prevented and that the private healthcare provider Elysium Healthcare, which ran the hospital, did not properly manage her risk of suicide. It also found that serious failures of risk assessment, communication and the setting of observation levels contributed to her death. Elysium accepted that had she been placed on 24-hour observations, Brooke would not have died.
    In 2018, Brooke, who was autistic, was repeatedly sectioned under the Mental Health Act because of her escalating self-harm and suicide attempts. After a spell in an NHS facility in Surrey she moved to Chadwick Lodge, which specialises in treating personality disorders.
    After a few weeks there, Brooke was doing well and staff were pleased with her progress. She was due to move to Hope House, a separate unit at the hospital, to start more specialist therapy for emotionally unstable personality disorder, and was keen to make the switch.
    But then the teenager’s mental health deteriorated again. On 5 June 2019 she tried to kill herself. Five days later she was seen twice that evening secretly handling potential ligatures, but no appropriate action was taken. A few minutes later she was found unresponsive in her room. She received CPR but died the next day in Milton Keynes university hospital.
    After hearing the evidence about the care Brooke received in her final days, Tom Osborne, the coroner at the inquest, took the unusual step of issuing a prevention of future deaths notice. He sent it to Sajid Javid, the health secretary, and to Elysium Healthcare, as the owner of Chadwick Lodge.
    It set out the detailed criticisms that the jury had made of Elysium’s interaction with Brooke after her attempt to take her own life on 5 June. They cited the hospital’s failures to communicate information regarding Brooke’s suicide attempt, to search her room after she was found handling potential ligatures on the night she died, and to place Brooke on constant observations afterwards.
    Read full story
    Source: The Guardian, 24 April 2022
  17. Patient Safety Learning
    A new poll has found only 8 out of the 1,618 respondents believed the health service was ready to deal with an outbreak when asked by The Doctors’ Association UK (DAUK), despite the prime minister’s insistence that the NHS will cope if it is hit by a surge in the number of people falling ill.
    Common concerns included difficulties coping with increased demand, a shortage of beds and poor staffing levels, according to the group who led the poll. 
    Some doctors asked said they were worried that there could be not enough laboratory space to do testing in the case of a pandemic. Others claimed that NHS 111 had been giving out “inappropriate advice” to go to A&E and GP practices, according to DAUK. 
    “The NHS has already been brought to its knees and many frontline doctors fear that our health system simply will not cope in the event of a Coronavirus (Covid-19) outbreak,” Dr Rinesh Parmar, the DAUK chair, said. 
    “Many hoped the threat of Covid-19 would prompt an honest conversation to address the issue of critical care capacity and our ability to look after our sickest patients. By simply saying ‘the NHS is well prepared to deal with coronovirus’ it seems that yet again doctors’ concerns have been brushed under the carpet.”
    The findings come after the number of people infected with the coronavirus which rose to 39 in the UK on Monday. 
    Read full story
    Source: The Independent, 3 March 2020
  18. Patient Safety Learning
    One of the NHS’ most high-profile mental health trusts has ‘multiple’ corporate governance problems and ‘deep-seated’ cultural issues, according to an external review.
    Tavistock and Portman NHS Foundation Trust, which provides mental health, educational and training services in London, commissioned an external firm to look into its leadership amid a period of intense public scrutiny in the latter half of 2021.
    Among cultural issues identified at the trust, which reviewers described as “deep seated”, was a reluctance of staff to speak up about concerns.
    Assessors said a recent employment tribunal, which ruled the trust’s treatment of a whistleblower had damaged her professional reputation and “prevented her from proper work on safeguarding”, had impacted the ability of staff to raise concerns.
    They urged leaders to review their Freedom to Speak Up and whistleblowing procedures. 
    And while reviewers commended board members for commissioning an external review of race equality, they said it had “yielded an outpouring of emotion” which suggested many staff from minority ethnic groups do not feel consistently supported, respected or valued.
    Read full story
    Source: HSJ, 25 January 2022
  19. Patient Safety Learning
    A new £700,000 computer system has been deployed in an intensive care unit at Aberdeen Royal Infirmary. The new Philips system will replace bedside charts, freeing up clinical time and improving patient safety at the NHS Grampian hospital.
    ICU clinical director Dr Iain MacLeod said: “At the heart of this change is patient safety. The system records physical measurements like blood pressure and heart rate as well as blood results and parameters from the various machines used in ICU, such as dialysis machines and ventilators."
    “It will also save on staff time. Currently medical staff members waste lots of time transcribing blood results from a computer onto sheets of paper. The new system allows this to happen automatically. That’s great from a timesaving point of view but more importantly there will be a reduction of errors that can happen when writing something down.”
    Read full story
    Source: FutureScot, 11 November 2019
  20. Patient Safety Learning
    An advanced nurse practitioner working in primary care services at Grimsby Hospital has called on the hospital senior leadership to ‘see for themselves how unsafe it is’.
    The nurse, who has penned a letter to bosses at Northern Lincolnshire and Goole NHS Foundation Trust says they are having “worst experience to date” in their career and fears somebody will die unnecessarily unless something is urgently done.
    “I have never in my whole career seen patients hanging off trolleys, vomiting down corridors, having ECGs down corridors, patients desperate for the toilet, desperate for a drink. Basic human care is not being given safely or adequately," says the nurse.
