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News ArticleGreater Manchester Mental Health NHS Foundation Trust said a number of staff at its Edenfield Centre had been suspended after an undercover investigation found what was described as a "toxic culture" of humiliation, verbal abuse, and bullying of patients. BBC Panorama reporter, Alan Haslam, spent 3 months as a support worker at the Centre in Prestwich. Wearing a hidden camera, he said he observed staff swearing at patients, mocking them, and falsifying observation records. A consultant psychiatrist, Dr Cleo Van Velsen, who was asked by the BBC to review its footage, said it showed a "toxic culture" among staff at the Centre with "corruption, perversion, aggression, hostility, [and a] lack of boundaries". Dr Van Velsen told the BBC that staff members at the Edenfield Centre acted "like a gang, not a group of healthcare professionals". Patients at the Centre told the undercover reporter that they felt "bullied and dehumanised". Greater Manchester Police said it was working with the Crown Prosecution Service with a view to prosecuting anyone who had committed a crime. In a statement, Greater Manchester Mental Health NHS Foundation Trust said: "We are taking the allegations raised by Panorama very seriously since the BBC sent them to us earlier this month. We have put in place immediate actions to protect patient safety, which is our utmost priority. "Since then, senior doctors at the Trust have undertaken clinical reviews of the patients affected, we have suspended a number of staff pending further investigations, and we have also commissioned an independent clinical review of the services provided at the Edenfield Centre. " Read full story Source: Medscape. 29 September 2022
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News Article
Lawyers warned trust that staff could ‘pick and choose’ documents for coroners
Patient Safety Learning posted a news article in News
An ambulance trust accused of withholding key evidence from coroners was previously warned its staff needed training to ‘understand the real risk of committing criminal offences’ in relation to inquests into patient deaths. North East Ambulance Service, which has been accused by whistleblowers of withholding details from coroners in more than 90 deaths, was told by its lawyers in 2019 about serious shortcomings in its processes for disclosing information, according to internal documents obtained by a campaigner. According to the documents, the lawyers said trust staff could “pick and choose” documents to release to coroners “regardless of relevance.” The following year, an audit report said the issues had not been addressed. Whistleblowers’ concerns about the trust were first reported by The Sunday Times in the spring, with a review highlighting several cases between 2018 and 2019 where key facts were omitted in disclosures to coroners. But campaigner Minh Alexander has since obtained new details of warnings that were being made to internally, from lawyers and auditors who were advising the trust. Read full story Source: HSJ, 20 September 2022 -
News Article
Muckamore Abbey Hospital: Bid to suspend public inquiry dismissed
Patient Safety Learning posted a news article in News
A legal bid to suspend the public inquiry into alleged abuse at Muckamore Abbey hospital has been dismissed by a High court judge. The applicant in the case has been granted anonymity. They challenged Health Minister Robin Swann's refusal to suspend the public inquiry until criminal proceedings against them had concluded. Lawyers argued that the applicant's article six right to a fair trail had been jeopardised. The applicant's lawyers cited "adverse and prejudicial" commentary already in the media. Rejecting the application the judge, Mr Justice Colton, said that the applicant's article six rights were fully protected within the criminal trial process. The judge referred to submissions from the applicant's legal team who had argued that if the inquiry recommences as planned this month, it would consider evidence reported by the media which could affect the ability of a jury to act impartially. The judge told the court there was nothing to suggest that there had been a "virulent media campaign" about the applicant. Read full story Source: BBC News, 15 September 2022 -
News ArticlePolice are preparing to investigate alleged mistreatment of patients at a mental health unit. The Edenfield Centre based in the grounds of the former Prestwich Hospital in Bury is at the centre of the claims. The unit cares for adult patients. The Manchester Evening News understands that action was taken after the BBC Panorama programme embedded a reporter undercover in the unit and then presented the NHS Trust which runs it with their evidence. A spokesperson for Greater Manchester Police said: "We are aware of the allegations and are liaising with partner agencies to safeguard vulnerable individuals and obtain all information required to open an investigation." A spokesperson for Greater Manchester Mental Health NHS Foundation Trust said: "We can confirm that BBC Panorama has contacted the Trust, following research it conducted into the Edenfield Centre. We would like to reassure patients, carers, staff, and the public that we are taking the matters raised by the BBC very seriously". "Immediate action has been taken to address the issues raised and to ensure patient safety, which is our utmost priority. We are liaising with partner agencies and stakeholders, including Greater Manchester Police. We are not able to comment any further on these matters at this stage." Read full story Source: Manchester Evening News, 14 September 2022
