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Content ArticleBabies 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.
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News ArticleNurse 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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News Article
Ian Paterson: Eleven further inquests set to open
Patient Safety Learning posted a news article in News
A further 11 inquests are to be opened this week as part of an investigation into dozens of deaths linked to jailed breast surgeon Ian Paterson. Paterson is currently serving a 20-year sentence after he carried out unnecessary or unapproved procedures on more than 1,000 breast cancer patients. Judge Richard Foster said 417 cases of former patients had been reviewed. The inquests will open and be adjourned on Friday. More than 30 deaths are already the subject of an inquest. Paterson worked at Spire Parkway Hospital and Spire Little Aston Hospital in the West Midlands between 1997 and 2011, as well as NHS hospitals run by the Heart of England NHS Foundation Trust. Paterson was jailed in 2017 after being convicted of 17 counts of wounding with intent. An independent inquiry found he had been free to perform harmful surgery in NHS and private hospitals due to "a culture of avoidance and denial" in a healthcare system where there was "wilful blindness" to his behaviour. Read full story Source: BBC News, 10 July 2023 -
News ArticleDaniel was about to get the fright of his life. He was sitting in a consulting room at the Royal Free hospital in London, speaking to doctors with his limited English. The 21-year-old street trader from Lagos, Nigeria, had come to the UK days earlier for what he had been told was a "life-changing opportunity". He thought he was going to get a better job. But now doctors were talking to him about the risks of the operation and the need for lifelong medical care. It was at that moment, Daniel told investigators, that he realised there was no job opportunity and he had been brought to the UK to give a kidney to a stranger. "He was going to literally be cut up like a piece of meat, take what they wanted out of him and then stitch him back up," according to Cristina Huddleston, from the anti modern slavery group Justice and Care. Luckily for Daniel, the doctors had become suspicious that he didn't know what was going on and feared he was being coerced. So they halted the process. The BBC's File on 4 has learned that his ground-breaking case alerted UK authorities to other instances of organ trafficking. Read full story Source: BBC News, 4 July 2023
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News Article
Survey shows high levels of abuse of UK doctors by patients
Patient Safety Learning posted a news article in News
More than half of UK doctors have seen or experienced abuse by patients or their relatives in the last year, including incidents in which they have been spat at and threatened. Doctors have variously had their hair ripped out, been backed up against a wall and been racially abused, a survey and dossier of testimonies collated by a medical organisation has revealed. Long delays for care and staff shortages are cited as the main triggers for what NHS leaders say is an increased readiness by the public to be aggressive towards frontline staff. The research by the Medical Protection Society (MPS) found that 56% of the doctors questioned had experienced or witnessed a situation involving verbal or physical abuse over the last year. Almost half said incidents had occurred because of a lack of staff, while 45% blamed it on patients’ frustration at having to wait a long time to be treated. One doctor told the MPS how a “patient’s partner threatened to kill me as he felt his wife had waited too long to be seen”, while another said: “I had a handful of my hair ripped out despite the patient being in handcuffs and with the police.” Read full story Source: The Guardian, 22 June 2023 -
News ArticleA Swedish appeals court on Wednesday increased a prison sentence for an Italian surgeon over experimental stem cell windpipe transplants on three patients who died. Dr Paolo Macchiarini made headlines in 2011 for carrying out the world’s first stem cell windpipe transplants at Sweden’s leading hospital and had been sentenced to no prison time by a lower court. But the Svea Court of Appeal concluded that there were no emergency situations among two of the three patients who later died, while the procedure on the third could not be justified. The appeals court sentenced the Italian scientist to 2 1/2 years in jail for causing the death of three people between 2011 and 2014. “The patients have been caused bodily harm and suffering,” the appeals court said of the two men and one woman. The patients, it concluded, “could have lived for a not insignificant amount of time without the interventions.” Macchiarini denied any criminal wrongdoing. Once considered a leading figure in regenerative medicine, Macchiarini has been credited with creating the world’s first windpipe partially made from a patient’s own stem cells. Read full story Source: ABC News, 21 June 2023
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News ArticlePolice are investigating about 40 hospital deaths over allegations of medical negligence made by two consultant surgeons who lost their jobs after blowing the whistle about patient safety. The allegedly botched operations took place at Royal Sussex County hospital (RSCH) in Brighton, part of University hospital Sussex NHS trust, when it was run by a management team hailed by Jeremy Hunt as the best in the NHS. Last week, detectives from Sussex police wrote to the trust’s chief executive, George Findlay, confirming they had launched a formal investigation into “a number of deaths” at the RSCH. They were investigating allegations of “criminal culpability through medical negligence” made by “two separate clinical consultants” at the trust, the letter said. It is understood about 40 deaths occurred between 2015 and 2020 after alleged errors in general surgery and neurosurgery departments. Both whistleblowers alleged the trust failed to properly investigate the deaths and learn from the mistakes made. Read full story Source: The Guardian, 9 June 2023
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Content ArticleThe MHRA has been made aware that falsified medical oxygen has been provided to several dental practices across the UK.
