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Sam

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  1. Sam
    A 40-year-old mother of four took her own life at an NHSmental health unit after multiple opportunities were missed to keep her safe, an inquest has found, prompting her family to call for a public inquiry.
    Azra Parveen Hussain was allegedly the seventh in-patient in seven years to die by the same means while in the care of Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHT).
    Despite this, an inquest at Birmingham and Solihull Coroner’s Court last week heard that the Trust had not installed door pressure sensor alarms, which could have potentially alerted staff to the fatal danger these patients faced.
    While BSMHT is now taking action to install pressure sensors at Mary Seacole House, where Hussain died on 6 May, Coroner Emma Brown noted a lack of national regulation or guidance on the risks presented by internal doors in patients’ bedrooms and is issuing a Prevention of Future Deaths report calling for this to be remedied across the country.
    Read full story
    Source: The Independent, 28 March 2021
  2. Sam
    The Healthcare Safety Investigation Branch (HSIB) has launched a new online feedback form so that anyone involved or interested in HSIB's healthcare safety investigations can "tell us what they think".
    There are options to give feedback on national investigations in general, specific national investigations, maternity investigations and HSIB in general. 
    The feedback form is available from the HSIB website
    Source: HSIB, 1 August 2019
  3. Sam
    Dying patients are going without care in their own homes because of a collapse in community nursing services, new data shared with The Independent reveals.
    Across England a third of district nurses say they are now being forced to delay visits to end of life care patients because of surging demand and a lack of staff. This is up from just 2% in 2015. The situation means some patients may have to wait for essential care and pain medication to keep them comfortable.
    Other care being delayed includes patients with pressure ulcers, wounds which need treating and patients needing blocked catheters replaced.
    More than half of district nurses said they no longer have the capacity to do patient assessments and psychological care, in an investigation into the service.
    Professor Alison Leary, director of the International Community Nursing Observatory, said her study showed the country was “sleepwalking into a disaster,” with patients at real risk of harm.
    She said the situation was now so bad that nurses were being driven out of their jobs by what she called the “moral distress” they were suffering at not being able to provide the care they knew they should.
    “People are at the end of their tether. District nurses are reporting having to defer work much more often than they did two years ago. What they are telling us is that the workload is too high. This is care that people don’t have time to do.”
    Read full story
    Source: The Independent, 29 November 2021
  4. Sam
    Staff failed to provide kind and compassionate care and did not treat children with respect at a private hospital downgraded from ‘good’ to ‘inadequate’, a report by health inspectors has revealed.
    Huntercombe Hospital Stafford was placed in special measures in 2016, but was rated “good” by the Care Quality Commission two years later.
    Now, its first inspection under provider Huntercombe Young People Ltd in October 2021 has exposed a raft of safety concerns and instances of poor care. Huntercombe Young People Ltd took over the service in February 2021. 
    Heavy reliance on agency staff, workers spotted with their “eyes closed” on observations, and staff not respecting young people’s pronouns were among concerns inspectors flagged.
    Staff observation of patients was also found to be “undermined” by a blind spot where people could self-harm unseen, the CQC report, published today, said.
    Children also told the CQC they felt staff did not always understand their mental health condition or know how to support them, particularly those on the psychiatric intensive care ward with eating disorders or autism.
    Read full story (paywalled)
    Source: HSJ, 10 March 2022
  5. Sam
    A GP has been given three life sentences for 90 sex assaults on female patients.
    Manish Shah assaulted 23 women and a 15-year-old girl while working in London - carrying out invasive examinations for his own gratification. The Old Bailey heard he used Angelina Jolie and Jade Goody as examples to frighten patients about their health.
    Judge Anne Molyneux described him as a "master of deception who abused his position of power". "You made up stories which got into heads and caused panic," she said.
    Shah, from Romford, convinced his victims to have unnecessary checks between May 2009 and June 2013.
    Read full story
    Source: BBC News, 7 February 2020
  6. Sam
    A “very tense” behind-the-scenes row over how quickly hospitals in England can be expected to reduce the massive backlog of surgery has broken out between NHS bosses and ministers.
