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Patient Safety Learning

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  1. News Article
    Tracey Fletcher, chief executive of East Kent Hospitals, said: "I want to say sorry and apologise unreservedly for the harm and suffering that has been experienced by the women and babies who were within our care, together with their families, as described in today’s report. "These families came to us expecting that we would care for them safely, and we failed them. "We must now learn from and act on this report; for those who have taken part in the investigation, for those who we will care for in the future, and for our local communities. I know that everyone at the Trust is committed to doing that. "In the last few years we have worked hard to improve our services and have invested to increase the numbers of midwives and doctors, in staff training, and in listening to and acting on feedback from the people who receive our care. "While we have made progress, we know there is more for us to do and we absolutely accept that. Now that we have received the report, we will read it in full and the Board will use its recommendations to continue to make improvements so that we are providing the safe, high-quality care our patients expect and deserve. "I want every family – whether they contributed to the investigation or not – to know I am here to listen to them, to learn and to lead our Trust in acting on this report. "I would like to thank Dr Bill Kirkup and the investigation team for their work. Today, our thoughts remain with those who have shared their experiences. We are grateful to them.” Source: NHS East Kent Hospitals, 19 October 2021
  2. Content Article
    The Medicines and Healthcare products Regulatory Agency (MHRA) is reviewing its approach to engagement with healthcare professionals to improve the safety of medicines and medical devices. It wants to ensure that healthcare professionals are receiving actionable information and guidance on safe use of medicines and medical devices that they can take into their working practice, providing timely advice to patients. The MHRA wants to hear from you to enable them to transform how they communicate with you and how they work together with you for the common goal of greater patient safety. The consultation closes 18 January 2023.
  3. News Article
    Jeremy Hunt has been told that any cuts to the health budget will in effect “kill” dental services across the UK and deny millions of patients access to a dentist on the NHS. The chancellor has told members of the cabinet that “everything is on the table” as he seeks to find tens of billions of pounds in savings after ditching the economic plan of Liz Truss, who said on Thursday she was standing down as prime minister. Health is one key area expected to be hit. But in an email to Hunt seen by the Guardian, the head of the British Dental Association (BDA) said in plain terms that because NHS dentistry had already “faced cuts with no parallel anywhere in the health service” over the last decade, any further reduction in funding could trigger its collapse. “In blunt terms, NHS dentistry is approaching the end of the road,” Martin Woodrow, the BDA chief executive, wrote in the memo. “There is simply no more fat to trim, short of denying access to an even greater proportion of the population.” In the memo to Hunt, Woodrow wrote: “Recent NHS England board papers confirm officials are euphemistically ‘taking steps to maximise access from existing resources’. We know what that means. Yes, we recognise the unparalleled pressures on public spending. Equally, we cannot escape the hard fact that a service millions depend on materially lacks the resources to underpin any rebuild. “You have also spoken of the need for all departments to seek ‘efficiency savings’. Since the financial crash, NHS dentistry has faced cuts with no parallel anywhere in the health service, going into the pandemic with lower government contributions – in cash terms – than it saw a decade ago. Read full story Source: The Guardian, 21 October 2022
  4. Content Article
    Reports showing that babies and mothers died or were harmed as a result of failures by, and sometimes heartless cruel treatment in, NHS maternity units are becoming worryingly common. Dr Bill Kirkup’s just-published 192-page exposé of an appalling catalogue of failings at East Kent NHS trust between 2009 and 2020 is the second in the last 12 months. As many as 45 babies and 23 mothers in East Kent died avoidably during that time because their care was substandard, his inquiry found. March brought Donna Ockenden’s grim findings about poor maternity care at the Shrewsbury and Telford trust. And Kirkup produced the first detailed exposition of what inadequate care of women and their offspring during childbirth looked like when in 2015 he laid bare “serious and shocking” lapses in care at Morecambe Bay trust. A fourth official inquiry, again being led by Ockenden, is under way into death, brain damage and other horrendous outcomes at the Nottingham trust. Families affected claim that, despite coroners’ findings, close scrutiny of the trust by regulators, media coverage of lapses in care and pressure for change, “babies, mothers and their families continue to be harmed”. No wonder Rob Behrens, the NHS Ombudsman, says: “The phrase ‘never again’ is starting to ring hollow.”
