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Found 541 results
  1. News Article
    The Centers for Disease Control and Prevention alerted doctors nationwide Monday about a limited availability of certain doses of a newly approved antibody drug given to infants to prevent RSV infection. Cases of RSV, or respiratory syncytial virus, have started to rise as cold and flu season begins. "RSV season is here," said Dr. Buddy Creech, a pediatric infectious disease doctor at Vanderbilt University Medical Center in Nashville, Tennessee. "We are seeing a substantial increase in the amount of RSV such that in many areas, it has become the most commonly identified respiratory virus causing disease in children. "This is one of the reasons why there's probably a lot of scrambling going on," he said, "to identify those babies at highest risk and to try to prioritize them, since it's such a limited resource right now." Read full story Source: NBC News, 23 October 2023
  2. Content Article
    This is the first report of a national confidential enquiry specifically focussed on child deaths. Confidential enquiries have already contributed to major improvements in obstetrics, neonatal, and perioperative care in the UK. However they are time consuming and require extensive collaboration between various professional groups as well as the attention of a dedicated full-time research team. Hence, when planning a confidential enquiry in a new patient group, it is pertinent to investigate both feasibility and utility at its outset. The aim of this enquiry was to evaluate the feasibility of using this methodology to reduce the number of child deaths and make a significant contribution to child health in the UK. The basic functions of a confidential enquiry are: To develop and maintain a register of the cases under scrutiny. To subject cases in the register (or a specific sample of them) to review by a panel of experts with a focus on identifying avoidable factors where there have been adverse outcomes. Subsequent recommendations are then derived from both the analysis of the register and the conclusions of the expert review panels. This report presents the findings of a feasibility study “The Child Death Review” in which confidential enquiry methodology was applied to child deaths (28 days to 17 years 364 days) occurring in three regions of England, all of Wales and Northern Ireland in the calendar year 2006. A surveillance programme was mounted in order to determine where and when deaths occurred. A comprehensive core dataset was developed and then collected on all deaths. A sample, designed to have an even spread across age groups and the geographical areas involved, was then subjected to more detailed enquiry. This involved scrutiny of the available records by a multidisciplinary panel in each case.
  3. Content Article
    Research clearly demonstrates that from conception onwards, rapid brain development influences the cognitive, emotional and social development of babies and young children. Pre-conception to five years is an important time in a child’s life and critical for brain and psychological development, the formation of enduring relationship patterns, and emotional, social and cognitive functioning – all of which are foundations for healthy development, but which can also confer protection against mental health conditions. The establishment of sensitive, attuned and responsive relationships is essential for positive mental health and wellbeing and underpins interventions to address problems in social and emotional development, poor mental health and mental health conditions in under 5s. This report by the Royal College of Psychiatrists (RCPsych) aims to outline the importance of mental health in babies and young children under 5 to policy makers, commissioner and healthcare practitioners.
  4. Content Article
    The Medicines and Healthcare products Regulatory Agency (MHRA) are providing an update on a retrospective observational study on the risk to children born to men who took valproate in the 3 months before conception and on the need for the re-analysis of the data from this study before conclusions can be drawn. No action is needed from patients.  For female patients, healthcare professionals should continue to follow the existing strict precautions related to preventing the use of valproate in pregnancy (Valproate Pregnancy Prevention Programme).
  5. Content Article
    The Thirlwall Inquiry has been set up to examine events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital. This document sets out the terms of reference for this inquiry, following an engagement process led by the inquiry’s independent chair, Lady Justice Thirlwall, with the affected families and other stakeholders.
  6. Content Article
    This is guidance for dispensing of valproate-containing medicines in the manufacturer’s original full pack, following amendments to the Human Medicines Regulations (HMRs). These amendments currently apply in England, Scotland and Wales. This guidance should be regarded as good practice by pharmacists in Northern Ireland. The change comes into force in England, Scotland and Wales from 11 October 2023. 