    The dispute has delayed publication of the government’s “elective recovery plan”, which Downing Street had indicated would be part of Boris Johnson’s “Operation Red Meat” political fightback this week.
    No 10, the Treasury and Department of Health and Social Care are pressing NHS England to ensure that hospitals do as many operations as they can, as quickly as possible, in order to tackle the backlog, which now stands at a record 6 million patients.
    They want to impose “stretching and demanding” targets on hospitals, sources with knowledge of the discussions said.
    However, NHS trust bosses say the ongoing impact of treating patients sick with Covid, due to the current Omicron surge, longstanding gaps in their workforce, exhaustion at the frontline and record levels of staff sickness, mean they need time to get back to doing as much surgery as they did before the pandemic.
    The Treasury is said to be frustrated with NHS England and privately believes it is “foot-dragging” over the targets. NHS bosses for their part fear the plan is being driven by “political expediency”, given the growing concern at the sheer number of people facing long delays for care.
    Read full story
    Source: The Guardian, 20 January 2022
  7. Sam
    The United States is now in its fourth-biggest Covid surge, according to official case counts – but experts believe the actual current rate is much higher.
    America is averaging about 94,000 new cases every day, and hospitalizations have been ticking upward since April, though they remain much lower than previous peaks.
    But Covid cases could be undercounted by a factor of 30, an early survey of the surge in New York City indicates.
    “It would appear official case counts are under-estimating the true burden of infection by about 30-fold, which is a huge surprise,” said Denis Nash, an author of the study and a distinguished professor of epidemiology at the City University of New York School of Public Health.
    While the study focused on New York, these findings may be true throughout the rest of the country, Nash said. In fact, New Yorkers likely have better access to testing than most of the country, which means undercounting could be even worse elsewhere.
    “It’s very worrisome. To me, it means that our ability to really understand and get ahead of the virus is undermined,” Nash said.
    Read full story
    Source: The Guardian, 2 June 2022
  9. Sam
    A hospital that was at the centre of a major inquiry into unsafe maternity care five years ago is facing new questions over its safety after bosses admitted a baby boy would have survived if not for mistakes by hospital staff.
    Jenny Feasey, from Heysham in Lancashire, is still coming to terms with the loss of her son Toby who was stillborn at the Royal Lancaster Infirmary, part of the University Hospitals of Morecambe Bay Foundation Trust in January 2017 after a series of mistakes by staff who did not act on signs she had pre-eclampsia.
    Jenny, 33, has backed The Independent’s campaign for improved maternity safety and called on midwives to learn lessons after what happened to her family.
    She added: “This was an easily avoidable situation. They just didn’t piece it together, all they had to do was carry out a test and I lost my son because of it."
    Read full story
    Source: The Independent, 25 October 2020
  10. Sam
    Staff at a Midlands hospital trust told regulators they had repeatedly raised safety concerns internally without action being taken.
    The Care Quality Commission (CQC) has downgraded maternity services at Worcestershire Acute Hospital from “good” to “requires improvement” following an inspection prompted by the whistleblowers’ concerns.
    Staff had reported “continuously escalating” staffing level concerns to senior managers, but said they got “no response”. Some said they were fearful of raising concerns internally.
    Whistleblowers also reported delays to induction of labour, with examples of women waiting up to a week to be induced instead of one to two days. Managers said women who suffered delays were risk assessed.
    The CQC also identified a risk women might not be informed of significant harm caused to them or their babies following an incident, due to the way the trust was grading some babies who were admitted to the neonatal unit. However, it added: “When things went wrong, staff apologised and gave patients honest information and suitable support.”
    The report added the trust’s leaders were aware of the challenges in maternity, but “timely” action was not always taken to address the concerns.
    Read full story (paywalled)
    Source: HSJ, 19 February 2021
  11. Sam
    Women undergoing NHS operations are not being routinely informed that a drug commonly used in anaesthesia may make their contraception less effective, putting them at risk of an unplanned pregnancy, doctors have warned.
