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News Article
Senegal midwives convicted over mother's death
Patient Safety Learning posted a news article in News
Three Senegalese midwives involved in the death of a woman in labour have been found guilty of not assisting someone in danger. They received six-month suspended sentences, after Astou Sokhna died while reportedly begging for a Caesarean. Her unborn child also died. Three other midwives who were also on trial were not found guilty The case caused a national outcry with President Macky Sall ordering an investigation. Mrs Sokhna was in her 30s when she passed away at a hospital in the northern town of Louga. During her reported 20-hour labour ordeal, her pleas to doctors to carry out a Caesarean were ignored because it had not been planned in advance, local media reported. The hospital even threatened to send her away if she kept insisting on the procedure, according to the press reports. Her husband, Modou Mboup, who was in court, told the AFP news agency that bringing the case to light was necessary. "We highlighted something that all Senegalese deplore about their hospitals," "If we stand idly by, there could be other Astou Sokhnas. We have to stand up so that something like this doesn't happen again." Read full story Source: BBC News, 11 May 2022 -
News ArticleHeart surgery patients in London have died “unnecessarily” and faced increased risk of death as botched NHS investigations into dozens of deaths reduced a hospital’s ability to treat people, a coroner has warned. “Unnecessary” patient deaths have occurred as a result of heart surgery at St George’s University Hospital Trust being restricted and emergencies diverted to other “over stretched” hospitals, following investigations by national NHS bodies. The warning that deaths have occurred and may occur in the future, comes following the conclusion of a series of inquest hearings in March, during which it was found the NHS’ wrongly blamed a team of cardiac surgeons for the deaths of dozens of patients. Coroner Fiona Wilcox, in a report published on Wednesday, has now said the “inadequate” NHS led investigations, which criticised the care of 67 patients, led to people being put increased risk of death. The NHS’ investigations into the deaths of 67 patients ruled there were “shortcomings” in care. It led to complex operations being diverted elsewhere and doctors being referred to the General Medical Council. Two doctors have sinced been exonerated following GMC hearings. According to the coroner’s findings, capacity within cardiac surgery at the unit is down by 60% and staff are becoming “deskilled.” Read full story Source: The Independent, 11 May 2022
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News Article
Nurse who filmed unconscious patients at hospital jailed for 12 years
Patient Safety Learning posted a news article in News
A nurse who filmed up the gowns of unconscious women patients and recorded staff using the toilet at a large teaching hospital has been jailed for 12 years by a judge who said he had "brought shame on an honourable profession". Paul Grayson, 51, was also told by the judge he must serve an extended licence period of 4 years when he is eventually released. The judge described how four patients were targeted as they recovered from surgery at Sheffield's Royal Hallamshire Hospital – one of whom has never been identified from the footage. Sentencing Grayson on Tuesday, Judge Jeremy Richardson QC said: "You have betrayed every ounce of trust reposed in you. Earlier this week, the court heard one victim, who was secretly filmed in the shower by Grayson over a number of years, face him directly in court as she told him his "sick and disgusting perversions" and "evil actions" were crimes that "have torn me into pieces". The court heard that one victim was unconscious after an eye operation when Grayson filmed her up her gown, and could be seen moving her underwear. The woman told police she had "put her trust in staff at the hospital to keep her safe". The victim said that she has since been due to have an operation at another hospital but she "can't bring myself to go". Read full story Source: Medscape UK, 11 May 2022 -
News Article
Plymouth maternity staff missed chances to save baby’s life, report finds
Patient Safety Learning posted a news article in News
