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Found 545 results
  1. News Article
    One of the NHS’ largest hospital trusts is being investigated over “possible gross negligence manslaughter” after a baby died 24 hours after her birth. Polly Lindop died at St Mary’s Hospital on 13 March and Greater Manchester Police have now launched a probe into her death. Police said its major incident team launched the investigation into “possible Gross Negligence manslaughter” after concerns were raised to the force and local coroner. DCI Mark Davis of GMP’s major incident team said: “First, I want to express my condolences to the parents of Polly at what is an extremely difficult time for them. Our thoughts will remain with them as we carry out our investigation. “A number of hospital staff have been spoken to as witnesses by officers and no arrests have been made at this time. “The hospital trust has been fully cooperative with the police and all relevant authorities have been kept informed. The investigation into Polly’s death is on-going and her family will continue to be kept updated in relation to any significant developments.” Read full story Source: The Independent, 5 June 2023
  2. News Article
    An NHS maternity department has been handed a warning notice by the health regulator because of safety failings. The Care Quality Commission (CQC) said it was taking the action over the James Paget Hospital in Norfolk to prevent patients coming to harm. Inspectors found the unit did not have enough staff to care for women and babies and keep them safe. The maternity department has been deemed "inadequate" by the CQC, which meant the overall rating for the hospital has now dropped from "good" to "requires improvement". Between June and November 2022 there were 30 maternity "red flags" that the inspectors found, of which more than half related to delays or cancellations to time-critical activity. In one instance, there was a delay in recognising a serious health problem and taking the appropriate action. The report also highlighted the service did not have enough maternity staff with the right qualifications, skills, training and experience "to keep women safe from avoidable harm and to provide the right care and treatment". Read full story Source: BBC News, 31 May 2023
  3. News Article
    Health inspectors considered shutting down a maternity unit earlier this year over safety concerns. The Care Quality Commission (CQC) instead called for "immediate improvements" following a visit to the William Harvey hospital in Ashford, Kent. Helen Gittos, whose newborn daughter died in the care of the East Kent Hospitals Trust, said there were "fundamental" problems at the trust. The inspection of East Kent's William Harvey hospital laid bare multiple instances of inadequate practices at the unit, including staff failing to wash their hands after each patient, and life-saving equipment not being in the right place. Days after the visit, the watchdog raised safety concerns and threatened the trust with enforcement action to ensure patients are protected. Ms Gittos, whose baby Harriet was born at the East Kent trust's Queen Elizabeth the Queen Mother Hospital (QEQM) in 2014 and died eight days later, said: "When my daughter Harriet was born, the then head of midwifery was so concerned about safety that she thought that the William Harvey in particular should be closed down." She told BBC Radio 4's Today programme: "Here we are, almost nine years later, in a similar kind of situation. What has been happening has not worked. "I keep being surprised at how possible it is to keep being shocked about all of this, but I am shocked, that under so much scrutiny, and with so much external help, it's still the case that so much is not right. "The problems that are revealed are so fundamental that we have to do things differently." Read full story Source: BBC News, 26 May 2023
  4. News Article
    A baby has died and seven others were left requiring intensive care after a “usually mild” virus appeared to trigger a serious heart condition, health officials have said. The World Health Organization (WHO) said it had been notified of an “unusual” increase in myocarditis –inflammation of the heart – among newborns in south Wales infected with an enterovirus over the past year. While enteroviruses are common and often asymptomatic, they are known to cause “occasional outbreaks in which an unusually high proportion of patients develop clinical disease, sometimes with serious and fatal consequences – in this instance myocarditis”, the UN health agency said. While prior to the recent cluster of cases, south Wales had experienced only two similar cases in six years, the 10 months to April saw 10 cases of myocarditis in babies under the age of 28 days who tested positive for enterovirus, according to WHO. Read full story Source: The Independent, 19 May 2023