  5. News Article
    Two out of five maternity units in England are providing substandard care to mothers and babies, the NHS watchdog has warned. “The quality of maternity care is not good enough,” the Care Quality Commission (CQC) said in its annual assessment of how health and social care services are performing. It published new figures showing it rated 39% of maternity units it inspected in the year to 31 July to “require improvement” or be “inadequate” – the highest proportion on record. Ian Trenholm, the CQC’s chief executive, said maternity services were deteriorating, substandard care was unacceptably common and failings were “systemic” across the NHS. Its latest state of care report said: “Our ratings as of 31 July 2022 show that the quality of maternity services is getting worse, with 6% of NHS services (nine out of 139) now rated as inadequate and 32% (45 services) rated as require improvement. “This means that the care in almost two out of every five maternity units is not good enough.” The report said: “The findings of recent reviews and reports … show the same concerns emerging again and again. The quality of staff training, poor working relationships between obstetric and midwifery teams and a lack of robust risk assessment all continue to affect the safety of maternity services. These issues pose a barrier to good care.” Staff not listening to women during pregnancy and childbirth is a recurring problem, Trenholm said. Their concerns “are not being heard” by midwives and obstetricians “in the way that they should”. Read full story Source: The Guardian, 21 October 2022
  6. News Article
    Women waiting for breast reconstruction surgery on the NHS in England face a “postcode lottery” of care, with some forced to wait more than three years, a damning report warns. Two in five women (40%) waiting for breast reconstruction during the pandemic after having their breasts removed due to cancer faced a delay of 24 months or longer, according to research involving 1,246 women who either underwent reconstruction surgery or were waiting for it. The report by charity Breast Cancer Now also warned that some breast reconstruction services are still not operating at full capacity after temporarily pausing at the start of the Covid-19 pandemic. It says there was a 34% drop in breast reconstruction activity in England in 2021-22 compared with 2018-19. The charity added that on top of the delays, women face a “postcode lottery” of care, with some women offered certain types of reconstruction while others are denied the same operation. Breast Cancer Now called on NHS England to develop a plan to address the backlog of breast reconstruction services. One woman told the authors of the report she waited for three and a half years for breast reconstruction surgery, while another said she “wants to move on with my life” but has no idea when her surgery will go ahead. Baroness Delyth Morgan, the chief executive of Breast Cancer Now, said: “For women who choose breast reconstruction, it is a core component of their recovery – far from a solely aesthetic choice, this is the reconstruction of their body and indeed their identity after they have been unravelled by breast cancer treatment and surgery. “We hear of patients affected by delays to reconstruction surgery and the significant emotional impact this has on them, including altered body confidence, loss of self-esteem and identity, anxiety and depression, and hindering their ability to move forward with their lives, knowing their treatment is incomplete." Read full story Source: The Guardian, 19 October 2022
  7. Content Article
    'State of Care' is the Care Quality Commission's annual assessment of health care and social care in England. The report looks at the trends, shares examples of good and outstanding care, and highlights where care needs to improve.