A baby died after maternity staff repeatedly missed chances to intervene to save his life, an official investigation has found. Giles Cooper-Hall was just 16 hours old when he died after a catalogue of errors in the maternity care of his mother, Ruth Cooper-Hall, at Derriford hospital in Plymouth. A Healthcare Safety Investigation Branch (HSIB) report into the incident has exposed how inexperienced and overstretched staff failed to carry out proper checks, recognise there was an emergency or seek help from senior doctors until it was too late. It comes just weeks after the independent Ockenden report into more than 1,800 cases revealed serious failings in the maternity care provided at Shrewsbury and Telford hospital NHS Trust. It revealed how Ruth Cooper-Hall, then aged 37, was not personally seen by a consultant when she went into labour in October last year, despite recommendations made in the interim Ockenden report published in December 2020. The HSIB report also suggested Giles’ death could have been avoided if staff had known about the care plan for his mother’s labour. Instead, vital messages were not passed on, with the investigation finding this was likely to be because the staff responsible were “distracted” by other tasks. Read full story Source: The Guardian, 10 May 2022 -
News Article
Big rise in delayed GP referrals sparks safety warning
Patient Safety Learning posted a news article in News
A big rise in GP referrals being deferred because no appointment slots are available, in the wake of the covid pandemic, has sparked concerns that patients are going undiagnosed and missing out on the correct treatment. Outpatient referrals are typically classed as having an “appointment slot issue” when no booking slot is available within a timeframe specified by the provider, under the NHS e-referral system. The latest NHS Digital figures, analysed by HSJ, show the number of ASIs was 52% higher in March 2022 than February 2020 — up from 245,582 to 374,209. The statistics suggests appointment slot issue accounted for 77% of all bookings in March 2022, 26% of all referrals and 19% of bookings and referrals combined. In February 2020, this was 32%, 17% and 11% respectively. The Royal College of GPs told HSJ there was a risk of patients “simply disappearing” off lists if the issue was not properly managed, while charity Patient Safety Learning said the issue was a “growing problem” which NHS England must “urgently investigate”. Patient Safety Learning chief executive Helen Hughes said: “NHS England needs to urgently investigate, quantify the scale of the problem and take action if we are to prevent these capacity problems resulting in avoidable harm for patients. “Patients who cannot access outpatient services may deteriorate further while they wait for care, and it is not clear that in these cases there is the appropriate support available for them. There is also the potential for patients to be misdiagnosed and receive inappropriate treatment without specialist involvement, and the potential of a postcode lottery of care emerging for some conditions.” Read full story (paywalled) Source: HSJ, 6 May 2022 Read Patient Safety Learning's blog: Rejected outpatient referrals are putting patients at risk and increasing workload pressure on GPs -
News Article
‘Staff holidays’ delay death review by up to nine months
Patient Safety Learning posted a news article in News
A coroner has expressed ‘serious concern’ after a trust-wide safety review – prompted by the death of a young mother – was delayed by up to nine months due to ‘staff holidays’. An inquest heard that 25-year-old Natasha Adams, who died by suicide in August 2021, had had her level of care downgraded by Birmingham and Solihull Mental Health Foundation Trust a month earlier, in July, something her family suggested had a “dramatic impact”. She was moved from a “care programme approach” (known as CPA, which involves enhanced care for people with complex needs and/or safety concerns) to “care support” (a non-clinical programme for people with lower-level concerns and complexities). An earlier investigation into her death by the trust, finalised in December, said the trust should audit other cases to check whether the trust’s 2019 “care management and CPA/care support policy” was being complied with. Now Birmingham and Solihull coroner James Bennett has criticised a delay in carrying out the trust-wide audit – writing in a prevention of future deaths report that, as of last month, four months after the report investigating Ms Adams’ care was completed, “no action has been taken”. Read full story (paywalled) Source: HSJ, 5 May 2022 -
News Article
Hospital staff charged over patient mistreatment
Patient Safety Learning posted a news article in News
Five healthcare staff have been charged with criminal offences as part of a major investigation into the ill-treatment of hospital patients. Concerns had been raised over the welfare of some patients on the stroke unit at Blackpool Victoria Hospital. Three nurses and two healthcare assistants will appear at court for offences including unlawful sedation of patients and theft, police said. The charges relate to a period between August 2014 and November 2018. Those charged are Catherine Hudson, 52, of Coriander Close, Blackpool; Charlotte Wilmot, 47, of Bowland Crescent, Blackpool; Matthew Pover, 39, of Bearwood Road in Smethwick; Victoria Holehouse, 31, of Riverside Drive, Hambleton, and Marek Grabianowski, 45, of Montpelier Avenue, Bispham. They face charges including ill-treatment or wilful neglect, encouraging a nurse to sedate a patient, theft, supplying drugs and perverting the course of justice. Read full story Source: BBC News, 6 May 2022 -