  5. News Article
    Hundreds of babies are dying unnecessarily because overstretched maternity services are delivering substandard care and struggling to overcome entrenched poverty and racial inequalities, a report has warned. The report by baby loss charities Sands and Tommy’s says the government’s aim to halve the number of stillbirths and neonatal deaths in England by 2025 is stalling, while there is no target in Scotland, Wales or Northern Ireland. Stillbirths are creeping up in England after falling in the past decade. Babies dying before and during delivery rose to just over four in every 1,000 births in 2021. Similarly, long-falling rates of neonatal deaths, where newborns die within the first four weeks of birth, are also rising. There were 1.4 deaths of newborn babies for every 1,000 births in 2021, compared with 1.3 in 2020. Robert Wilson, head of the charities’ joint policy unit, said the government and NHS need to make fundamental changes. “The UK is not making enough progress to reduce rates of pregnancy loss and baby death, and there are worrying signs that these rates are now heading in the wrong direction,” he said. Read full story Source: The Guardian, 14 May 2023
  6. News Article
    Grieving parents have been left waiting more than 14 months for answers about why their 12-day-old son died. Elijah was born at Merthyr Tydfil's Prince Charles Hospital on 25 February 2022 and died after being diagnosed with enterovirus and myocarditis. Joann and Christian Edwards said they were told they would have a report by the end of 2022, but are still waiting. Joann and Christian, from Mountain Ash, Rhondda Cynon Taf, said they were told Elijah's myocarditis was a "one off" but subsequently read about 10 babies, including one who died, getting severe enterovirus with myocarditis across south Wales. Public Health Wales (PHW) said Elijah's death was not being looked into as part of an investigation into this cluster of cases, as the dates were set at June 2022 to April 2023 to coincide with the enterovirus season. But it said it would look to include Elijah's death as part of a "wider clinical investigation" of the cases. Read full story Source: BBC News, 15 May 2023
  7. News Article
    A father whose baby died at six weeks after his vitamin K jab was missed has urged parents not to be taken in by misinformation spreading across social media. Alex Patto, 33, and his wife wanted their newborn son, William, to have the vitamin K jab to protect him against a rare but serious bleeding disorder known as vitamin K deficiency bleeding (VKDB). But the Rosie Hospital in Cambridge missed the jab and their firstborn child tragically passed away at six weeks old after suffering a bleed on his brain. Cambridge University Hospitals NHS Foundation Trust has completed a serious incident report and an inquest is due to take place in the coming months. Having gone through baby loss, Alex said he finds it “hard to understand” why parents would trust unverified information on social media over advice from their healthcare professional to opt into the jab. iNews previously revealed an increase in anti-vaccination misinformation on social media discouraging parents from getting the vitamin K jab for their newborn babies. The jab is a vitamin injection, not a vaccine – which are given to protect against infectious diseases – but doctors have reported videos on social media are incorrectly mislabelling it as such. Read full story Source: iNews, 23 March 2023
  8. News Article
    Staff in hospital emergency departments in England are struggling to spot when infants are being physically abused by their parents, raising the risk of further harm, an investigation has found. Clinicians often do not know what to do if they are concerned that a child’s injuries are not accidental because there is no guidance, according to a report from the Healthcare Safety Investigation Branch (HSIB) that identifies several barriers to child safeguarding in emergency departments. Matt Mansbridge, a national investigator, said the report drew on case studies of three children who were abused by their parents, which he said were a “hard read” and a “stark reminder” of the importance of diagnosing non-accidental injuries quickly, since these are the warning sign