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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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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
Devon carer who murdered woman had violent crime history
Patient Safety Learning posted a news article in News
A carer who murdered the elderly woman he was employed to look after had a history of violent crime including actual bodily harm, a report found. A safeguarding adults review over the death of a 77-year-old Devon woman in 2021 criticised working practices among organisations involved in her care. Devon and Cornwall Police did not disclose information about domestic abuse callouts involving the killer in a DBS check by the care provider. He was jailed for life in July 2022. The woman had seen her killer as "a grandson" figure, it said. The 35-year-old killer attacked his victim after she discovered he had stolen several thousand pounds from her. The had no previous employment experience of care before being taken on as her sole carer by Complete Quality Care Ltd, an independent care provider. Read full story Source: BBC News, 24 November 2022 -
News Article
Logan Mwangi murder: Injuries seen as accident by doctor
Patient Safety Learning posted a news article in News
Hospital doctors failed to share with child protection services a list of "significant" injuries a five-year-old boy suffered 11 months before he was murdered, a case review has found. Logan Mwangi had a broken arm and multiple bruises across his body when he was taken to A&E in August 2020. But a paediatric consultant said these injuries were accidental and did not make a child protection referral. Logan, from Bridgend, was murdered by his mother, stepfather and a teenager. A Child Practice Review (CPR) has looked at how different agencies were involved with Logan's family in the 17 months before his death. Cwm Taf Morgannwg health board said it welcomed the commissioning of an independent review into how it identifies and investigates non-accidental injuries. The report said that if the injuries had been shared with social services, appropriate action could have been taken to safeguard Logan. Jan Pickles, the independent chair of the review panel, said it was a "a significant missed opportunity". She added: "Had further information from health been shared it most likely, though we cannot say for sure because of hindsight bias, would have triggered a child protection assessment in line with the joint agreed guidelines, as the nature of those injuries clearly met the threshold." Read full story Source: BBC News, 24 November 2022 -
News Article
Ministers consider staff body cameras to tackle NHS mental health abuse scandals
Patient Safety Learning posted a news article in News
Ministers are considering the use of body cameras within mental health units as part of the government’s response to NHS abuse scandals, The Independent has learned. Senior sources with knowledge of the conversation between the Department for Health and Social Care and the NHS have raised concerns about the plans. There are fears that using the technology in mental health units could have implications for human rights and patient confidentiality. One senior figure criticised the proposals and said: “The DHSC are all talking about body-worn cameras, closed circuit TV, etc... The whole thing is fraught with huge difficulties regarding human rights, about confidentiality. They are thinking about it [cameras] and it is ridiculous.” The DHSC’s mental health minister Maria Caulfield said in parliament earlier this month that she and health secretary Steve Barclay were due to meet with NHS officials to discuss what response was needed to recent exposes of abuse within mental health services. It comes after a string of reports from The Independent, BBC Panorama and Dispatches revealing abuse of inpatients. The Panorama and Dispatches reports included video evidence of abuse captured by hidden cameras. Following a scathing independent review into the deaths of three young women, Tees, Esk and Wear Valleys NHS Trust said it is piloting the use of body-worn cameras across 10 inpatient wards “to support post incident reviews for staff and patients.” Read full story Source: The Independent, 23 November 2022 -
News Article
Care home killing: No risk assessment done on attacker
Patient Safety Learning posted a news article in News