News Article
Maternity scandal review chair resigns after pressure from families
Patient Safety Learning posted a news article in News
The newly appointed chair of a major review into poor maternity care in Nottingham has resigned following mounting pressure from families. Julie Dent was appointed by the NHS just two weeks ago to lead a review into hundreds of cases of alleged poor care at Nottingham University Hospitals NHS Trust. On 7 April, more than 100 families called for Ms Dent to decline the offer after they had previously urged NHS England to appoint Donna Ockenden, who chaired the Shrewsbury and Telford maternity inquiry. In a letter to families on Wednesday, the chief operating officer of NHS England and NHS Improvement, David Sloman, said: “After careful consideration and further conversations with her family, Julie Dent has, for personal reasons, decided not to proceed as chair of the independent review of maternity services at Nottingham University Hospitals NHS Trust.” The letter said that NHS England and NHS Improvement would still have “oversight” of the independent review, and that a new review process was being established. Mr Sloman said he would write to families to inform them of the next stage in the review “shortly”. The Nottingham independent maternity review was launched in July last year, and since then more than 500 families have come forward, the majority in the last two months. Read full story Source: The Independent, 4 May 2022 -
News ArticleSir Robert Francis has announced he is to step down as chair of Healthwatch England 20 months early, claiming funding cuts mean the patient watchdog could soon struggle “to fulfil its vital role”. The prominent QC has also announced he will quit his position as a non-executive director of the Care Quality Commission on November 15 2022. In a letter to Mr Javid, Sir Robert said it had been an “honour and a privilege” to serve on the CQC’s board and a “great pleasure” to support Healthwatch England. He added: “I believe [Healthwatch England] has proved its worth to your department and the system more generally and is now in an ideal position to help you take forward your agenda for improving the patient’s voice. “However, if I have one regret about my time as chair[man], it is that we have been unable as yet to find a way of reversing the alarming decline in the resources available to Healthwatch – I am afraid there is a growing risk the network will be unable to fulfil its vital role unless urgent attention is paid to this issue.” Sir Robert has chaired a number of independent inquiries involving the NHS, most notably the inquiry into poor care and high mortality rates at Stafford Hospital – which was published in February 2013. Last June, Sir Robert was appointed by the government to undertake an independent study into a framework for compensation for victims of the infected blood scandal. Read full story (paywalled) Source: HSJ, 3 May 2022
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News Article
Maternity scandal families slam NHS over no confidence vote ‘silence’
Patient Safety Learning posted a news article in News
Families impacted by the Nottingham maternity scandal say they have been left in “limbo” following silence from NHS England in response to their concerns over a major review, as 50 more come forward. The review into failures in maternity services at Nottingham University Hospitals Foundation Trust has now had 512 families come forward with concerns, up from 460 last month, and has spoken to 71 members of staff. The update comes as families told The Independent they were yet to receive a direct acknowledgement or response to their warning on Monday that they had no confidence in newly appointed review chairwoman Julie Dent. In response to a letter outlining her appointment, the families asked for Ms Dent to decline the offer and instead pushed for NHS England to ask Donna Ockenden, who is chairing a similar inquiry into Shrewsbury maternity care. Former health secretary and health committee chairman, Jeremy Hunt, has now also challenged the NHS on Ms Dent’s appointment, and echoed the families’ call to ask Ms Ockenden. Read full story Source: The Independent, 29 April 2022 -
News Article
Failing NHS negligence system must change, say MPs
Patient Safety Learning posted a news article in News