  8. News Article
    University College London Hospitals (UCLH) is to host to a new collaboration researching patient safety, after being awarded £3 million in funding from the National Institute for Health and Care Research. The NIHR Central London Patient Safety Research Collaboration (PSRC) aims to improve safety in Surgical, Perioperative, Acute and Critical care (SPACE) services, which treat more than 25 million NHS patients annually. Perioperative care is care given at and around the time of surgery. Amongst the highest risk clinical settings are SPACE services because of the seriousness of the patients’ conditions and the complex nature of clinical decision making. Further risks arise at the transitions of care between SPACE services and other parts of the health and social care system. The research team led by UCLH and UCL will develop and evaluate new treatments and care pathways for SPACE services. This will include new interventions such as surgical and anaesthetic techniques, and new approaches to predicting and detecting patient deterioration. They will also help the NHS become safer for patients through the development of innovative approaches to organisational learning, and to how clinical evidence is generated. The PSRC’s learning academy will support the next generation of patient safety researchers through a comprehensive programme of funding, mentoring and peer support. The team includes frontline clinicians, policy makers and world-leading academics across a range of scientific disciplines including social and data science, mechanical and software engineering. Patients and the public representing diverse backgrounds are key partners in the collaboration. Professor Moonesinghe said: “We have a great multidisciplinary, multiprofessional team ready to deliver a truly innovative programme to improve patient safety in these high-risk clinical areas. As a uniquely rich research environment, UCLH and UCL are well placed to lead this work, and we are looking forward to collaborating with clinicians and patients across the country to ensure impact for the whole population which the NHS serves.”
  9. Content Article
    Many are still reporting minimisation of their Long Covid symptoms – and it’s partially attributable to the fact that female patients are routinely dismissed. Five women share their experiences.
  10. News Article
    A series of chairs and chief executives at an acute trust were ‘wrong’ to believe the organisation was providing acceptable care over an 11-year period and should be held accountable for one of NHS’s largest maternity care scandals, an inquiry concluded today. Bill Kirkup’s inquiry into East Kent Hospitals University Foundation Trust found 45 of the 65 deaths of babies examined could have been prevented. It also concluded the overall outcome of 48% of 202 cases investigated could have been different, if care had matched nationally recognised standards. It also warned that the unjustified belief that things “would get better” as a result of management changes still continued at the trust. The report added that problems in the service were visible to senior managers and the board through a succession of reports, dating back to 2009. The report stated: “We have concluded that accountability lies with the successive trust boards and the successive chief executives and chairs. They had the information that there were serious failings, and they were in a position to act; but they ignored the warning signs and strenuously challenged repeated attempts to point out problems. This encouraged the belief that all was well, or at least near enough to be acceptable. They were wrong.”
  11. Content Article
    In this short blog, Patient Safety Learning sets out its initial response to the publication of the report of the independent investigation into maternity and neonatal services at the East Kent Hospitals NHS Foundation Trust.
  12. Content Article
    Slides from a Bevan Brittan webinar reviewing recent case law and practice developments.
  13. News Article
    More than 200 families in south-east England will learn today the results of a major inquiry into the maternity care they received from a hospital trust. The investigation into East Kent Hospitals NHS Trust follows dogged campaigning by one determined bereaved grandfather. Derek Richford's grandson Harry died at East Kent Hospitals after his life support system was withdrawn. Sixty one-year-old Derek had never campaigned for anything in his life. His initial approach was to wait for East Kent Hospitals Trust to investigate the death, as it had promised. However, one nagging issue that was to become central to Derek's view of the trust, was the hospital's continual refusal to inform the coroner of Harry's death. The family repeatedly requested it, but the trust said it was unnecessary as it knew the cause, namely the removal of the life support system. The hospital also recorded Harry's death as "expected" - again because his life support system had been withdrawn. On both points, the family were left confused and increasingly angry. In early March 2018, some four months after Harry's death, the family finally received the outcome of the trust's internal investigation - known as the Root Cause Analysis (RCA). The RCA indicated multiple errors had been made in Harry and Sarah's care and treatment, and his death was "potentially avoidable". Prior to the meeting, Derek wrote to the Kent coroner's office outlining in general the circumstances of Harry's case, asking if that was the type they would expect to be notified of. The email response from the coroner's office was clear. It said: "Based on the facts you have presented, this death should have been reported to the coroner." Despite this, at the meeting with the trust, the lead investigator into Harry's death told the family: "If we have a clear cause of death by and large we do not involve the coroner." The family's insistence eventually paid off - five weeks after that meeting, the trust informed the coroner of Harry's death. While his son and daughter-in-law started trying to recover from the trauma of losing Harry, Derek turned his attention to investigating East Kent, one of the largest hospital trusts in England. "When I started investigating what was going on with Harry, it was very much like peeling back an onion. 