No formal risk assessment was done on a man who beat a fellow care home resident to death, a review has found. Alexander Rawson attacked 93-year-old Eileen Dean with a metal walking stick at a care home in south-east London. Mrs Dean suffered catastrophic injuries to her head and body and died later in hospital. A review found Fieldside Care Home in Catford did not provide the specialist mental health services that Rawson - who had a history of violence - needed. Rawson, who had a history of mental health problems caused by alcoholism, was 62 when he was placed in the home a few days before Christmas 2020. He was put in the room next to Mrs Dean and, in the first week of 2021, he went into her room at night and attacked her. In a review published on Friday, the Lewisham Safeguarding Adults Board said Rawson had been moved into the home after being an inpatient at a psychiatric unit run by the South London and Maudsley NHS Foundation Trust. The care home was the only place that agreed to take him after his discharge from hospital. In the months before he was moved into the care home, Rawson was involved in at least 34 recorded incidents of violence or threats to patients and health staff, including a threat to kill. Before he was placed in the home, no attempts were made to find out whether Rawson had come into contact with the criminal justice system over his behaviour, the report found. It states that the care home had asked about the risks Rawson posed before they took him and had been reassured by a social worker and medical staff. Read full story Source: BBC News, 12 November 2022 -
News Article
NHS cyber attack hits patient care with records left in ‘chaos’ three months on
Patient Safety Learning posted a news article in News
Patient care is still being undermined at NHS mental health trusts and social care providers that were hit by a major cyber attack in August, doctors have warned. Three months after the major attack wiped out NHS systems, patients’ records are missing, safety has been compromised, and medication doses are at risk of being missed amid ongoing “chaos”, i News has been told. Dr Andrew Molodynski, mental health lead at the British Medical Association, said the prolonged systems failure has damaged care because records are “integral to patients’ safety”. Mental health patients’ records and safeguarding alerts have not been available in some trusts since 4 August, when NHS software provider, Advanced, was hit by a ransomware attack which targeted its Carenotes records system. A total of 12 NHS mental health trusts have been impacted by the cyber attack, potentially impacting tens of thousands of patients as well as social care providers. According to Advanced’s own hazard log spreadsheet, seen by i News, the risks associated with disruption to its server include “medication doses missed”, “required number of carers not met”, “basic needs not met, such as nutrition and personal care”, and “health needs not met, such as wound care and physical support”. Advanced said: “We recognise that the restoration process has taken longer than we had initially anticipated and we have sought to communicate as clearly and transparently as we have been able.” It said planned dates for restoring the system for each client has been communicated directly and that the “overall restoration programme remains on track”. Read full story Source: i News, 4 November 2022 -
News Article
Teeth-whitening: Reports of illegal procedures up 26%
Patient Safety Learning posted a news article in News
Reports of illegal teeth-whitening that could leave patients at risk of health problems including burns or lost teeth have increased, the BBC has found. General Dental Council (GDC) figures showed a 26% rise in reports last year. Teeth-whitening can only be performed legally in the UK by professionals registered with the GDC. One beauty school claimed to have provided "thousands" of candidates with illegitimate qualifications, an undercover investigation found. Failure to comply with the requirement to be registered can result in a criminal record and an unlimited fine. Untrained beauticians using teeth-whitening kits have been known to cause tooth loss, burns and blisters. Dr Ben Atkins, president of the Oral Health Foundation, said: "When things go wrong in dentistry, they can really go wrong. I've been that dentist with the full back up service when the patient's had that heart attack. It would be catastrophic for the patient and the person who's been trained and told it's legal to do it." Read full story Source: BBC News, 10 February 2020 -
News ArticleA GP has been given three life sentences for 90 sex assaults on female patients. Manish Shah assaulted 23 women and a 15-year-old girl while working in London - carrying out invasive examinations for his own gratification. The Old Bailey heard he used Angelina Jolie and Jade Goody as examples to frighten patients about their health. Judge Anne Molyneux described him as a "master of deception who abused his position of power". "You made up stories which got into heads and caused panic," she said. Shah, from Romford, convinced his victims to have unnecessary checks between May 2009 and June 2013. Read full story Source: BBC News, 7 February 2020
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Content ArticleDr Robert D. Glatter, medical advisor for Medscape Emergency Medicine, Dr Megan Ranney, professor of emergency medicine and the academic dean at Brown University School of Public Health and Dr Jane Barnsteiner, emeritus professor at the University of Pennsylvania School of Nursing, discuss the tragic case involving RaDonda Vaught, who was an ICU nurse who was recently convicted in Tennessee of criminally negligent homicide and gross neglect following a medical error due to administration of the wrong medication that led to a patient's death.