A major reform of the way NHS clinical negligence claims are handled in England is needed, MPs say. The House of Commons' Health and Social Care Committee said the current system was too adversarial, leading to bitter and long legal fights for patients. More than £2bn a year is paid out on claims, but 25% goes to legal fees. An independent body should be set up to adjudicate on cases and the need to prove individual fault should be scrapped, the cross-party group said. Instead, the focus should be whether the system failed, which the MPs believe would create a better culture for learning from mistakes. The committee heard from families who had lost children or whose babies had been left with brain injuries from mistakes made during birth. Parents described how they had to fight for years to get recognition for the harm that had been caused. One woman criticised the "complacent attitude" of the hospital involved, saying they just wanted to put it down to one mistake and carry on as normal. Another woman whose daughter died aged 20 months after errors in her care said she felt lessons had not been learnt despite a settlement in her favour. She said the whole process had left her feeling devastated. The average length of time for these settlements was over 11 years, the committee was told. Read full story Source: BBC News, 27 April 2022 -
News Article
Hepatitis: UK investigates sudden cases in children
Patient Safety Learning posted a news article in News
The UK’s Health Security Agency (UKHSA) says it is investigating after finding more than 100 cases of sudden hepatitis in children. Doctors said they had seen "increasing" evidence the problem is linked to adenoviruses - a group of viruses that can cause illnesses such as the common cold and flu. The HSA said it cannot rule out other possible causes such as Covid, which it is also investigating, but that an adenovirus has been identified in 40 out of the 53 cases so far tested. In Britain, cases have reached 81 in England, 14 in Scotland, 11 in Wales and five in Northern Ireland, with the majority of patients under five years old. No children in the UK have died, it was confirmed, after the World Health Organization said there had been 169 cases globally with at least one child who had died from the illness. Read full story Source: The Independent, 26 April 2022 -
News ArticleThe death of a young woman a day after she was discharged from a mental health facility has sparked renewed calls for a public inquiry into a scandal-hit trust. Abbigail Smith, 26, who had autism and learning difficulties, was found dead in a park in Essex in February, 24 hours after she was allowed to leave the Linden Centre run by the Essex Partnership University Hospitals Foundation Trust (EPUT). The trust has launched an investigation into the care she received before she died, according to a letter seen by The Independent, and Essex Coroner’s Court will examine her death. The Independent can reveal 97 patient deaths have been declared by the trust between February 2021 and February 2022 under the national patient safety alert system. The trust is already facing an independent inquiry into 1,500 patient deaths between 2000 and 2020. Deaths after December 2020 will not be looked at by that inquiry. At least 68 families have called for a public inquiry into mental health services in Essex, led by Melanie Leahy, whose son Matthew died at the Linden Centre in 2012. Nina Ali, a solicitor at Hodge Jones & Allen, which is supporting the Wolffs and other families, told The Independent: “It is worrying that the government has and continues to completely ignore the call led by Melanie Leahy, now supported by some 68 families and individuals, for the current independent inquiry to be converted to a full statutory inquiry on the basis that the current inquiry – which lacks the statutory power to compel relevant documentary evidence to be obtained and to compel witnesses to attend and give their evidence under oath – will ultimately prove to be a complete waste of time and money.” Read full story Source: The Independent, 25 April 2022
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News Article
‘I thought she’d be safe’: a life lost to suicide in a place meant for recovery
Patient Safety Learning posted a news article in News