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News ArticleParamedics are being told to take a police escort to more than 1,200 addresses for fear of attack, The Times has revealed. The College of Paramedics said the figure was outrageous and called on courts to implement tougher sentences for assaults on paramedics. Ambulance services have marked hundreds of addresses after violence towards crew. Notes on addresses include “patient keeps axe under pillow — serrated knife hidden round the house and is known to be a risk”, “shoots/throws acid”, and “patient is anti-ambulance”. Read full story (paywalled) Source: The Times, 4 June 2023
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News Article
Approach to tackling violence raises concern among NHS England staff
Patient Safety Learning posted a news article in News
There has long been an acknowledgment by ministers and NHS leaders that violence against staff by patients was an issue that needed addressing, with a strategy to tackle it announced nearly five years ago. The health service’s 2019 long-term plan included a pilot for the use of body-worn cameras by paramedics in a bid to “de-escalate” situations. The following year the Crown Prosecution Service announced an agreement with the police and NHS England to “secure swift prosecutions” of those who assault staff, and the maximum penalty for assaulting emergency workers, including doctors and nurses, was also doubled to two years. Despite these measures, there have been internal disagreements within NHS England about the best approach to the problem, which affected almost 15% of staff last year, according to the latest national survey of the health service workforce. The Guardian understands that senior managers in NHS England told staff in its violence prevention and reduction (VPR) team last April that prosecutions of those who assaulted healthcare workers and dismissals of abusive staff should be a last resort. Instead, the focus should be on improving the culture of the NHS and staff wellbeing. It is also understood that managers cautioned against using the term “zero tolerance” because they said it did not take into account that some people who abuse NHS staff might lack capacity, an apparent reference to mentally ill patients. Read full story Source: The Guardian, 23 May 2023 -
News Article
Essex GP struck off over 'sexually motivated' examination
Patient Safety Learning posted a news article in News
A GP accused of trying to pull down a patient's gym shorts and of touching her genitalia has been struck off the medical register. The Medical Practitioners Tribunal Service found Dr Kamran Ali's behaviour towards four women at a surgery in Essex amounted to misconduct. The tribunal heard he had not practised since the allegations in 2016. The 44-year-old, of Glendale Gardens, Leigh-on-Sea, was cleared of criminal charges following a trial in 2018. Panel chairman William Hoskins said at the tribunal on Thursday that erasing him from the register was necessary to "protect public confidence in the medical profession". A female patient - referred to as Patient C - reported his behaviour to police in the November. She had complained of spots on her face, white coating on her tongue and wanted a repeat prescription for anxiety medication. The panel heard Dr Ali began to pull down her gym shorts and examined her genitalia without wearing gloves and without obtaining consent. Read full story Source: BBC News, 23 May 2023 -
News Article
35,000 cases of sexual misconduct or violence in NHS in five years
Patient Safety Learning posted a news article in News
More than 35,000 incidents of sexual misconduct or sexual violence - ranging from derogatory remarks to rape - were recorded on NHS premises in England between 2017 and 2022. Rape, sexual assault or being touched without consent accounted for more than one in five cases. Most incidents - 58% - involved patients abusing staff. The data was collected by the BMJ and the Guardian, and shared with BBC File on 4. Freedom of Information requests were received from 212 NHS trusts and 37 police forces in England. The data that came back from trusts showed at least 20% of incidents involved rape, sexual assault or inappropriate physical contact - including kissing. Other cases included sexual harassment, stalking and abusive or degrading remarks. One in five cases involved patients abusing other patients - although not all trusts provided a detailed breakdown. Meanwhile, police recorded nearly 12,000 alleged sexual crimes on NHS premises in the same time period - including 180 cases of rape of children under 16, with four children under 16 being gang-raped. Read full story Source: BBC News, 23 May 2023 -
News Article
150 ‘sexual safety incidents’ reported at ‘inadequate’ service in six months
Patient Safety Learning posted a news article in News