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Content ArticleIn this video, Dr Zubin Damania discusses the recent criminal conviction of US nurse RaDonda Vaught for a medical error and why this is terrible for patient safety, moral and the future of nursing and medicine.
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Content ArticleRaDonda Leanne Vaught faced criminal charges over a fatal medication error she made in 2017. Her trial has raised important questions over medical errors, reporting and process improvement, as well as who bears responsibility for widespread use of tech overrides in hospitals. There is debate over whether automated dispensing cabinet overrides are a reckless act or institutionalised as ordinary given the widespread use of IT workarounds among healthcare professionals. The Nashville District Attorney's Office described this override as a reckless act and a foundation for Ms. Vaught's reckless homicide charge, while some experts have said cabinet overrides are used daily at many hospitals.
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Content ArticleTwo professionals who treated Jack Adcock before his death were convicted of gross negligence manslaughter, receiving 24-month suspended sentences. His nurse, Isabel Amaro, was erased from the nursing register; but after reviews in the High Court and Court of Appeal, his doctor, Hadiza Bawa-Garba, was merely suspended. Nathan Hodson explores the proposition that nurses are at greater risk of erasure than doctors after gross negligence manslaughter through a close reading of the guidance for medical and nursing tribunals informed by analysis from the High Court and Court of Appeal in the Bawa-Garba cases.
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Content ArticleIn this article, the journalist Peter Hitchens examines the link between mental illness, prescription and illegal drugs and violent acts of terrorism. He argues that more attention needs to be given to defendants' mental health record, medication history and any past substance abuse.
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Content ArticleThis report from the Department of Health and Social Care sets out the Government’s response to the Independent Inquiry into the Issues raised by Paterson.
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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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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 ArticleNearly 150 doctors have been disciplined for sexual misconduct in the last five years, as surgeons call for action on the “systemic” and “cultural” problem of sexual assault within healthcare, The Independent can reveal. Doctors campaigning for the UK’s healthcare services to address widespread problems with sexual harassment and assault in medicine have warned that people do not feel safe to come forward with allegations amid deep-seated “hierarchies” within healthcare. The Royal College of Surgeons’ Women in Surgery chair has said the issues are “widespread” across the health services and improvements to protecting whistleblowers needed to be made nationally. Last year, surgeons Becky Fisher and Simon Fleming wrote an academic paper exposing the problem of sexual assault, harassment and rape in surgery and surgical training. In interviews with The Independent, both have warned the “institutional” problem goes beyond surgery and across all of the healthcare services. Mr Fleming said the figures from the GMC were the “the very tip of the iceberg” in terms of actual levels of sexual assault within healthcare. Talking about the role of the GMC, Mr Fleming said he’d been told “by more than one person” that when they’ve reached out to the GMC over sexual assault or misconduct they were “failed” by the regulator and were “either not helped, abandoned or told to deal with it locally”. Read full story Source: The Independent, 15 February 2022
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News Article
NHS hospital doctor arrested on suspicion of sexual assault
Patient Safety Learning posted a news article in News