    Hospital bosses say they are taking the letter seriously and are investigating. Earlier this month it was revealed that some hospitals were being forced to deploy ‘corridor nurses’ in a bid to maintain patient safety while dealing with unprecedented demand.
    Dr Peter Reading, Chief Executive, said: “I can confirm we have received this email and that the hospital and North East Lincolnshire CCG are taking these concerns seriously. The person who raised the concerns with us has been contacted and informed that we are jointly investigating what they have told us.
    Read full story
    Source: Nursing Notes, 22 January 2020
  21. Patient Safety Learning
    A hospital trust at the centre of Britain’s largest ever maternity scandal has widespread failings across departments and is getting worse, the care regulator has warned as it calls for NHS bosses to take urgent action.
    Ted Baker, chief inspector of hospitals, urged NHS England to intervene over the “worsening picture” at Shrewsbury and Telford Hospital Trust, which is already facing a criminal investigation.
    There are as many as 1,500 cases being examined after mothers and babies died and were left with serious disabilities due to poor care going back decades in the trust’s maternity units.
    Now, in a leaked letter seen by The Independent, Prof Baker has warned national health chiefs that issues are still present today across wards at the trust – with inspectors uncovering poor care in recent visits that led to “continued and unnecessary harm” for patients.
    He raised the prospect that the Care Quality Commission (CQC) could recommend the trust be placed into special administration for safety reasons, which has only been done once in the history of the NHS – at the former Mid Staffordshire NHS Trust, where a public inquiry found hundreds of patients suffered avoidable harm and neglect because of widespread systemic poor care.
    In a rarely seen intervention, Prof Baker’s letter to NHS England’s chief operating officer, Amanda Pritchard, warned there were “ongoing and escalating concerns regarding patient safety” and that poor care was becoming “normalised” at the trust, which serves half a million people with its two hospitals – the Royal Shrewsbury and Telford’s Princess Royal.
    Read full story
    Source: The Independent, 16 July 2020
  22. Patient Safety Learning
    In March 2015, the Morecambe Bay investigation, chaired by Dr Bill Kirkup, published its report into serious failures in care that led to the avoidable deaths of 11 babies and a mother at Furness General Hospital (FGH) between 2004 and 2012. One of the babies that died was James Titcombe's son, Joshua.
    The report described a seriously dysfunctional maternity unit where certain midwives pursued an “over-zealous” approach to promoting “normal” childbirth, relationships between doctors and midwives was poor, midwifery practice fell well below acceptable standards and, unforgivably, instances of avoidable harm and death were covered up – meaning lessons were not learned and similar failures were repeated year after year. 
    The report detailed how opportunities to intervene at Morecambe Bay were missed at all levels and how the families who raised concerns were treated as problems to be managed, rather than voices that needed to be heard. More than four years later, it is both tragic and distressing to read about the litany of failures identified in the leaked interim report into care at Shrewsbury and Telford Hospital Trust (SaTH). Far from events at Morecambe Bay being a “one-off”, it is now painfully clear that not only have similar failures in care occurred elsewhere, but that they have happened on an even larger scale.
    James, speaking to The Independent, says "Worryingly, the reason why we are reading about these issues now isn’t because the regulatory system identified a problem and called for further scrutiny, but rather because of the extraordinary efforts of bereaved families."
    Read full story
    Source: The Independent, 21 November 2019
     
     
  23. Patient Safety Learning
    Rachel Hardeman has dedicated her career to fighting racism and the harm it has inflicted on the health of Black Americans. As a reproductive health equity researcher, she has been especially disturbed by the disproportionately high mortality rates for Black babies.
    In an effort to find some of the reasons behind the high death rates, Hardeman, an associate professor at the University of Minnesota School of Public Health, and three other researchers combed through the records of 1.8 million Florida hospital births between 1992 and 2015 looking for clues.
    They found a tantalising statistic. Although Black newborns are three times as likely to die as White newborns, when Black babies are delivered by Black doctors, their mortality rate is cut in half.
    "Strikingly, these effects appear to manifest more strongly in more complicated cases," the researchers wrote, "and when hospitals deliver more Black newborns." They found no similar relationship between White doctors and White births. Nor did they find a difference in maternal death rates when the doctor's race was the same as the patient's.
    Read full story
    Research paper
    Source: The Washington Post, 9 January 2021
  24. Patient Safety Learning
    The number of notified “extreme” and “major” incidents involving serious harm to patients and others in hospital has risen significantly in the Republic of Ireland in recent years, new figures reveal.
    Reported “extreme” incidents, which can involve death or permanent incapacity, rose from 373 in 2017 to 579 last year.
    The number of cases classified as “major”, where there is long-term disability or incapacity, climbed from 46 to 82 in the same period.
    “Moderate” incidents, when there is a patient injury involving medical treatment, also increased from 9,219 in 2017 to 13,563 last year.
    Minor incidents, involving injury or illness needing first aid, also increased over the same time from 9,210 to 15,483.
    The figures, involving patients, staff, visitors, contractors and the public, were released by the HSE in response to a parliamentary question from Aontú leader Peadar Tóibín.
    A spokewoman for the HSE said: “It is HSE policy that all incidents are identified, reported and reviewed so that learning from events can be shared to improve the quality and safety of services.” 
    “The number of reported incidents has increased year on year since 2004 with a significant increase noted since 2015, with the introduction of the National Incident Management System.”
    Read full story
    Source: Independent.ie, 3 May 2022
  25. Patient Safety Learning
    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
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