    Administered at the end of surgery before patients wake up, sugammadex reverses the action of drugs that are given earlier in the procedure to relax the patient’s muscles. The drug is known to interact with the hormone progesterone and may reduce the effectiveness of hormonal contraceptives, including the progesterone-only pill, combined pill, vaginal rings, implants and intra-uterine devices.
    However, new research suggests that robust methods for identifying at-risk patients and informing them of the associated risk of contraceptive failures is not common practice across anaesthetic departments in the UK.
    Current guidance says doctors must inform women of child-bearing age about the drug. Women taking oral hormonal contraceptives should be advised to follow the missed pill advice in the leaflet that comes with their contraceptives, and those using other types of hormonal contraceptive should be advised to use an additional non-hormonal means of contraception for seven days.
    But doctors at a major London hospital trust found no record within the medical notes of relevant patients that they had been given advice on the risks of contraceptive failure due to sugammadex.
    Read full story
    Source: The Guardian, 2 June 2022
  12. Sam
    An anaesthetist who had been drinking before an emergency caesarean that led to the death of a British woman should serve the maximum three years in jail if convicted and should be banned from working as a doctor, a French prosecutor has demanded.
    Helga Wauters is on trial in Pau, south-west France, for the manslaughter of Xynthia Hawke in 2014. She is accused of starving Hawke of oxygen for up to an hour after pushing a ventilation tube into the wrong passageway.
    Orlane Yaouang, prosecuting, described the scene in the operating theatre when Hawke turned blue as “carnage” and spoke of the “surreal situation” in which the panicked hospital staff called the emergency services.
    Read full story
    Source: The Guardian, 9 October 2020
  13. Sam
    Families have blasted a NHS Trust after it said it did not intend to publish an independent review into their loved ones deaths. Three young people died in nine months at the same mental health unit.
    A Coroner was told last week that the review will be "ready" this month. Rowan Thompson, 18, died while a patient at the unit, based in the former Prestwich Hospital, Bury, in October 2020, followed by Charlie Millers, 17, in December that year, and Ania Sohail, 21, in June last year.
    Earlier this year, Greater Manchester Mental Health NHS Foundation Trust (GMMH), which runs the hospital, commissioned an 'external report' into the deaths. A pre-inquest hearing into the death of Rowan - who used the pronoun 'they' - heard that the full report would be available for the coroner to read 'on or around September 30'.
    Asked by the Manchester Evening News if the review would be published a spokesperson for the Trust said the Trust "always act on the wishes of the family regarding publication of reports," adding "and so in line with this we have no immediate plans to make the report public."
    But the parents of both Rowan Thompson and Charlie Mllers said they wanted the report publishing. Charlie's mother, Sam, said: "We want it published. It needs to be put out there, otherwise there is no point in having it. We are hoping they (The Trust) will learn lessons. We want answers but it should also be published for the benefit of the wider public - and the parents of other young people who are being treated in that unit."
    Read full story
    Source: The Manchester News, 13 September 2022
  14. Sam
    A 23-year-old woman who begged doctors to remove her womb to relieve chronic pain says the surgery is being refused due to her age and childless status.
    Hannah Lockhart has endometriosis, a condition that can cause debilitating pain, heavy periods and infertility.
    Although she has always wanted her own children, Hannah says her daily pain is now so severe she wants a hysterectomy.
    "It's heartbreaking that just because I'm so young I have to keep suffering," she told the BBC's Evening Extra.
    Ms Lockhart, from Bangor in County Down, has been in hospital seven times in the past year because of crippling pain from endometriosis.
    "Every single day I'm taking morphine, I'm taking different tablets for nerves to try and stop the pain and nothing works," she said.
    Read full story
    Source: BBC News, 14 April 2021
  15. Sam
    Maternity services are at risk because demoralised midwives are planning to quit the NHS, healthcare leaders have warned.
    A new report, carried out by the Institute for Public Policy Research, suggests 8,000 midwives may depart due to the “unprecedented pressure” of the coronavirus pandemic.