in nearly a third of child protection cases for infants under the age of one. “For staff, these situations are fraught with complexity and exacerbated by the extreme pressure currently felt in emergency departments across the country,” Mansbridge said. He said the clinicians interviewed wanted to “see improvement and feel empowered” to ask difficult questions. “The evidence from our investigation echoes what staff and national leads told us – that emergency department staff should have access to all the relevant information about the child, their history and their level of risk, and that safeguarding support needs to be consistent and timely/ Gaps in information and long waits for advice will only create further barriers to care,” he said. Read full story Source: The Guardian, 13 April 2023
  9. News Article
    Giving women a third scan at the end of their pregnancy could dramatically reduce the number of unexpected breech births and the risk of babies being born with severe health problems, research suggests. Pregnant women in the UK have routine scans at 12 and 20 weeks only, with no further scan offered in the third trimester unless they are considered at risk of a complicated pregnancy. The researchers hope their findings could lead to a change in guidance for clinicians that will improve maternity care. Prof Asma Khalil, who led the study at St George’s, University of London, said: “For the first time we’ve shown that just one extra scan could save mothers-to-be from trauma, an emergency C-section, and their babies from having severe health complications which could otherwise have been prevented.” She said the two routine scans were “far too early” to establish how the baby would be positioned during labour. “That’s why a third scan at 36-37 weeks could be a gamechanger to pregnancy and birth care.” Read full story Source: The Guardian, 7 April 2023
  10. News Article
    Mothers and babies are being put at risk because maternity services are still providing unsafe care, despite a series of scandals that have cost lives, the NHS ombudsman has warned. More tragedies will occur unless the health service takes decisive action to put an end to repeated and deeply ingrained problems which lead to “the same mistakes over and over again”, he said. Rob Behrens, the NHS ombudsman for England, voiced his concerns when he launched a report on Tuesday which details the failings several women experienced while giving birth. It also sets out the lessons the NHS needs to learn, but Behrens claimed that too many trusts were not doing so. Behrens voiced alarm that, although efforts have been made to improve the care mothers and their children receive, progress is too slow – and that means patients remain in danger. His report says that: “We recognise that people working in maternity services want to provide high-quality care. Culture, systems and processes can get in the way of achieving that goal. “But improvements are not happening quickly enough, and we have not seen sustainable change. We must do more to make services safer for everyone.” Read full story Source: The Guardian, 28 March 2023 Further reading on the hub: Patient Safety Learning - Mind the implementation gap: The persistence of avoidable harm in the NHS
  11. News Article
    Dilshad Sultana was 36 weeks pregnant with her second child in 2019 when she experienced stomach pain and noticed her baby was moving less. Mrs Sultana, from Sutton Coldfield, said she had been due to have a Caesarean section on 8 July but on 20 June she started to feel pain in her abdomen and lower back. She said she was confused but that it did not feel like a contraction and called hospital staff at about 17:00 to say it felt like her baby was moving less. After following advice to rest and take pain relief, she attended hospital at about 22:30 and staff started monitoring Shanto's heart rate. It was not until almost three hours later that Shanto was delivered by emergency C-Section. Shanto suffered severe brain damage and would spent the next 22 days in intensive care, suffering seizures and multiple brain haemorrhages. Shanto now requires around-the-clock care and Mrs Sultana enlisted lawyers to pursue a care of medical negligence against the trust. Birmingham Women's and Children's NHS Foundation Trust has admitted liability and made a voluntary interim payment allowing the family to move to a new home specifically adapted to meet Shanto's extensive care, therapy and equipment needs. Fiona Reynolds, the chief medical officer, said: "We'd like to offer our heartfelt apologies again to the family. "It's clear the standard of care we offered to them fell below those required and expected. For this, we are truly sorry." Now, Mrs Sultana is campaigning for change - she wants to see mothers listened to in maternity care and more attention paid to monitoring babies' heart rates. Read full story Source: BBC News, 27 March 2023