Two NHS hospital trusts are working with police after a doctor was arrested on suspicion of sexual assault. Staffordshire Police has launched a major incident review of the doctor's work at hospitals in Dudley, West Midlands, and Stoke-on-Trent, The Sunday Times reported. The force said the 34-year-old man from the West Midlands was arrested in December and released on bail. It is reviewing an investigation into the same suspect it undertook in 2018. The doctor was suspended from seeing patients at the Royal Stoke University Hospital in Staffordshire when the parents of a vulnerable female raised concerns about his examination of her, the Sunday Times reported. The case was referred to police in 2018 who said there was "insufficient evidence to take further action" at the time. The Staffordshire force has now reported itself to the Independent Office for Police Conduct. University Hospitals of North Midlands NHS Trust, which runs the Royal Stoke, said it was working with police and had set up a helpline for any patient and guardian who may have concerns. Read full story Source: BBC News, 13 February 2022 -
News ArticleA formal complaint accuses the British Government of facilitating ‘the largest single health and safety disaster to befall the United Kingdom workforce since the introduction of asbestos products’. An expert letter to the UK Government’s Health & Safety Executive (HSE) from one of its own advisors accuses the agency of failing to use its statutory authority to correct “seriously flawed” guidance on infection protection and control (IPC), imperilling “the health and safety of healthcare workers by failing to provide for suitable respiratory protection”. The continued failure to protect healthcare workers by ensuring they are wearing the appropriate form of PPE (personal protective equipment) to minimise the risk of infection from COVID-19 airborne transmission, the letter says, has led to thousands of avoidable deaths. The failures amount both to “gross negligence” and serious “criminal offences”, claims the letter seen by Byline Times. The letter addressed to HSE chief executive Sarah Albon is authored by 27-year chartered health and safety consultant David Osborn, who is a ‘consultee member’ of the HSE’s COSHH (Control of Substances Hazardous to Health) Essentials Working Group, where he has helped HSE to prepare guidance for employers and employees. Written in his own personal capacity, the letter is a formal complaint accusing the members of the Government’s “IPC Cell” – a group of experts behind official guidance on infection protection and control – along with other senior Government officials of committing a “criminal offence… ultimately punishable by fine and/or imprisonment” by breaching Section 36 of the Health and Safety at Work Act. The letter argues that a police investigation is needed. The guidance, Osborn writes in his letter, has failed to ensure that healthcare workers understand that they should wear and have access to respiratory protection equipment (RPE) designed to protect from COVID-19 airborne transmission. “There is sufficient prima-facie evidence to suggest that the offence has led to the potentially avoidable deaths of hundreds of healthcare workers and the debilitating disease known as Long COVID in thousands of other healthcare workers,” the letter says. “I firmly believe that the primary source of infection was the inhalation of aerosols whilst caring for infected patients at close quarter,” says Osborn in his letter. Read full story Source: Byline Times, 10 February 2022
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News Article
Muckamore Abbey Hospital abuse inquiry to begin
Patient Safety Learning posted a news article in News
An inquiry into allegations of abuse at Muckamore Abbey Hospital officially begins on Monday. The Co Antrim facility treats patients with severe learning difficulties and mental health problems. Allegations of abuse at Muckamore Abbey Hospital - which is run by the Belfast Trust and located on the outskirts of Antrim - first came to light in 2017. Police said they reviewed thousands of hours of CCTV footage as part of a major investigation. At present seven people are to be prosecuted and more than 20 have been arrested for a range of offences, including alleged ill-treatment and wilful neglect. The core objectives of the inquiry are "to examine the issue of abuse of patients at Muckamore Abbey Hospital (MAH), to determine why the abuse happened and the range of circumstances that allowed it to happen and ensure that such abuse does not occur again at MAH or any other institution providing similar services in Northern Ireland". Read full story Source: Belfast Telegraph, 11 October 2021