  7. Content Article
    In this article, Sharon Hartles highlights the high-profile legal battle involving numerous Primodos-affected claimants against pharmaceutical companies and the government. The court ruled against the claimants, dismissing their claims related to hormone pregnancy tests and foetal harm. This decision led to disappointment and criticism from advocates, MPs, and academics involved in the Primodos scandal. Sharon Hartles is affiliated with the Risky Hormones research project, which is an international collaboration in partnership with patient groups. Additionally, she is a member of the Harm and Evidence Research Collaborative at the Open University. Related reading on the hub: Primodos 2023: The fight for justice continues for the Association for Children Damaged by Hormone Pregnancy Tests Primodos, mesh and sodium valproate: Recommendations and the UK Government’s response Primodos: The next steps towards justice Patient Safety Spotlight interview with Marie Lyon, chair of the Association for Children Damaged by Hormone Pregnancy Tests
  8. Content Article
    Harry's Story is a website set up by Derek Richford, the grandfather of Harry Richford, who died in November 2017 at just a week old following failures in care during and after his birth. The site outlines how Harry's family worked tirelessly to uncover what happened to Harry and the poor standard of care at the maternity unit at East Kent University Hospitals Foundation Trust (EKUHFT). It covers the following aspects of the family's experience: Our Investigation The Inquest Cover Up? - You Decide HSIB Involvement What Happened Next The Kirkup Inquiry Accountability Harry's Legacy The site also contains a section offering advice for parents whose babies die or suffer harm in hospital during the perinatal period.
  9. Content Article
    The Maternal, Newborn and Infant Clinical Outcome Review Programme, which is delivered by MBRRACE-UK, has published a report on UK Perinatal Deaths for Births from January to December 2021. Overall, it found that perinatal mortality rates increased across the UK in 2021, with 3.54 stillbirths per 1,000 total births and 1.65 neonatal deaths per 1,000 live births (3.33 and 1.53 respectively in 2020). However, there was a wide variation in stillbirth and neonatal mortality rates across organisations, though these rates increased in almost all gestational age groups. It was also found that inequalities in mortality rates by deprivation and ethnicity remain, but the most common causes of stillbirth and neonatal death are unchanged (for example, congenital anomalies continue to contribute to a significant proportion of perinatal deaths).
  10. Content Article
    On 18 August 2023, Lucy Letby was found guilty of murdering seven babies and convicted of trying to kill six other infants at the Countess of Chester Hospital. Looking ahead to the forthcoming independent inquiry into this case, Patient Safety Learning, reflecting on the inquiries of the past, sets out some key patient safety themes and issues that should be considered as part of this.
  11. Content Article
    This digital story produced by Patient Voices, hears from Claudia who reflects on the unexpected death of a baby she helped care for in hospital. Claudia describes her own and her team's emotions as they debriefed and embarked on their serious incident report.
  12. Content Article
    This is an oral statement given to the House of Commons by the Secretary of State for Health and Social Care, Steve Barclay MP, to update on the Lucy Letby statutory inquiry.
  13. News Article
    Babies could be needlessly hospitalised this winter because the government has delayed a vaccine that protects them from a life-threatening virus, the UK’s top children’s doctor has warned. Dr Camilla Kingdon, president of the Royal College of Paediatrics and Child Health (RCPCH), said she was “frustrated” by delays in introducing a new vaccine for respiratory syncytial virus (RSV), which drives 30,000 hospital admissions each winter and leads to dozens of deaths. She warned the delay meant thousands of children’s operations will have to be cancelled as RSV patients fill up beds – piling further pressure on already soaring waiting lists. It comes after the UK’s most senior A&E doctor, Dr Adrian Boyle, told The Independent that the government’s failure to prepare the NHS for winter could see thousands of people die needlessly this year. The Joint Committee on Vaccination and Immunisation (JCVI) said in June that a rollout of two RSV vaccines, one for babies and one for pregnant women, would be “cost-effective”, while the UK Health Security Agency (UKHSA) said there was a “strong case” for a jab. But it confirmed there was no timeframe for when vaccinations could start. Read full story Source: The Independent, 4 September 2023
  14. News Article
    Campaigners have expressed alarm at new analysis showing a sharp increase in new or expectant mothers waiting for mental health care, with one woman found to have waited 319 days for a first appointment. More than 30,000 women who are pregnant or have newly given birth are on waiting lists for mental health support, according to NHS England data analysed by Labour, with the party saying many of them were being left to “suffer in silence”. Amid rising demand for what are known as perinatal mental health services, during the period from August 2022 to March 2023 the numbers of women waiting rose by 40%. Over that same period, the numbers who accessed support also rose, but only by 8%. Read full story Source: Guardian, 4 September 2023
  15. News Article
