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Found 549 results
  1. News Article
    Bereaved families are having to report maternity blunders because watchdogs and hospitals are unable to spot failings, an expert has warned. Bill Kirkup said avoidable deaths were "a badge of shame" but would continue without urgent change. Eight years on from his report into the Morecambe Bay maternity scandal, he said the failure of officials to act had needlessly cost more lives. "I am very disappointed – and surprised – that we're still where we are", he said. "That's a terrible badge of shame for the health service that it takes families to come and tell us what's wrong. "Yet just about every tragedy that I've ever been involved with investigating has come to light when there's a group of families who say 'You've got a problem here'. "People are lying, they're not being open and they're concealing what's happening. "If we can't bring this change, I'm not confident that there won't be another East Kent, Morecambe Bay or Nottingham, somewhere else." Read full story Source: Mail Online, 10 March 2023
  2. News Article
    A surgeon who may have infected two new mothers with herpes has been granted anonymity during the inquests into their deaths in an "unprecedented" ruling. Coroner Catherine Wood said she made the decision because the surgeon's "apprehension" about being named when he stands as a witness would "likely impede his evidence in court" and affect his health. Mid Kent and Medway Coroners is investigating the cases of Kimberly Sampson, 29, and Samantha Mulcahy, 32, who both died in 2018 after the same obstetrician conducted their caesareans. They were treated 6 weeks apart in hospitals run by East Kent Hospitals University NHS Trust (EKHUT). On February 26 – the day before the inquest was due to begin and 16 months after it was first announced – EKHUT made a last-minute bid for anonymity covering the surgeon and a midwife also involved in both cases. The trust said they should not be named unless the inquest concluded they had passed on the infection, because of the "reputational damage" they would suffer, and because the surgeon's health was already being impacted by reports. Read full story Source: Medscape, 9 March 2023
  3. News Article
    A two-month-old baby died after doctors mistook symptoms of a suspected perforated bowel for a cow’s milk intolerance. Nailah Ally was diagnosed with a hole in the heart before she was born and necrotising enterocolitis (NEC) shortly after her birth in October 2019. Nailah died from multiple organ failure after she was sent home from hospital and went into septic shock A consultant believed Nailah might have an intolerance to cow’s milk and changed the formula she was being fed. A spokesman for the family said: “Nailah’s case not only vividly highlights the dangers of sepsis, but the potential consequences of poor communication between doctors as well as between doctors and families.” Read full story (paywalled) Source: The Telegraph, 7 March 2023
  4. Content Article
    Statement from Maria Caulfield, Parliamentary Under Secretary of State (Minister for Mental Health and Women's Health Strategy) on the Government’s initial response to the report of the independent review into the maternity and neonatal services at East Kent University NHS Foundation Trust that was published on the 19 October 2022. NHS England commissioned Dr Bill Kirkup to undertake this review following concerns about the quality and outcomes of care.
  5. Content Article
    Pain and trauma experienced as a preterm baby in the NICU have been linked to lasting psychological injury, altered brain development and individuals' ability to regulate emotions later in life. In this blog, Vox's Science and Health Editor Brian Resnick looks at how scientists are investigating how to treat pain in babies who can’t tell you when it hurts.