  12. News Article
    A terminally ill mother says she was "horrified" after she was handed her baby's remains in a supermarket carrier bag by NHS officials. Lydia Reid's son Gary was a week old when he died in 1975. She later discovered his organs had been removed for tests without her permission and only received them last month after almost 50 years of campaigning. The 74-year-old, told BBC Scotland she was visited last month by the head of NHS Lothian as well as another senior NHS official. "I thought they were coming to help me sign some papers. When they arrived I noticed one of them was carrying a Sainsbury's carrier bag," Ms Reid said. "Then they said they wanted to complete the list of body parts in case anything had been missed out. She handed me the Sainsbury's bag and said she wanted me to check them now." Inside the carrier bag was a six-inch box containing body parts preserved in wax. "I was so shocked and said 'How dare you. That is the only parts of my son and you want to hand them to me in a carrier bag. "I was absolutely horrified. She said she didn't realise it would be a problem." Tracey Gillies, medical director for NHS Lothian said: "I would like to repeat publicly the apology we made to Ms Reid in person for the upset and distress this has caused. Ms Reid has been a leading figure in the Scottish campaign to expose how hospitals unlawfully retained dead children's body parts for research. Read full story Source: BBC News, 23 March 2023
  13. News Article
    A woman was denied the chance to have children with her husband after a contraceptive coil was accidentally left in place for 29 years. Jayne Huddleston, from Crewe, had eight rounds of fertility treatment she did not need because the correct checks were not carried out by her doctor. She said the mistake happened in 1990. "The GP said it couldn't be seen, so I was sent for a scan and the scan didn't pick anything up, the GP recommended another coil was fitted," she told the BBC. She was told the coil she had fitted around a year earlier had probably fallen out. When she and her husband, David, then decided they wanted to have a child, the second coil was removed, but the first coil, which had gone undetected, remained inside her. They tried for years to have a baby, with no success, including IVF treatment which cost them thousands of pounds. The mistake was only discovered when she went for an X-ray in 2019 after complaining of back pain and the original coil was revealed. Mr and Mrs Huddleston were awarded a six-figure out of court settlement after taking their case to Irwin Mitchell solicitors. Read full story Source: BBC News, 16 March 2023
  14. News Article
    A new US study highlights a striking racial disparity in infant deaths: Black babies experienced the highest rate of sudden unexpected deaths (SIDS) in 2020, dying at almost three times the rate of White infants. The findings were part of research by the Centers for Disease Control and Prevention, which also found a 15% increase in sudden infant deaths among babies of all races from 2019 to 2020, making SIDS the third leading cause of infant death in the United States after congenital abnormalities and the complications of premature birth. “In minority communities, the rates are going in the wrong direction,” said Scott Krugman, vice chair of the department of pediatrics and an expert on SIDS at Sinai Hospital in Baltimore. The study found that rising SIDS rates in 2020 was likely attributable to diagnostic shifting — or reclassifying the cause of death. The causes of the rise in sleep-related deaths of Black infants remain unclear but it coincided with the arrival of the coronavirus pandemic, which disproportionately affected the health and wealth of Black communities. Read full story (paywalled) Source: The Washington Post, 13 March 2023
  15. 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.
  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. 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.
  18. 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.
  19. 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.
  20. 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
  21. 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.