"I thought she would be safe at Chadwick Lodge,” said Natasha Darbon, recalling how she felt in April 2019 when her 19-year-old daughter, Brooke Martin, was admitted to the mental health hospital in Milton Keynes. Eight weeks later, Brooke took her own life. The jury at the inquest found that Brooke’s death could have been prevented and that the private healthcare provider Elysium Healthcare, which ran the hospital, did not properly manage her risk of suicide. It also found that serious failures of risk assessment, communication and the setting of observation levels contributed to her death. Elysium accepted that had she been placed on 24-hour observations, Brooke would not have died. In 2018, Brooke, who was autistic, was repeatedly sectioned under the Mental Health Act because of her escalating self-harm and suicide attempts. After a spell in an NHS facility in Surrey she moved to Chadwick Lodge, which specialises in treating personality disorders. After a few weeks there, Brooke was doing well and staff were pleased with her progress. She was due to move to Hope House, a separate unit at the hospital, to start more specialist therapy for emotionally unstable personality disorder, and was keen to make the switch. But then the teenager’s mental health deteriorated again. On 5 June 2019 she tried to kill herself. Five days later she was seen twice that evening secretly handling potential ligatures, but no appropriate action was taken. A few minutes later she was found unresponsive in her room. She received CPR but died the next day in Milton Keynes university hospital. After hearing the evidence about the care Brooke received in her final days, Tom Osborne, the coroner at the inquest, took the unusual step of issuing a prevention of future deaths notice. He sent it to Sajid Javid, the health secretary, and to Elysium Healthcare, as the owner of Chadwick Lodge. It set out the detailed criticisms that the jury had made of Elysium’s interaction with Brooke after her attempt to take her own life on 5 June. They cited the hospital’s failures to communicate information regarding Brooke’s suicide attempt, to search her room after she was found handling potential ligatures on the night she died, and to place Brooke on constant observations afterwards. Read full story Source: The Guardian, 24 April 2022 -
News Article
NHS orders new chair of review into baby deaths
Patient Safety Learning posted a news article in News
The NHS has ordered a new chair for the Nottingham maternity scandal review which is looking into hundreds of cases of alleged poor care. In a letter published late on Friday the NHS said there needed to be “urgent” changes to the way the review was being carried out and this included appointing a former NHS trust chair Julie Dent to lead the review. More than 100 bereaved families wrote to the health secretary Sajid Javid on 7 April calling for the review, to be overhauled and the chair Cathy Purt, to be replaced by Donna Ockenden who chaired the Shrewsbury maternity scandal inquiry. The Nottingham review, dubbed an “independent thematic review”, was launched in July 2021 and is being led by local NHS commissioners and NHS England. It was announced after The Independent and Channel 4 revealed millions had been paid out by the trust over 30 baby deaths and 46 incidents of babies left permanently brain damaged by Nottingham University Hospitals Foundation Trust. Sir David Sloman, the NHS chief operating officer, said in his letter on Friday: “Following discussions at both a regional and national level, it is clear that urgent changes to how the review is being delivered need to be made. A new chair needs to lead this review with sufficient senior experience to address the concerns and challenges faced at Nottingham University Hospitals, to speed up the process and to deliver a review that can bring about real change for women and babies in Nottingham. “It has therefore been agreed that the review will now have enhanced national oversight by NHS England and NHS Improvement and I am pleased to announce that Julie Dent CBE has agreed to take on the role of chair for this review and she will begin this work with immediate effect.” Read full story Source: The Independent, 23 April 2022 -
News Article
Hospital admits negligence over failings leading to baby’s sepsis death
Patient Safety Learning posted a news article in News
A hospital has admitted clinical negligence over maternity care failings that led to the potentially avoidable death of a 10-day-old baby, The Independent has learned. Kingsley Olasupo and his twin sister Princess were born on 8 April 2019 at Royal Bolton Hospital. Kingsley died 10 days later following a catalogue of mistakes, which included failing to screen him for sepsis. Kingsley and his sister were born premature at 35 weeks. Three days later he was admitted to the special care unit due to a low temperature and “poor” feeding. Despite being reviewed by two doctors he was not screened for an infection and not given antibiotics. His condition deteriorated and on 12 April he was diagnosed with bacterial meningitis and sepsis. Days later scans revealed he had severe brain damage and would not survive. Kingsley’s family said they had been “torn apart” by their son’s death and had pursued the trust to ensure a full independent investigation was carried out and lessons