  6. News Article
    The trust at the centre of a maternity scandal has been ordered to report on urgent improvements in services for women and babies, amid ‘significant concerns’ about the risk of harm. The Care Quality Commission (CQC) used its enforcement powers to issue the conditions on East Kent Hospitals University Foundation Trust, after it carried out an unannounced inspection last month. However, the “section 31” warning letter has just been made public, and the first deadline for the trust to report back to the CQC is Monday (20 February). The CQC said some of the problems it found were due to the labour ward environment – but others involved monitoring of women and babies whose conditions deteriorate and the risk of cross-infection due to poor cleanliness standards. “We have significant concerns about the ongoing wider risk of harm to patients and a need for greater recognition by the trust of the steps that can be taken in the interim to ensure safety and an improved quality of care,” Carolyn Jenkinson, CQC’s deputy director of secondary and specialist healthcare, said in a statement today. Read full story (paywalled) Source: HSJ, 17 February 2023
  7. News Article
    Two health watchdogs have issued safety warnings after junior staff were left to work unsupervised on maternity wards previously criticised after a baby’s death. Training regulator, Health Education England (HEE), criticised the “unacceptable” behaviour of consultants who left junior doctors to work without any superiors at South Devon and Torbay Hospital Foundation Trust’s wards. The maternity safety watchdog Healthcare Safety Investigation Branch (HSIB) also raised “urgent concerns” over student midwives and “unregistered midwives” providing care without supervision. The latest criticism comes after the trust was condemned over the death of Arabella Sparkes, who lived just 17 days in May 2020 after she was starved of oxygen. According to a report from December 2022, seen by The Independent, the HEE was forced to review how trainees were working at the trust’s maternity department after concerns were raised to the regulator. It was the second visit carried out following concerns about the department, and reviewers found there had been “slow progress” against concerns raised a year earlier. Read full story Source: The Independent, 16 February 2023
  8. News Article
    Most health claims on formula milk products have little or no supporting evidence, researchers have said, prompting calls for stricter marketing rules to be introduced worldwide. Millions of parents use formula milk in what has become a multibillion-dollar global industry. But a study published in the BMJ has found most health and nutritional claims about the products appear to be backed by little or no high-quality scientific evidence. “The wide range of health and nutrition claims made by infant formula products are often not backed by scientific references,” said Dr Ka Yan Cheung and Loukia Petrou, the joint first co-authors of the study. “When they are, the evidence is often weak and biased.” Dr Daniel Munblit and Dr Robert Boyle, senior co-authors for the study, added: “There is a clear need for greater regulation and oversight to ensure that these claims are supported by sound scientific evidence and to protect the health and wellbeing of our youngest and most vulnerable populations.” Read full story Source: The Guardian, 15 February 2023
  9. News Article
    Exploitative and “underhand” marketing of formula milk is preventing millions of women from breastfeeding, according to a series of reports published in the Lancet. The reports, by 25 experts from 12 countries, including paediatricians, public health specialists, scientists, economists and midwives, finds that the commercial milk formula companies “exploit parents’ emotions and manipulate scientific information to generate sales at the expense of the health and rights of families, women and children”. Breastfeeding promotes brain development, protects infants against malnutrition, infectious diseases and death, while also reducing risks of obesity and chronic diseases in later life. It also helps protect mothers against breast and ovarian cancers. The World Health Organization (WHO) recommends exclusively breastfeeding babies for the first six months and giving breast milk alongside solid food until the age of two or beyond. Over three reports, the series reveals how, more than 40 years since the World Health Assembly developed a voluntary international code prohibiting the marketing of infant formula, widespread violation of the code persists, with promotion of infant formula milk continuing in about 100 countries in every region of the world since the code was adopted. Read full story Source: The Guardian, 7 February 2023
  10. Content Article
    This Sky News investigation looks at one of the pharmaceutical industry's biggest scandals—the hormone pregnancy test Primodos which was prescribed to pregnant mothers in the UK between 1958 and 1978. Primodos was found to lead to birth defects, miscarriages and stillbirth, and regulatory failings led to avoidable harm to thousands of babies.