A mental health trust’s acute and intensive care wards have been downgraded to “inadequate”, following a series of incidents including sexual assaults, fire setting, and patients taking their own lives while on leave. The Care Quality Commission (CQC) inspection was prompted by reports of several serious incidents involving patients in these services. These included three occasions where patients had taken their own lives while on leave from wards, and four incidents where fires had been set at the Redwoods Centre in Shrewsbury. Inspectors also identified a steep rise in mixed accommodation breaches, with just one ward out of the four inspected at St George’s Hospital in Stafford and none of the three inspected at Redwoods providing single sex units. The CQC report added “there were concerns about the implications of mixed sex ward environments contributing to sexual safety incidents”, with 158 such incidents recorded in a six-month period leading up to the inspection. These included assaults, verbal threats of sexual assault, and sexual orientation related abuse, with 126 recorded at Redwoods and 32 at St George’s. Read full story (paywalled) Source: HSJ, 19 May 2023 -
News Article
Gosport hospital drug deaths: Police identify 19 suspects
Patient Safety Learning posted a news article in News
Nineteen suspects have been identified by police as part of a new inquiry into hundreds of deaths at a hospital. An independent panel found 456 patients died after being given opiates inappropriately at Gosport War Memorial Hospital between 1987 and 2001. The new criminal investigation is being led by Kent Police after three previous ones by Hampshire Constabulary resulted in no prosecutions. Police said interviews with the suspects under caution were ongoing. Detectives are examining more than 750 patient records as part of Operation Magenta after families, who have also campaigned for judge-led "Hillsborough-style" inquests, repeatedly called for justice. Read full story Source: BBC, 17 May 2023 -
News Article
Patient aggression up by a fifth despite trust’s interventions
Patient Safety Learning posted a news article in News
A hospital trust, which has already implemented a series of safety measures to protect employees, has reported a 17% rise in incidents of abuse against staff by patients and the public in the last year. Data from the Oxford University Hospital’s clinical incident system, shared with HSJ, shows there were 1,181 cases of violence and aggression against staff in 2022, up from 1,003 in 2021. Before late 2021, the monthly incident rate very rarely hit 100, while since January 2022 it has topped 100 in seven months, including 162 and 131 incidents respectively in January and February this year. The ongoing growth is despite the trust launching a campaign, called “No Excuses”, in January 2022,. Measures include bodyworn cameras, and safety devices with alarms and positioning technology for lone workers. Read full story (paywalled) Source: HSJ, 16 May 2023 -
News Article
Majority of NHS trusts provide no dedicated training to prevent sexual harassment
Patient Safety Learning posted a news article in News
Only one NHS trust in England provides dedicated training to prevent sexual harassment, according to research, raising concerns that the NHS is failing to adequately protect staff and patients. According to health union figures, sexual harassment of staff is pervasive. A 2019 survey by Unison found that one in 12 NHS staff had experienced sexual harassment at work during the past year, with more than half saying the perpetrator was a co-worker. In a recent BMA survey, 91% of female doctors reported sexism, 31% had experienced unwanted physical contact and 56% unwanted verbal comments. Yet research by the University of Cambridge, published in the Journal of the Royal Society of Medicine found that the vast majority of NHS trusts did not provide any dedicated training to prevent sexual harassment. The report analysed data from freedom of information requests from 199 trusts in England and found that just 35 offered their workers any sort of active bystander training (ABT), while only one NHS trust had a specific module on sexual harassment. ABT is designed to give individuals the skills to call out unacceptable behaviour, from workplace bullying to racism and sexual misconduct. It is widely used by the military, universities and Whitehall, including the Home Office. Read full story Source: The Guardian, 5 May 2023- Posted
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News Article
Whorlton Hall: Four guilty of ill-treating hospital patients
Patient Safety Learning posted a news article in News
Four carers have been found guilty of ill-treating patients at a secure hospital, following a BBC Panorama investigation. Nine former staff at Whorlton Hall, near Barnard Castle, County Durham, had faced a total of 27 charges. Five of those on trial have been cleared. Jurors heard vulnerable patients were mocked and treated with "contempt". Lawyers for the defendants argued their clients had been doing their best in very challenging circumstances. The men found guilty have been bailed and will be sentenced at Teesside Crown Court in July. Speaking after the verdicts, Christopher Atkinson, of the Crown Prosecution Service, said the four men had a "duty of care for patients who, due to significant mental health issues, were wholly dependent on their support every day of their lives". He said it was "clear" there were times when the care provided was "not only devoid of the appropriate respect and kindness required but also crossed the line into criminal offending". Read full story Source: BBC News, 27 April 2023- Posted