learnt. BFT launched an investigation into Kingsley’s care after Mr Olasupo and Ms Daley raised concerns over their son’s death. According to the trust’s investigation report, seen by The Independent, failings in care included that Kingsley was not screened for sepsis despite several “red flags”. Had this been done he would have been given antibiotics. When midwives first escalated concerns to the neonatal team no physical medical review of Kingsley took place. The investigation also found neonatal staff did not carry out daily reviews, and reviews that were done were incomplete and contained “inaccurate” and “misleading” information. Other failings included: “Ineffective” assessment of Kingsley’s wellbeing on the postnatal ward Poor communication between staff and poor handover processes No consideration was given to the fact Kingsley was not feeding well Inadequate recording of observations. Read full story Source: The Independent, 20 April 2022 -
News Article
GP sexually abused 48 patients over 35 years
Patient Safety Learning posted a news article in News
A doctor from North Lanarkshire has been found guilty of 54 sex offence charges against women over 35 years. Krishna Singh, 72, kissed, groped, gave inappropriate examinations and made sleazy comments to 48 patients during appointments in various medical settings. Prosecutors described how the sexual predator was "hiding in plain sight" over nearly four decades. The offences mainly occurred at medical practices in North Lanarkshire, but also at a hospital accident and emergency department, a police station and during visits to patients' homes. An investigation was launched into his behaviour when one woman reported him to authorities in 2018. A letter was then sent to all patients at the practice to see if they could help in the police inquiry. Many women became so uncomfortable going to see the GP that they brought a friend or relative to appointments. One woman tried to make her medication last longer to delay having to go back and see him. Prosecutor Angela Gray told the jury during the trial that Singh had been in a routine of abusing his position to offend against women. She said: "Sexual offending was part of his working life. Access to women as and when the situation arose and taking the chances when he could." Read full story Source: BBC News, 14 April 2022 -
News Article
CEO describes anger at ‘disrespectful’ staff
Patient Safety Learning posted a news article in News
The chief executive of a mental health trust grappling with care quality failures has described his anger at ‘disrespectful’ staff who have ‘now had to leave the organisation’. In a message to staff, seen by HSJ, Brent Kilmurray, chief executive of Tees Esk and Wear Valleys Foundation Trust, said a number of staff had “stepped away from our values”. HSJ has heard reports of 12 staff members within the trust’s forensic secure inpatient services being suspended in recent weeks, and some dismissed, after being caught sleeping on shifts and using electronic devices while meant to be observing patients. The reports are unconfirmed, but appear to be referenced in a message sent by Brent Kilmurray on 14 March, which said: “I’m sorry to say, there’s been a handful of people who have stepped away from our values and in doing so have now had to leave the organisation." Mr Kilmurray said the staff were in a “minority” and that when the trust investigated these matters “we have found far more excellent caring practice”. He added the trust is working with service leaders “to ensure that they understand their accountabilities for ensuring that services are safe”. Read full story (paywalled) Source: HSJ, 14 April 2022 -
News Article
UK officials investigate 74 child hepatitis cases
Patient Safety Learning posted a news article in News
Health officials are investigating 74 cases of hepatitis - or liver inflammation - in children across the UK since the start of this year. They say one potential cause of the illness could be adenoviruses, but they have not ruled out Covid-19 as a cause. Officials are examining 49 cases in England, 13 in Scotland and 12 across Wales and Northern Ireland. The UK Health Security Agency (UKHSA) said parents should be on the lookout for symptoms such as jaundice. Dr Meera Chand, director of clinical and emerging infections at UKHSA, said officials were looking at a wide range of possible factors which could be causing children to be admitted to hospital with liver inflammation. "One of the possible causes that we are investigating is that this is linked to adenovirus infection. However, we are thoroughly investigating other potential causes," she said. Other possible explanations being investigated include Covid-19, other infections or an environmental trigger. Read full story Source: BBC News, 13 April 2022 -