  11. News Article
    East Kent Hospital University Foundation Trust has been criticised for failures in services by the Care Quality Commission, after an unannounced inspection last month, years after major problems began to come to light. The Care Quality Commission has highlighted: Issues with processes for fetal monitoring and escalation at the William Harvey Hospital, Ashford. There had been “incidents highlighting fetal heart monitoring” problems in September and October, and the trust’s measures to improve processes were not “embedded and understood by the clinical team”; Slow maternity triage, due to staffing problems, and infection control problems at the William Harvey. The trust is reviewing how issues with infection prevention and control and cleanliness were not identified or escalated; and Fire safety issues at the Queen Elizabeth, the Queen Mother Hospital, in Thanet with problems linked to fire doors and an easily accessible secondary fire escape route. Three years ago issues with reading and acting on fetal monitoring were highlighted at the inquest into baby Harry Richford, whose poor care by the trust led to an independent inquiry into widespread failings in its maternity services, led by Bill Kirkup. Read full story (paywalled) Source: HSJ, 6 February 2023
  12. News Article
    Nurse Lucy Letby sent a sympathy card to the grieving parents of a baby girl just weeks after she allegedly murdered the infant, a court has heard. She is accused of trying to kill the premature baby, referred to as Child I, three times before succeeding on a fourth attempt on 23 October 2015. She denies murdering seven babies and attempting to murder 10 others. Manchester Crown Court was shown an image of a condolence card Ms Letby sent to the family of Child I ahead of her funeral on 10 November. The card was titled "your loved one will be remembered with many smiles". Inside, Ms Letby wrote: "There are no words to make this time any easier. "It was a real privilege to care for [Child I] and get to know you as a family - a family who always put [Child I] first and did everything possible for her. "She will always be part of your lives and we will never forget her. "Thinking of you today and always. Lots of love Lucy x." It is alleged that before murdering Child I, Ms Letby attempted to kill the infant on 30 September and during night shifts on 12 and 13 October. The prosecution said she harmed the premature infant by injecting air into her feeding tube and bloodstream before she eventually died in the early hours of 23 October 2015. Read full story Source: BBC News, 2 February 2023
  13. News Article
    Hepatitis B transmission from mothers to babies has been eliminated in England, according to the World Health Organisation (WHO). The WHO elimination target is that less than 2% of babies born to mothers with hepatitis B go on to develop the infection. And data from the UK Health Security Agency (UKHSA) shows the figure for England currently stands at 0.1% The UKHSA said progress had been made in tackling the viral infection, which can cause liver damage, cancer and death if left untreated. A six-in-one vaccine is offered to all babies on the NHS when they are eight, 12 and 16 weeks of age. Health and Social Care Secretary Steve Barclay said: “We are paving the way for the elimination of hepatitis B and C, with England set to be one of the first countries in the world to wipe out these viruses.” Read full story Source: The Independent, 2 February 2023 .
  14. News Article
    Donna Ockenden, who is leading an independent review examining how dozens of babies died or were injured at the Nottingham University Hospitals (NUH) trust, is due to meet with chief executive of NUH, Anthony May, and other members of the NUH executive team. Speaking ahead of the meeting, she said: "The commitment I want to give to the women and families of Nottingham is that real learning, real improvement in maternity safety will happen throughout the life of this review. "It won't be a case of waiting until the end and then presenting the trust with a huge amount of learning that they then have to start putting in place. "Today's meeting with the trust is at executive level. Along with colleagues from NHS England, I'll be meeting with the chief executive and some of his colleagues to talk about how we will ensure that learning reaches the trust on a regular basis and in a timely way so families can be assured that the maternity improvement plan is including learning from our review." Read full story Source: BBC News, 2 February 2023
  15. News Article
    An acute trust has been fined a record sum by the Care Quality Commission for failing to provide safe maternity care, which resulted in the death of a baby after 23 minutes. Nottingham University Hospitals must pay a fine of £800,000 within two years. It is only the second time the regulator has brought a case against a NHS maternity service, and the highest fine ever given for failings of this nature. The trust pleaded guilty earlier this week to two charges of failing to provide safe care and treatment to Sarah Andrews and her baby daughter Wynter Andrews at Queen’s Medical Centre in 2019, a short time after her birth by Caesarean section. This guilty plea saw the fine reduced from £1.2m. An inquest in 2020 found the death was a “clear and obvious case of neglect”. It was also found there was “an unsafe culture prevailing within maternity services”, including a “failure to listen and respond to staff safety concerns”. Read full story (paywalled) Source: HSJ, 27 January 2023
  16. Content Article