'Hang on a minute, that can't be right, that doesn't add up.' Ever since I was a small kid, justice has been so important to me. "What I found was that, up to that point, no-one had ever joined the dots. And that's so important. I think this had to happen, someone had to do it. There will be families before us that wish they did it. We will be saving a level of families after us." Read full story Source: BBC News, 19 October 2022
  14. News Article
    A major trust’s former chief executive and medical director have been cleared, after being accused of failing to protect breast patients from a rogue surgeon. The Medical Practitioners Tribunal Service has ruled neither Mark Goldman nor Ian Cunliffe’s fitness to practise was impaired, in a case brought by the General Medical Council. Mr Goldman was chief executive of the Heart of England Foundation Trust from 2001 until 2010, while Dr Cunliffe served as HEFT medical director between 2006 and 2010. Both held roles at HEFT while Ian Paterson was there. Mr Paterson was jailed for 20 years in 2017 after being convicted of 17 offences of wounding with intent while being employed at HEFT, while a later inquiry concluded he may have conducted up to 1,000 botched and unnecessary operations over a 14-year period. Mr Goldman and Dr Cunliffe are now pursuing the GMC for the costs of the case, which is expected to be heard over five days in January 2023. Read full story (paywalled) Source: HSJ, 18 October 2022
  15. News Article
    More than a third of the 3143 counties in the US are maternity “deserts” without a hospital or birth centre that offers obstetric care and without any obstetric providers—and the situation is getting worse, says a report from the March of Dimes organisation. Maternity deserts have increased by 2% since the 2020 report, said the organisation which seeks to improve the health of women and babies. Care is diminishing where it is needed most—especially in rural areas. It affects nearly seven million women of childbearing age and about half a million babies. Read full story (paywalled) Source: BMJ, 17 October 2022
  16. Content Article
    Dr Anthony Fauci, America’s top infectious disease expert, has warned against prematurely declaring victory over the pandemic, not only due to short-term needs but because long Covid represents an “insidious” public health emergency for millions of people. In an interview with the Guardian, Fauci urged US Congress to avoid complacency and resume funding to combat the virus as well as Long Covid, a chronic and prolonged illness that continues to elude scientists and healthcare providers.
  17. Content Article
    In February 2020 the UK Government commissioned Dr Bill Kirkup to undertake a review into maternity and neonatal care services between 2009 and 2020 in two hospitals, the Queen Elizabeth The Queen Mother Hospital (QEQM) at Margate and the William Harvey Hospital (WHH) in Ashford. Both these services fall under the East Kent Hospitals NHS Foundation Trust. The report found that over this period those responsible for these services too often provided clinical care that was suboptimal and led to significant harm, failed to listen to the families involved, and acted in ways which made the experience of families unacceptably and distressingly poor. It identifies four key areas for action which must be addressed to improve patient safety in maternity and neonatal care services.
  18. News Article
    The former lead governor of East Kent Hospitals University Foundation Trust has resigned this morning, claiming there is “a cancer at the top of the organisation” and that its services won’t be safe until the government provides funding for critical estates work. His resignation as a governor came hours before the publication of what is expected to be a “harrowing” report into maternity services at the trust from an independent review led by Sir Bill Kirkup. He is also expected to raise concerns about national progress on maternity services safety in recent years. Alex Lister, who is chair of the council of governors’ membership engagement and communications committee, said in the letter: “I believe officials on six-figure salaries continue to mislead, obfuscate, bully and conceal vital information. I consider the way the trust communicates internally and externally to be completely unacceptable and utterly untrustworthy. “Without the valiant efforts of the brave families caught up in a tragedy of the trust’s making, the world may never have found out about the disastrous health failings at our trust.” In the letter to chair Niall Dickson, Mr Lister says he has seen a continuation “of the same apparent policy of manipulation and discrediting dissenting voices that existed prior to the scandal”. Read full story (paywalled) Source: HSJ, 19 October 2022
  19. Content Article
    Access useful case studies as well as the NHS Confederation's latest reports, blogs, podcasts and the ICS Communications Toolkit.