    Tonjanic Hill was overjoyed in 2017 when she learned she was 14 weeks pregnant. Despite a history of uterine fibroids, she never lost faith that she would someday have a child. But, just five weeks after confirming her pregnancy she seemed unable to stop urinating. She didn’t realize her amniotic fluid was leaking. Then came the excruciating pain. “I ended up going to the emergency room,” said Hill, now 35. “That’s where I had the most traumatic, horrible experience ever.” An ultrasound showed she had lost 90% of her amniotic fluid. Yet, over the angry protestations of her nurse, Hill said, the attending doctor insisted Hill be discharged and see her own OB-GYN the next day. The doctor brushed off her concerns, she said. The next morning, her OB-GYN’s office rushed her back to the hospital. But she lost her baby. Black women are less likely than women from other racial groups to carry a pregnancy to term — and in Harris County, where Houston is located, when they do, their infants are about twice as likely to die before their 1st birthday as those from other racial groups. Black fetal and infant deaths are part of a continuum of systemic failures that contribute to disproportionately high Black maternal mortality rates. “This is a public health crisis as it relates to Black moms and babies that is completely preventable,” said Barbie Robinson, who took over as executive director of Harris County Public Health in March 2021. “When you look at the breakdown demographically — who’s disproportionately impacted by the lack of access — we have a situation where we can expect these horrible outcomes.” Read full story Source: KFF Health News, 24 August 2023
  16. News Article
    The inquiry into how nurse Lucy Letby was able to murder seven babies will now have greater powers to compel witnesses to give evidence. In a significant move, ministers upgraded the independent inquiry after criticism from families of the victims that it did not go far enough. The inquiry, ordered after Letby was found guilty this month, was not initially given full statutory powers. Health Secretary Steve Barclay said he had listened to the families. He said he had decided a statutory inquiry led by a judge was the best way forward and "respects the wishes" of the families. Mr Barclay said the key advantage was the power of compulsion. "My priority is to ensure the families get the answers they deserve and people are held to account where they need to be," he added. He said an announcement about who would chair the inquiry would be made in the coming days - ministers have already said it will be a judge. Richard Scorer, a lawyer who is representing two of the families, welcomed the government's announcement. "It is essential that the chair has the powers to compel witnesses to give evidence under oath, and to force disclosure of documents. Without these powers, the inquiry would have been ineffectual and our clients would have been deprived of the answers they need and deserve," he said. Read full story Source: BBC News, 30 August 2023
  17. News Article
    The cost of living squeeze is a significant factor in some stillbirths, according to case reviews carried out in one of England’s most deprived areas. The review was undertaken in Bradford last year, and concluded: ”the current financial crisis is impacting on the ability of some women to attend essential antenatal appointments”. Missing these appointments was a factor in a range of maternity safety events, including stillbirths, it said. The researchers are now calling for new national funding to help ensure expectant parents do not miss important appointments because they cannot afford to attend. The research findings include: ‘Did not attend’ rates increased due to lack of funds for transport to antenatal appointments; “Lack of credit on phones prevented communication between women and maternity services, for example, making [them] unable to rearrange scans or appointments”; Wide spread incidence of “digital poverty, [for example] a lady with type 1 [diabetes] was unable to monitor her glycaemic control over night due to only having one phone charger in the house”; and “Families with babies on a neonatal unit going without food in order to finance transport to and from the unit.” Read full story (paywalled) Source: HSJ, 25 August 2023
  18. Content Article
    In this letter, Rob Behrens, the Parliamentary and Health Service Ombudsman, calls on the Secretary of State for Health and Social Care, Steve Barclay MP, to prioritise improving patient safety in the wake of the Lucy Letby trial.
  19. News Article
    A paediatric nurse who called in to LBC news during a discussion on Lucy Letby, says she can see how Letby was able to get away with her crimes as she herself was 'blacklisted' when she reported a colleague. Watch the video Source: LBC News, 19 August 2023
  20. Content Article
    We now know that Lucy Letby is a murderer, responsible for the deaths of seven babies and the attempted murders of six more. But as unimaginable as her crimes were, this verdict raises as many questions as it answers. Letby was not working in a vacuum. Could the killings at the Countess of Chester Hospital NHS Foundation Trust have been stopped sooner? Did organisational failures cost the lives of babies who could have been protected? The timeline gives us a clue, writes Minh Alexander, a retired consultant psychiatrist and NHS whistleblower, in this Guardian opinion piece. In June 2016, Letby’s hospital trust commissioned a review of neonatal care by the Royal College of Paediatrics and Child Health after “concerns about increasing neonatal mortality”, which oddly did not feature a case-note review. This prevented detailed examination of the deaths, which should have been the prime objective. The college reported “extremely positive relationships” among staff but “remote” relationships with executives. Astonishingly, the college’s report seemingly did not explicitly acknowledge a possibility of deliberate harm. Nevertheless, the college raised concern that not all deaths were followed by postmortem investigations – as they should have been, according to guidelines – and that where postmortems did take place, they did not include systematic blood tests and toxicology. It noted concerns from obstetrics staff about four unexpected deaths. In the coming days, there will be many questions. Why did it take so long for the hospital to refer matters to the police? Were doctors pressured not to persist with their concerns about Letby? How many trust board members knew there was a possibility of deliberate harm but failed to act?