    Researchers, who surveyed about 1,000 healthcare professionals from around the country in mid-February, discovered that two-thirds reported being mentally exhausted once a week or more.
    Read full story (paywalled)
    Source: The Independent, 31 March 2021
  16. Sam
    Nurse Lucy Letby has been found guilty of murdering seven babies on a neonatal unit, making her the UK's most prolific child serial killer in modern times.
    The 33-year-old has also been convicted of trying to kill six other infants at the Countess of Chester Hospital between June 2015 and June 2016.
    Letby deliberately injected babies with air, force fed others milk and poisoned two of the infants with insulin.
    Commenting on the verdict, Parliamentary and Health Service Ombudsman Rob Behrens said:
    “We know that, in general, people work in the health service because they want to help and that when things go wrong it is not intentional. At the same time, and too often we see the commitment to public safety in the NHS undone by a defensive leadership culture across the NHS.
    “The Lucy Letby story is different and almost without parallel, because it reveals an intent to harm by one individual. As such, it is one of the darkest crimes ever committed in our health service. Our first thoughts are with the families of the children who died. 
    “However, we also heard throughout the trial, evidence from clinicians that they repeatedly raised concerns and called for action. It seems that nobody listened and nothing happened. More babies were harmed and more babies were killed. Those who lost their children deserve to know whether Letby could have been stopped and how it was that doctors were not listened to and their concerns not addressed for so long. Patients and staff alike deserve an NHS that values accountability, transparency, and a willingness to learn.  
    “Good leadership always listens, especially when it’s about patient safety. Poor leadership makes it difficult for people to raise concerns when things go wrong, even though complaints are vital for patient safety and to stop mistakes being repeated. We need to see significant improvements to culture and leadership across the NHS so that the voices of staff and patients can be heard, both with regard to everyday pressures and mistakes and, very exceptionally, when there are warnings of real evil.”
  17. Sam
    More than 200 GPs a month are seeking mental health support as COVID-19 drives up pressure on the NHS - and demand for help is rising fastest among doctors in primary care, figures from a confidential support service suggest.
    NHS Practitioner Health medical director and former RCGP chair Professor Dame Clare Gerada warns that the pandemic 'must surely be contributing to the increase in numbers of doctors presenting for help compared to pre-pandemic levels'.
    Before the pandemic, around 60 doctors per week were coming forward for support from NHS Practitioner Health, a free, confidential NHS service for doctors and dentists in England with mental illness and addiction problems.
    After an initial dip during the first wave of the pandemic, numbers of doctors coming forward each week spiked to 90 per week by June and now 'regularly over 100' per week, Professor Gerada said.
    Junior doctors and international medical graduates now make up 25% of referrals to the service, and younger women have been particularly affected.
    Data from NHS Practitioner Health show that up to 69% of all referrals to the service are for women, and nearly a third of all referrals it receives are for female doctors aged 30-39 - for issues 'ranging from anxiety, depression, burnout, PTSD and suicidal thoughts'.
    Read full story
    Source: GP Online, 28 October 2020
  18. Sam
    Sending thousands of older untested patients into care homes in England at the start of the coronavirus lockdown was a violation of their human rights, Amnesty International has said.
    A report says government decisions were "inexplicable" and "disastrous", affecting mental and physical health.
    More than 18,000 people living in care homes died with COVID-19 and Amnesty says the public inquiry promised by the government must begin immediately.
    According to Amnesty's report, a "number of poor decisions at both the national and local levels had serious negative consequences for the health and lives of older people in care homes and resulted in the infringement of their human rights" as enshrined in law.
    Researchers for the organisation interviewed relatives of older people who either died in care homes or are currently living in one; care home owners and staff, and legal and medical professionals.
    Amnesty said it received reports of residents being denied GP and hospital NHS services during the pandemic, "violating their right to health and potentially their right to life, as well as their right to non-discrimination".
    It adds that care home managers reported to its researchers that they were "pressured in different ways" to accept patients discharged from hospital who had not been tested or had COVID-19.