  20. News Article
    The NHS is setting up “war rooms” as it prepares for one of the toughest winters in its history, officials have announced. In a letter to staff, health leaders in England set out “winter resilience plans”, which include new system control centres that are expected to be created in every local area. These centres will be expected to manage demand and capacity across the entire country by constantly tracking beds and attendances. They will be operated by clinicians and experts who can make quick decisions about emerging challenges in the health service, NHS England said. The data-driven centres will be able to spot when hospitals are near capacity and could benefit from mutual aid. Where A&Es are especially busy, ambulances will be diverted to nearby hospitals with more space. Meanwhile, NHS England announced plans to expand falls response services so people are treated in their homes, avoiding unnecessary trips to hospital where possible. NHS England’s chief executive, Amanda Pritchard, said: “Winter comes hot on the heels of an extremely busy summer – and with the combined impact of flu, Covid and record NHS staff vacancies – in many ways, we are facing more than the threat of a ‘twindemic’ this year. “So it is right that we prepare as much as possible – the NHS is going further than it ever has before in anticipation of a busy winter, and today we have set out further plans to step up these preparations – building on our existing plans to boost capacity set out in August this year." Read full story Source: The Guardian, 19 October 2022
  21. News Article
    Shortages and rising costs of medicines could result in patients not receiving important prescriptions, community pharmacists have warned. Commonly prescribed drugs used to treat conditions such as osteoporosis, high blood pressure and mental health are among those affected. The Department of Health (DoH) said a support package worth £5.3m for the sector is being finalised. But Community Pharmacy NI said this "falls way short of what is needed". David McCrea from Dundela Pharmacy said the price of some medicines had been raised "fiftyfold". "As a community pharmacist for over 30 years, I have never witnessed the price of medicines rise this sharply," Mr McCrea said. "It is becoming increasingly hard for us to afford to buy the medicines from wholesalers because we are not being paid the full cost of these drugs by the department." Mr McCrea added the current situation was causing "financial stress" and was becoming unsustainable. "The bottom line is that we are now facing the situation where we will not be able to afford to supply our patients with essential medicines, within weeks." Read full story Source: BBC News, 18 October 2022
  22. News Article
    The NHS faces a record £90 billion maternity bill, The Telegraph can reveal ahead of a “harrowing” report into failings at East Kent Hospitals Trust. Official figures show the number of claims have risen by almost one quarter in just two years following a series of scandals. The data show 1,243 maternity negligence claims in 2021/22 - up from 1,015 in 2019/20. Safety campaigners said the figures were “staggering” - with £90 billion now set aside to cover the costs of claims. It means that in total, 70% of total liability provision for NHS negligence is associated with failings in pregnancy and childbirth, amid rising claims. The figure - equivalent to two-thirds of the NHS annual budget - represents an estimate for the total costs if all claims it expects to settle were paid out, at today’s prices. An NHS spokesperson said: “Despite improvements to maternity services over the last decade – with significantly fewer stillbirths and neonatal deaths – we know that further action is needed to ensure safe care for all women, babies and their families. “The NHS is ensuring that work is already underway to make these improvements, including a £127 million investment this year to boost the maternity workforce, strengthen leadership and increase neonatal cot capacity – which is on top of an annual boost of £95 million for staff recruitment and training announced last year.” Read full story (paywalled) Source: The Telegraph, 18 October 2022
  23. News Article