    This investigation by the Healthcare Safety Investigation Branch (HSIB) explored the detection and diagnosis of jaundice in newborn babies, in particular babies born prematurely (before 37 weeks of pregnancy). Specifically, it explored delayed diagnosis due to there being no obvious visual signs of jaundice apparent to clinical staff. Jaundice is a condition caused by too much bilirubin in a person’s blood. Bilirubin is a yellow substance produced when red blood cells are broken down. If left undiagnosed and untreated, high bilirubin levels in newborn babies can lead to significant harm. Newborn babies have a higher number of red blood cells in their blood which increases their risk of jaundice. Jaundice can cause yellowing of the skin and whites of the eyes; however, sometimes the visual signs of jaundice are not obvious, particularly for premature or newborn babies with brown or black skin. The reference event for this investigation was the case of baby Elliana, who was born at 32 weeks and 1 day via a forceps delivery and then transferred to the Trust’s special care baby unit (SCBU). Elliana was assessed on admission to the SCBU by staff as a clinically stable premature baby and a routine blood sample was taken from around two hours after her birth to establish a baseline. Analysis of the blood sample indicated bilirubin was present and so the level was measured. This result was uploaded onto the Trust’s computer system alongside the results of the blood tests that had been requested by the clinical team. The bilirubin result was seen by a SCBU member of staff who recognised that the level was high, indicating the possible need for treatment. However, this member of staff was then required to attend an emergency and the bilirubin result was not acted upon. Another blood sample was taken when Elliana was two days old and was uploaded to the Trust’s computer system. It is unclear if this bilirubin result was seen by staff; it was not documented in clinical records and was not acted upon. Over the next two days, Elliana continued to show no visible signs of jaundice that were detected by staff and she was documented to be developing well. When Elliana was five days old, a change in her skin colour was observed and visible signs of jaundice were detected. A further blood sample was taken which showed she had a high level of bilirubin in her blood and treatment was started accordingly. Elliana’s bilirubin levels returned to within acceptable levels over the next three days and she was subsequently discharged home.
  17. News Article
    A hospital trust is facing a fine in a criminal prosecution over the death of a baby. The Care Quality Commission (CQC) is prosecuting Nottingham University Hospitals (NUH) NHS Trust over the death of Wynter Andrews. Wynter died 23 minutes after she was born by Caesarean section in September 2019 at the Queen's Medical Centre.  The prosecution is one of only two the CQC has brought against an NHS maternity unit. The trust is due to face sentencing at Nottingham Magistrates' Court later. Read full story Source: BBC News, 25 January 2023
  18. Content Article
    This video from the Irish Health Services Executive (HSE) tells the story of Barry, a paediatric nurse who made a medication error when treating a critically ill baby. Barry describes how the incident and the management response to it affected his mental health and confidence over a long period of time. He also describes how he had to fight to ensure the family were told the full story of what had happened, and the positive relationship he developed with the baby's mother as a result. The baby received the treatment they needed and recovered well.
  19. Content Article
    This Health and Social Care Select Committee report reviews the progress that the UK Government has made in implementing the recommendations of the Independent Medicines and Medical Devices Safety Review, sometimes referred to as the Cumberlege Review. You can read Patient Safety Learning’s reflections on this report here.
  20. Content Article
    Institute of Health Visiting executive director Alison Morton warns national policy has developed a “baby blind spot” amid the NHS crisis, with many young children missing out on government’s promise of the “best start in life”, and calls for a shift towards prevention and early intervention.
  21. News Article
    With the distressing spate of news reports about mums and ­babies who weren’t kept safe in hospital, an initiative in the Midlands to improve patient safety in maternal and acute care settings comes as a relief. The newly announced Midlands Patient Safety Research Collaboration will bring together NHS trusts, ­universities and private business to evaluate how digital tools can help clinical decision making and reduce danger for patients. Problems can arise if communication is poor between medics when patients move between departments. Professor Alice Turner of Birmingham University said: “The power of new technology available to us means that we can address one of the ongoing areas of risk for patients, which is effective communication and clinical decision making. “The new collaboration will be looking at how digital tools can make a real difference to reduce risks and support patient safety in the areas of acute medicine and maternal health.” Digital decision-making tools could improve prescribing and personalised management for patients needing emergency care. Importantly, these tools should provide a smoother flow of information between healthcare professionals in acute care between hospitals, doctors and the West Midlands Ambulance Service, and hopefully reduce risks of patient harm at key points during acute care. Read full story Source: The Mirror, 18 December 2022