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Content ArticleA research paper was published in October 2021 highlighting results of Freedom of Information (FOI) Requests sent to NHS Trusts in England. The FOI Requests asked for the number of incidents of sexual assault reported by hospitals where the victim was aged over 60, and the alleged perpetrator was a member of staff. The resulting findings were that there were at least 75 reports of sexual assault on patients over 60 by hospital staff in the past five years. The findings also show that whilst the majority of victims were female, 30% were male and that a disappointing number were reported to police – only 16. Of these, 14 were closed as “No Further Action” by the police. In this viewpoint paper published in the Journal of Adult Protection, Amanda Warburton-Wynn highlights the findings of this research.
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News ArticleThe NHS has been criticised for sending vulnerable patients to a children’s hospital despite receiving reports of more than 1,600 “sexual safety incidents” at the 59-bed unit. A series of investigations by The Independent have exposed allegations of systemic abuse across a group of children’s hospitals run by the former Huntercombe Group. The latest revealed that a total of 1,643 “sexual safety incidents” had been reported in four years at its hospital in Maidenhead – accounting for more than half of all sex-related investigations reported in the 209 children’s mental health units across the country since 2019. Despite the majority of these reports being made prior to 2022-23, the NHS did not take any action and only stopped using the hospital, also known as Taplow Manor, this year. Gemma Byrne, head of health policy and campaigns at Mind, said in response to The Independent report on sexual incidents: “These horrific reports reveal the systemic scale of abuse and neglect in inpatient mental health settings. Even when patients bravely came forward to share their stories, some of which took place more than 10 years ago, young people continued to be sent to a unit which was known to have catastrophic failings in physical and sexual safety.” Read full story Source: The Independent, 18 April 2023
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News Article
Probe opened into deaths of 650 patients treated by jailed breast cancer surgeon
Patient Safety Learning posted a news article in News
The deaths of 650 patients treated by a breast cancer surgeon who was convicted of maiming hundreds are being investigated, it has been reported. Once one of the country’s leading doctors, Ian Paterson carried out thousands of operations before he was jailed for uneccesarily performing hundreds of life-changing surgeries. The Sunday Times has now revealed medical experts are sifting through the records of women who were cared for by the disgraced surgeon over more than twenty years. He is currently serving a 20-year jail term, having been found guilty of 17 counts of wounding with intent. Many of the procedures, which took place between 1997 and 2011, had “no medically justifiable reason”, a court heard. According to The Sunday Times, 27 inquests have been opened in cases where coroners “believe there is evidence to have reason to suspect that some of those deaths may be unnatural”. Read full story Source: The Independent, 16 April 2023 -
News ArticleA company which ran children's homes where residents were systemically abused also failed to prevent adults being harmed, BBC News has learned. An investigation found 99 cases of abuse at a Doncaster home for vulnerable adults in 2010. One worker even ordered a Taser to use there. The care home company - Hesley - said improvements were made at the time. But children at other Hesley homes were later reported to have been punched, kicked and fed chillies. The BBC reported in January how more than 100 reports of appalling abuse and neglect - dating from 2018 to 2021 - were uncovered at sites run by the Hesley Group. They included children being locked outside in freezing temperatures while naked, and having vinegar poured on wounds. Now the BBC has obtained confidential reports from within Hesley and the local authority which reveal wider safeguarding failings spanning more than a decade at both children's homes and placements for vulnerable young adults. Read full story Source: BBC News, 14 April 2023
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Content ArticleNine care home workers are facing trial for neglecting, verbally abusing and deliberately antagonising extremely vulnerable patients at Whorlton Hall. The six men and three women, aged 25-54, are being prosecuted after a reporter went undercover and filmed the behaviour for a BBC Panorama documentary. George Julian repots on the case at Teesside crown court in Middlesbrough.