    People could die because of Thérèse Coffey’s “ultra-libertarian ideological” reluctance to crack down on smoking and obesity, a Conservative ex-health minister has warned. The strongly worded criticism of the health secretary came from Dr Dan Poulter, a Tory MP and NHS doctor who served as a health minister in the coalition government from 2012 to 2015. Poulter claims Coffey’s “hostility to what the extreme right call ‘nanny statism’” is stopping her from taking firm action against the “major killers” of tobacco and bad diet. His intervention – in an opinion piece for the Guardian – was prompted by Coffey making clear that she opposed banning adults from smoking in cars containing children, even though the practice was outlawed in 2015 and is credited with reducing young people’s exposure to secondhand smoke. The government’s widely anticipated scrapping of measures to curb obesity such as the sugar tax and ditching of the tobacco control plan and health inequalities white paper – both of which previous health ministers had promised to publish – have led Poulter to brand Coffey’s stance “deeply alarming”. He writes: “More smoking and more obesity means more illness, more pressure on the NHS and shorter lives, particularly amongst the poorest in society. “I am acutely concerned that the health secretary’s ideological hostility to what history shows is government’s potentially very positive role in protecting us against these grave threats to our health will exacerbate the problems they already pose. “At its worst such a radically different approach to public health could cost lives, as it will inevitably lead to more people smoking and becoming dangerously overweight.” Read full story Source: The Guardian, 18 October 2022
  24. News Article
    More than a quarter of women with ovarian cancer saw their GP three or more times before getting a referral for tests, according to a new study. Researchers also found that almost a third had waited for longer than three months after first going to see their GP before being given the right diagnosis. If doctors are able to diagnose ovarian cancer at the earliest stage, nine out of 10 women will go on to live for five years or longer, but only around one in 10 survive if it is not caught until it has progressed to stage 4, the most advanced stage. The report, by Target Ovarian Cancer, also revealed that 14 per cent of women polled said they were not given their diagnosis in private, meaning others could listen in on the exchange. “I was told of my stage 4 diagnosis behind the curtain on a busy respiratory ward. The rest of the ward heard the conversation,” one woman said. Meanwhile, GPs and ovarian cancer patients told researchers that the support available for the disease is insufficient – with almost half of the women polled not having been asked by a doctor, nurse or other individual providing treatment about how the cancer diagnosis was affecting their mental health. This is despite the fact that 60% of the women diagnosed with ovarian cancer said their mental health had been harmed by the disease. Read full story Source: The Independent. 18 October 2022
  25. News Article
    The deaths of at least 45 babies could have been avoided if nationally recognised standards of care had been provided at one of England’s largest NHS trusts, a damning inquiry has found. Dr Bill Kirkup, the chair of the independent inquiry into maternity at East Kent hospitals university NHS foundation trust, said his panel had heard “harrowing” accounts from families of receiving “suboptimal” care, with mothers ignored by staff and shut out from discussions about their own care. The inquiry’s report said: “An overriding theme, raised with us time and time again, is the failure of the trust’s staff to take notice of women when they raised concerns, when they questioned their care, and when they challenged the decisions that were made about their care.” Of 202 cases reviewed by the experts, the outcome could have been different in 97 cases, the inquiry found. In 69 of these 97 cases, it is predicted the outcome should reasonably have been different and it could have been different in a further 28 cases. Of the 65 babies’ deaths examined, 45 could have had a different outcome if nationally recognised standards of care had been provided. In nearly half of all cases examined by the panel, good care could have led to a different outcome for the families. Some of the bereaved parents accused the trust of “victim blaming” mothers for their children’s deaths. Kelli Rudolph and Dunstan Lowe, whose daughter Celandine died at five days old, said: “Doctors sought to blame Kelli for Celandine’s death. This victim blaming was the first in a long line of interactions with those in the trust who sought to delay, deflect and deny our search for the truth about what happened to our baby. “In isolation, these tactics traumatised us after the tragedy of our daughter’s death. But when seen in the light of 10 years of failures, they signal a concerted effort to cover up the trust’s responsibility for what happened to Celandine and the many others who lost their lives due to failures in clinical judgment.” Read full story Source: The Guardian. 19 October 2022
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