  22. Content Article
    On the 19 July 2021, an investigation commenced into the death of Quinn Lias Parker, born on the 14 July 2021, who died on 16 July 2021. The investigation continues and the case will come to Inquest in 2022. Quinn was born in a very poor condition, and it was sadly clear within 1- 2 hours of his birth, that he remained extremely unwell, and there was a high probability that he would not survive. There were concerns raised by his parents at this early point, regarding the care provided by The Trust, in relation to the management of Emmie, his mother, in late pregnancy, and regarding the timing of Quinn’s delivery. In the event of Quinn’s death, it would therefore require referral to the coroner, and thought needed to be given to the preservation of the placenta, to ensure that it was available for examination as part of the Paediatric post mortem. In this case, the placenta was cut into/dissected after Quinn’s death without discussion with the Coroner. This has affected the ability of the Paediatric Pathologist instructed by the Coroner, to determine the likely cause of Emmie’s antepartum haemorrhage. Whilst the medical cause of Quinn’s death will be explored in full at the Inquest, it is likely that the antepartum haemorrhage, and the underlying pathology causing it, is directly related to Quinn’s death. It is not clear how the placenta was cut into after Quinn’s death without discussion with the Coroner - this will be fully explored at the Inquest, but what is clear is that the outcome is highly detrimental to the independent investigation by the Coroner and other agencies investigating the circumstances of this case. This death follows a number of similar early neonatal deaths in Nottingham, where the placenta has not been retained, and therefore key information regarding placental pathology has been lost
  23. News Article
    Rare genetic disorders will be diagnosed and treated in babies thanks to a project to sequence the complete DNA of 100,000 newborns. It should spare hundreds of families in England months, or years, of anguish waiting to find out why their children are ill. The project is the first time that whole genome sequencing (WGS) has been offered to healthy babies in the NHS. It will screen for around 200 disorders, all of them treatable. The Newborn Genomes Programme, to begin next year, is thought to be the biggest study of its kind in the world. If successful, it could be rolled out across the country. Owen, 9, has an extremely rare genetic condition which affects his growth and development. Called THRA-related congenital hypothyroidism, it is one of the disorders which will be included in the new genetic test. Father, Rob Everitt, told the BBC: "I think of all the hours we spent in hospital waiting rooms, getting referred around different departments, all the tests - some of which were quite invasive - that drew a blank every time. I lost count of how many doctors and consultants we went to see and how many tests they did on him." Mother, Sarah Everitt, says getting the diagnosis was life-changing: "It was like winning the lottery….because we knew there was a treatment pathway; we knew we could get him support and he could attend a mainstream school." Read full story Source: BBC News, 13 December 2022
  24. News Article
    Lucy Letby used a plunger to force milk and air into one of the babies she is accused of attempting to murder, a medical expert has told a court. The alleged attack caused the infant’s stomach to distend to such a degree that she then projectile vomited a “massive” amount of milk so violently that the material left her cot and splashed over a chair several feet away. Staff at the Countess of Chester Hospital managed to save Baby G’s life but the incident was so catastrophic that it caused the child severe brain damage. Seven years later she still suffers from quadriplegic cerebral palsy. Dr Dewi Evans, a consultant paediatrician called in by the prosecution, said the use of a plunger on the end of a syringe was the only explanation for the baby’s sudden collapse in the early hours of 7 September 7 2015. Letby, 32, of Hereford, is accused of murdering seven children in the neonatal unit of the hospital in Cheshire, and of ten attempted murders, between June 2015 and June 2016. She denies all the charges. Read full story (paywalled) Source: The Times, 13 December 2022
  25. Content Article
    This report from the National Child Mortality Database (NCMD) covers the two-year period from 2019 to 2021, and is unique in two ways. It is the first national report to have investigated all unexpected deaths of infants and children—not just those that remained unexplained. It is also the first national review of the 'multi-agency investigation process' into unexpected deaths. The report found that, of all infant and child deaths occurring between April 2019 and March 2021 in England, 30% occurred suddenly and unexpectedly, and of these 64% had no immediately apparent cause. Other key findings relating to sudden and unexpected infant deaths (under 1 year) include: 70% were aged between 28 and 364 days, and 57% were male Infant death rates were higher in urban areas and the most deprived neighbourhoods For sudden and unexpected infant deaths that occurred during 2020 and had been fully reviewed, 52% were classified as unexplained (Sudden Infant Death Syndrome) and 48% went on to be explained by other causes such as metabolic or cardiac conditions.
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