    Amnesty says the public inquiry into the pandemic should begin with an "interim phase". "The pandemic is not over," it added. "Lessons must be learned; remedial action must be taken without delay to ensure that mistakes are not repeated."
    Read full story
    Source: BBC News, 4 October 2020
  19. Sam
    Strong leadership, challenging poor workplace culture, and ringfencing maternity funding are key to improving safety. That’s the message from two leading Royal Colleges as they respond to the independent review of maternity services at Shrewsbury and Telford NHS Trust led by Donna Ockenden.
    The RCOG and the Royal College of Midwives (RCM) have today welcomed the Ockenden Review and its recognition of the need to challenge poor working relationships, improve funding and access to multidisciplinary training and crucially to listen to women and their families to improve learning and to ensure tragedies such as those that have happened at Shrewsbury and Telford NHS Trust never occur again. 
    The Colleges have said that the local actions for learning and the immediate and essential actions laid out in this report must be read and acted upon immediately in all Trusts and Health Boards delivering maternity services across the UK.
    Commenting, Dr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, said: 
    “This report makes difficult reading for all of us working in maternity services and should be a watershed moment for the system. Reducing risk needs a holistic approach that targets the specific challenges of fetal monitoring interpretation and strengthens organisational functioning, culture and behaviour."
    Read press release
    Source: RCOG, 10 December 2020
  20. Sam
    Widespread nursing shortages across the NHS could lead to staff burnout and risk patient safety this winter, the Royal College of Nursing has warned.
    The nursing union said a combination of staff absence due to the pandemic, and around 40,000 registered nursing vacancies in England was putting too much strain on the remaining workforce.
    The government says more than 13,000 nurses have been recruited this year.
    It has committed to 50,000 more nurses by 2025.
    It also hopes England's four-week lockdown will ease pressure on the NHS.
    The RCN has expressed concern that staff shortages are affecting every area of nursing, from critical care and cancer services to community nursing, which provides care to people in their own homes.
    The union said it was worried the extra responsibility and pressure placed on senior nurses could lead to staff "burnout", as hospitals struggle to clear the backlog of cancelled operations from the first wave of coronavirus and cope with rising numbers of new Covid patients, as well as the annual pressures that winter typically brings.
    Read full story
    Source: BBC News, 7 November 2020
  21. Sam
    NHS bosses have denied claims that thousands of frail elderly people were denied potentially life-saving care at the peak of the pandemic in order to stop the health service being overrun.
    NHS England took the unusual step on Sunday of issuing a 12-page rebuttal to allegations in the Sunday Times that patients deemed unlikely to survive were “written off” by being refused intensive care.
    Prof Stephen Powis, NHS England’s national medical director, said: “These untrue claims will be deeply offensive to NHS doctors, nurses, therapists and paramedics, who have together cared for more than 110,000 severely ill hospitalised Covid-19 patients during the first wave of the pandemic, as they continue to do today."
    “The Sunday Times’ assertions are simply not borne out by the facts. It was older patients who disproportionately received NHS care. Over two-thirds of our COVID-19 inpatients were aged over 65. “The NHS repeatedly instructed staff that no patient who could benefit from treatment should be denied it and, thanks to people following government guidance, even at the height of the pandemic there was no shortage of ventilators and intensive care.”
    The newspaper claimed the high coronavirus infection rate in the UK before lockdown began on 23 March and the NHS’s limited supply of mechanical ventilators going into the pandemic meant that “the government, the NHS and many doctors were forced into taking controversial decisions – choosing which lives to save, which patients to treat and who to prioritise – in order to protect hospitals”.
    The Sunday Times said its claims were the result of a three-month investigation that involved speaking to more than 50 sources in the NHS and the government about the health service’s response to the pandemic.
    Read full story
    Source: The Guardian, 25 October 2020
  22. Sam
    More than one in four patients with severe mental health conditions are missing diagnosis when they are admitted to hospital for other reasons, new research suggests.