  22. News Article
    A key national policy change recommended by the inquest which led to the East Kent maternity inquiry will not be implemented until next February – more than three years after it was called for by a coroner. The recommendation – that obstetric locum doctors be required to demonstrate more experience before working – was made in a prevention of future deaths report following the inquest into the death of seven-day-old Harry Richford at East Kent Hospitals University Foundation Trust. The remaining 18 recommendations from the PFD report were requiring specific actions by the trust, rather than national policy makers. The trust says they have been implemented. However, NHS England and the Royal College of Obstetricians and Gynaecologists have only in recent months produced guidance on using short-term locums in these services, and it will not come into effect until February. When it does, it will require them to complete a certification of eligibility, demonstrating they have had recent experience in a number of clinical situations, including complex Caesarean sections. Middle-grade locums have until next February to gain the certificate. The independent inquiry into maternity at the trust – prompted by Harry’s death – will report tomorrrow, Wednesday 19 October, and is expected to be highly critical of the trust, and of national efforts to make services safe over recent years. Read full story (paywalled) Source: 18 October 2022
  23. News Article
    The grandfather of a baby who died at a hospital that was fined over failings in the delivery has spoken of his five-year fight for justice. Derek Richford was speaking as an independent report into baby deaths at the East Kent Hospitals Trust will be released this week. He said he "came up against a brick wall" while searching for answers over the death of grandson Harry Richford. An inquest into Harry's death at Margate's Queen Elizabeth the Queen Mother Hospital in 2017 found it was wholly avoidable and contributed to by neglect. Coroner Christopher Sutton-Mattocks said the inquest, which was finally held in 2020, was only ordered due to the family's persistence. The following year the trust was fined £733,000 after admitting failing to provide safe care and treatment for mother Sarah Richford and her son following a prosecution by the Care Quality Commission (CQC). Mr Richford said: "To start with we felt fairly alone and we felt like we were coming up against a brick wall. "The trust were refusing at that time to call the coroner. They were reporting Harry's death as 'expected'. "We didn't contact anyone other than the CQC just to say 'look there's been a problem here'." He said at a meeting with the trust, more than five months later, "we suddenly realised that there were a huge [number] of errors". Mr Richford told the BBC: "It took me about a year to come up with all the detail I needed and to speak to all the right people." He said the family then spoke to the Health Safety Investigation Branch who found there were issues. Mr Richford also tracked down a "damming" report by the Royal College of Obstetricians and Gynaecologists (RCOG). "In the end it was like peeling back the layers of an onion, and the more you took off, the more you found," he said. Read full story Source: BBC News, 18 October 2022
  24. News Article
    Imtiaz Fazil has been pregnant 24 times, but she only has two living children. She first fell pregnant in 1999 and, over the subsequent 23 years, has had 17 miscarriages and five babies die before their first birthdays due to a rare genetic condition. The 49-year-old, from Levenshulme in Manchester, told BBC North West Tonight her losses were not easy to talk about, but she was determined to do so, in part because such things remained a taboo subject among South Asian groups. She said she wanted to change that and break down the stigma surrounding baby loss. She said her own family "don't talk to me very much about the things" as they think "I might get hurt [by] bringing up memories". "It's too much sadness; that's why nobody approaches these sort of things," she said. Sarina Kaur Dosanjh and her husband Vik also have the hope of breaking the silence surrounding baby loss. The 29-year-olds, from Walsall in the West Midlands, have set up the Himmat Collective, a charity which offers a virtual space for South Asian women and men to share their experiences. The couple, who have had two miscarriages in the past two years, said the heartache was still not something that people easily speak about. "I think it's hidden," Sarina said. "It's really brushed under the carpet." Read full story Source: BBC News, 13 October 2022
  25. News Article
    The chief executive of an NHS trust at the centre of a maternity scandal where there were at least seven preventable baby deaths has warned staff to prepare for a "harrowing report" into what happened. In an email seen by Sky News, East Kent Hospitals University NHS Foundation Trust chief executive Tracey Fletcher told her staff to expect a "harrowing report which will have a profound and significant impact on families and colleagues, particularly those working in maternity services". An independent investigation into the trust, stretching back over a decade, will be published this week and is expected to expose a catalogue of serious failings. It is also expected to say the avoidable baby deaths happened because recommendations that were made following reports into other NHS maternity scandals were not implemented. The East Kent review is led by obstetrician Dr Bill Kirkup, who also chaired the investigation into mother and baby deaths in Morecambe in 2015. Dawn Powell's newborn son Archie died in February 2019 aged four days. In an emotional interview, Mrs Powell told Sky News she will never get over the loss of her son, who would be alive today if she or Archie had been given a routine antibiotic. "For families like us, where your child has been taken away, you have forever got that hole in your life that you will never heal," Mrs Powell said. Read full story Source: Sky News, 16 October 2022
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