News Article
Governance scandal trust failing to manage complaints
Patient Safety Learning posted a news article in News
A trust which is facing major governance issues is failing to respond to hundreds of complaints properly, with patients and families waiting more than twice as long as the NHS target for responses to their concerns, an external review has found. Cornwall Partnership Foundation Trust, which is subject to regulatory action by NHS England, was found to be “not classifying complaints, concerns and comments accurately”, while staff had “no formal training”, meaning complaints were “not investigated appropriately”. Last year, the trust was embroiled in a governance scandal in which NHSE investigated multiple allegations of finance and governance failings, resulting in the departure of former CEO Phil Confue. Rachel Power, chief executive of the advocacy group Patients Association, told HSJ patient complaints often contain “vital intelligence” on how trusts can improve services and “essential warnings about any area where things might be going wrong”. According to the review, the backlog had stemmed from several factors. These included more work being needed on investigations that had not been thorough enough, and the relevant service teams not responding to enquiries by the complaints team. Additionally, there was a “lack of formal monitoring and review” to ensure complaint points were reported appropriately and consistently, and an “apparent lack of accountability by local teams for complaints” triaged through the trust’s patient liaison and complaints team. Read full story (paywalled) Source: HSJ, 12 April 2022- Posted
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News ArticlePatients continue to experience avoidable harms from unsafe care because the NHS fails to learn from its mistakes, a report that tracked what actions the NHS took following safety reviews over several decades has found. Patient Safety Learning looked at the findings of a variety of investigations, including widespread public inquiries, Healthcare Safety Investigation Branch (HSIB) reports, Prevention of Future Deaths reports, incident reports, and complaints and legal action by patients and their families. It found an “implementation gap” in learning lessons and taking action to prevent future harms. It highlighted an absence of a systemic and joined up approach to safety; poor systems for sharing learning and acting on that learning; lack of system oversight, monitoring, and evaluation; and unclear patient safety leadership. Helen Hughes, chief executive of Patient Safety Learning, said, “Time and time again there is a lack of action and coordination in responding to recommendations, an absence of systems to share learning, and a lack of commitment to evaluate and monitor the effectiveness of safety recommendations. “This is a shocking conclusion that is an affront to all those patients and families who have been assured that ‘lessons have been learnt’ and ‘action will be taken to prevent future avoidable harm to others.’ The healthcare system needs to understand and tackle the barriers for implementing recommendations, not just continually repeat them.” The report calls for “systemwide commitment and resources, with effective and transparent performance monitoring” for patient safety inquiries and reviews and HSIB reports to ensure that the accepted recommendations translate into action and improvement. Read full story Source: BMJ, 8 April 2022
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News Article
Care home resident died after unqualified nurse administered wrong medication
Patient Safety Learning posted a news article in News
A nurse with no qualifications gave a care home resident a fatal dose of the wrong drug, leading to her death before she then tried to cover up her mistake. Katherine Hutchinson gave Fiona Jayne Thorne a fatal overdose of a powerful anti-psychotic drug, which was meant for another patient, an inquest heard. She then tried to cover up her errors which contributed to the death of the 36-year-old with learning difficulties, Derbyshire Live reported . Ms Hutchinson had, at the time, been the nurse in charge at Whitwell Park Care Home, in Whitwell, Derbyshire despite not having any qualifications. She gave Miss Thorne clozapine, which had been intended for another resident, on October 6, 2010. Instead of owning up to what she did, Ms Hutchinson then tried to cover up her mistake by taking Miss Thorne to bed and leaving her there until she was discovered, Senior Coroner Dr Robert Hunter said. Miss Thorne was "found by the care support worker around midnight, when undertaking routine checks on residents”, the inquest heard. And then Ms Hutchinson’s mistake was only discovered after an audit was carried out of the medication trolley and a dosage of clozapine was found. Read full story Source: Mirror, 8 April 2022 -