  21. Content Article
    On the 20 February 2019 an investigation commenced into the death of Bethan Naomi Harris who was born on the 16 November 2018 at the St George's University Hospitals NHS Foundation Trust. Bethan Naomi Harris died at Shooting Star Hospice on the 26 November 2018. Her mother's pregnancy had been uneventful. After admission to labour ward labour progressed very quickly indeed and Bethan sustained severe brain injury during delivery. Despite best efforts by the neonatal team she succumbed to her injuries. The Investigation concluded at the end of the Inquest on the 19 November 2019. The conclusion of the inquest was that the medical cause of Bethan's death was (1a) hypoxic ischaemic encephalopathy.
  22. News Article
    US regulators this week have approved the first RSV vaccine for pregnant women so their babies will be born with protection against the respiratory infection. The Food and Drug Administration cleared Pfizer’s maternal vaccination to guard against a severe case of RSV when babies are most vulnerable – from birth through six months of age. The next step: the Centers for Disease Control and Prevention must issue recommendations for using the vaccine, named Abrysvo, during pregnancy. “Maternal vaccination is an incredible way to protect the infants,” said Dr Elizabeth Schlaudecker of Cincinnati Children’s Hospital, a researcher in Pfizer’s international study of the vaccine. If shots begin soon, “I do think we could see an impact for this RSV season.” RSV is a coldlike nuisance for most healthy people but it can be life-threatening for the very young. It inflames babies’ tiny airways so it’s hard to breathe or causes pneumonia. In the US alone, between 58,000 and 80,000 children younger than five are hospitalised each year, and several hundred die, from the respiratory syncytial virus. Read full story Source: The Guardian, 22 August 2023
  23. News Article
    Lucy Letby sat with her parents in a meeting with senior managers at the Countess of Chester Hospital, where she worked, waiting patiently for an apology. She had prepared a statement that was read out by her parents to Tony Chambers, the hospital’s chief executive, about being bullied and victimised on the neonatal unit. It was December 22, 2016, and for the previous 18 months, two doctors on the unit had been trying to find an answer for a series of mysterious deaths of babies. Their detective work had led them to a single common denominator: Letby. The neonatal nurse had been on shift for each of the incidents. Rumours of a killer on the ward had spread and Letby had complained about the doctors and their finger-pointing, claiming she was being wrongly blamed. Chambers, who had trained as a nurse, was convinced by Letby’s account, and in front of her parents, John and Susan, offered sincere apologies on behalf of the hospital trust. The doctors in question would be “dealt with’’. Except the doctors were right. By that point Letby had secretly murdered seven babies and tried to kill six more, one of them twice. An investigation by The Sunday Times, based on a cache of internal documents, reveals in detail how the hospital delayed calling the police for months and that senior management, including the board, sided with Letby against doctors after commissioning perfunctory investigations. Read full story (paywalled) Source: The Times, 19 August 2023
  24. Content Article
    Babies would have survived if hospital executives had acted earlier on concerns about the nurse Lucy Letby, a senior doctor who raised the alarm has said. In an exclusive Guardian interview, Dr Stephen Brearey accused the Countess of Chester hospital trust of being “negligent” and failing to properly address concerns he and other doctors raised about Letby as she carried out her killings. Brearey was the first to alert a hospital executive to the fact that Letby was present at unusual deaths and collapses of babies in June 2015. The paediatrician and his consultant colleagues raised concerns multiple times over months before Letby, then 26, was finally removed from the neonatal unit in July 2016. The police were contacted almost a year later, in May 2017. Speaking publicly for the first time, Brearey told the Guardian that executives should have contacted the police in February 2016 when he escalated concerns about Letby and asked for an urgent meeting.
  25. News Article
    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.”
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