    According to data analysed by scientists at University College London, those who are missing these mental illness diagnoses are more likely to be from ethnic minority groups or have a previously diagnosed mental illnesses.
    However, the situation has improved – in 2006 it was found that mental health diagnoses were missed in more than 50% of cases.
    "We found encouraging signs that clinicians are more frequently identifying severe mental illnesses in hospital patients than they were a decade ago,” Hassan Mansour, a research assistant at UCL psychiatry, said.
    “But there's a lot more that can be done, particularly to address disparities between ethnic groups, to ensure that everyone gets the best care available.
    Training in culturally-sensitive diagnosis may be needed to reduce inequalities in medical care."
    The researchers have suggested these findings may be due to language barriers or stigma felt by patients. It was also suggested that clinicians may be less able to detect these conditions in people from other ethnic and cultural groups.
    Read full story
    Source: The Independent, 18 September 2020
     
  23. Sam
    The government is facing criticism over its guidance on safe visits to care homes in England.
    Labour and a number of charities have described the suggestions, including floor-to-ceiling screens, designated visitor pods and window visits, as impractical. Alzheimer's Society has said it "completely misses the point".
    Justice Secretary Robert Buckland told BBC Radio 4's Today programme the guidance was "non-exhaustive".
    The updated government advice, which came into effect on Thursday, says care homes - especially those which have not allowed visits since March - "will be encouraged and supported to provide safe visiting opportunities".
    Labour's shadow care minister Liz Kendall said many care homes would not be able to comply with the government's requirements which meant "in reality thousands of families are likely to be banned from visiting their loved ones".
    She said instead of suggesting measures such as screens, the government should "designate a single family member as a key worker - making them a priority for weekly testing and proper PPE".
    Kate Lee, chief executive at Alzheimer's Society, said: "We're devastated by today's new care home visitor guidance - it completely misses the point: this attempt to protect people will kill them."
    She said the pandemic had left people with dementia isolated and thousands had died. The guidelines "completely ignore the vital role of family carers in providing the care for their loved ones with dementia that no one else can", she added.
    She said the "prison-style screens" proposed by the government with people speaking through phones were "frankly ridiculous when you consider someone with advanced dementia can often be bed-bound and struggling to speak".
    That view was echoed by Caroline Abrahams, charity director at Age UK, who said she was "acutely aware" that the methods being sanctioned were "unlikely to be useable by many older people with dementia, or indeed sensory loss".
    Read full story
    Source: BBC News, 5 November 2020
  24. Sam
    NHS bosses have warned the high prevalence of long Covid among staff is adding to rising healthcare pressures, amid growing concern that the new omicron variant could further drive infections and absences in the workforce.
    Some 40,000 (3.26%) of healthcare workers in the UK are estimated to have long Covid, according to the Office for National Statistics. This figure has risen by 5,000 since July.
    Many will be unable to work, though others are continuing to work despite their debilitating symptoms, experts say.
    “Trust leaders have told us they are concerned about the prevalence of long Covid amongst health and care staff,” said Chris Hopson, chief executive of NHS Providers.
    “Staff who are unwell need time to recover with support. But this may worsen unavoidable absences and sickness levels in the NHS at a time when pressures on the health service are mounting.”
    Read full story
    Source: The Independent, 9 December 2021
  25. Sam
    Allergy patients are being warned of a potential fault with Emerade adrenaline pens. The Medicines and Healthcare products Regulatory Agency (MHRA) said some have blocked needles, so cannot deliver adrenaline. Around two in every 1,000 pens are thought to be affected and patients are advised to follow the existing advice to carry two pens at all times. If patients follow the advice to carry two pens at all times, the risk of not being able to deliver a dose of adrenaline falls to virtually nothing - 0.23% to 0.000529%.
    The MHRA added: "Healthcare professionals should contact all patients, and their carers, who have been supplied with an Emerade device to inform them of the potential defect and reinforce the advice to always carry two in-date adrenaline auto-injectors with them at all times."
    Read full story
    Read MHRA alert
    Source: BBC News, 12 July 2019
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