News Article
NHS regulator ‘not fit for purpose’ for dismissing baby deaths scandal warnings
Patient Safety Learning posted a news article in News
The healthcare regulator has been branded “not fit for purpose” after dismissing warnings of the biggest maternity scandal in NHS history, The Telegraph can reveal. Letters seen by this newspaper show that the Care Quality Commission (CQC) told grieving parents it would not support an independent inquiry into baby deaths, just months before such an investigation was ordered. Rhiannon Davies wrote to the watchdog in Dec 2016, alerting the regulator to 19 avoidable deaths of mothers and babies at the Shrewsbury and Telford Hospital NHS Trust, as well as a string of cases where lives were put at risk. However, the head of the CQC at the time assured Ms Davies that the culture was “changing for the positive”, rebuffing her calls for an independent inquiry. Ms Davies had provided the watchdog with details of a string of deaths, which she and fellow bereaved parents had found from publicly available information. The information was contained in a letter to Jeremy Hunt, the health secretary at the time, and shared with the regulator, setting out why families believed an inquiry was required. On Tuesday night, Ms Davies said that the refusal of the CQC to back an investigation, and the false assurances given by its most senior figure, showed how it “never scratched beneath the surface” despite death after death. Ms Davies said that she had “absolutely no faith” in its current ability to regulate and spot future scandals, saying it had “pushed back” every effort made by families to expose the failings at Shrewsbury. “They are not fit for purpose because we cannot trust them to be doing their job properly,” she told The Telegraph. Read full story (paywalled) Source: The Telegraph, 5 April 2022 -
News Article
Families in Nottingham maternity inquiry hit out at review
Patient Safety Learning posted a news article in News
Dozens of families have written to the government expressing concern over a review into failing maternity units in Nottingham. A probe into Nottingham University Hospitals Trust is under way after dozens of babies died or were injured. But families say the review is "moving with the viscosity of treacle". They have called for Donna Ockenden, who led the inquiry into the UK's biggest maternity scandal, to take charge of a review. In a letter to Health Secretary Sajid Javid, a group of 100 people raised concerns with the current thematic review, which has been commissioned by the local clinical commissioning group (CCG) and NHS England, and NHS Improvement. According to the CCG, the review will look at themes and trends and put in "place detailed and measurable actions so improvements can be made fast". But families have questioned the independence of the review and the experience of the team to handle a probe of this magnitude. It is chaired by Cathy Purt, a long-time NHS manager who the families believe has no experience of running complex inquiries or maternity services. The letter states: "If families are to be safeguarded, real intervention is required." Read full story Source: BBC News, 7 April 2022 -
News Article
Increase in hepatitis (liver inflammation) cases in children under investigation
Patient Safety Learning posted a news article in News
The UK Health Security Agency (UKHSA) has recently detected higher than usual rates of liver inflammation (hepatitis) in children. Similar cases are being assessed in Scotland. Hepatitis is a condition that affects the liver and may occur for a number of reasons, including several viral infections common in children. However, in the cases under investigation the common viruses that cause hepatitis have not been detected. UKHSA is working swiftly with the NHS and public health colleagues across the UK to investigate the potential cause. In England, there are approximately 60 cases under investigation in children under 10. Dr Meera Chand, Director of Clinical and Emerging Infections, said: "Investigations for a wide range of potential causes are underway, including any possible links to infectious diseases. We are working with partners to raise awareness among healthcare professionals, so that any further children who may be affected can be identified early and the appropriate tests carried out. This will also help us to build a better picture of what may be causing the cases." "We are also reminding parents to be aware of the symptoms of jaundice – including skin with a yellow tinge which is most easily seen in the whites of the eyes – and to contact a healthcare professional if they have concerns." Read full story Source: UK Health Security Agency, 6 April 2022