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News Article
1,643 ‘sexual safety incidents’ in a single 59-bed children’s unit
Patient Safety Learning posted a news article in News
A single children’s mental health hospital with just 59 beds reported more than 1,600 “sexual safety incidents” in four years, shocking NHS figures reveal. Huntercombe Hospital in Maidenhead was responsible for more than half of the sex investigations reported in the 209 children’s mental health units across the country. Despite warnings at a rate of more than one a day to the health service since 2019, no action was taken to stop vulnerable NHS patients being sent to the scandal-hit unit as a result of the 1,643 sexual incident reports. The private unit is now finally due to be closed after an investigation by The Independent revealed allegations of verbal and physical abuse, prompting the NHS to withdraw patients. The hospital since said it plans to reopen as an adult unit. Figures obtained from the NHS show Huntercombe’s Maidenhead unit, Taplow Manor, was behind 57% of the 2,875 reported sexual incidents and assaults reported at England’s child and adolescent mental health services (CAMHS) over the past four years. Reported incidents can range from sexually inappropriate language to serious sexual assault and rape. Read full story Source: The Independent, 11 April 2023 -
News ArticleThe care watchdog is investigating possible safeguarding failures at an NHS trust after a documentary uncovered figures showing there were 24 alleged rapes and 18 alleged sexual offences in just three years at one of its mental health hospitals. The Care Quality Commission (CQC) told Disability News Service (DNS) that it had suspended the trust’s ratings for wards for people with learning difficulties and autistic people while it carried out checks. The figures were secured by the team behind Locked Away: Our Autism Scandal, a film for Channel 4’s Dispatches, which revealed the poor and inappropriate treatment and abuse experienced by autistic people in mental health units. None of the alleged rapes at Littlebrook Hospital in Dartford, Kent, led to a prosecution, with allegations of 12 rapes and 15 further sexual offences dropped because of “evidential difficulties” and investigations into 12 other alleged rapes and two sexual offences failing to identify a suspect. A CQC spokesperson said: “Sexual offences are a matter for the police in the first instance. “However, we take reports of sexual offences seriously and review them all, and raise these issues directly with the trust. “We do this alongside involvement from police and local authority safeguarding teams’ own investigations and monitor any actions and outcomes taken by the trust to ensure people are kept safe." Read full story Source: 30 March 2023
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News ArticleA scandal-hit children’s mental health hospital will close months after an investigation by The Independent uncovered claims of poor care and systemic abuse. Taplow Manor hospital, in Maidenhead, was threatened with closure by the NHS safety watchdog, the Care Quality Commission, only last week if it failed to make improvements following a damning report. Active Care Group, which runs the hospital, confirmed it would close by the end of May, saying a decision by the NHS to stop admitting patients had rendered its “service untenable”. The move comes after an investigation by The Independent and Sky News heard from more than 50 patients who alleged “systemic abuse” by the provider, while Taplow Manor is facing two police probes – one into a patient death and a second into the alleged rape of a child involving staff. Read full story Source: The Independent, 29 March 2023
