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Found 1,558 results
  1. News Article
    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
  2. News Article
    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
  3. News Article
    The 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
  4. News Article
    "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
  5. News Article
    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
  6. News Article
    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
  7. News Article
    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
  8. News Article
    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
  9. News Article
    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
  10. News Article
    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
  11. News Article
    Patients 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
  12. News Article
    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
  13. News Article
    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
  14. News Article
    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
  15. News Article
    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
  16. News Article
    Press release: 7 April 2022 Today the charity Patient Safety Learning has published a new report, ‘Mind the implementation gap: The persistence of avoidable harm in the NHS'. The report is an evidence-based summary of the failures over decades to translate learning into action and safety improvement. It highlights that avoidable unsafe care kills and harms thousands of people each year in the UK and costs the NHS billions of pounds for additional treatment, support, and compensatory costs. The report highlights how we fail to learn lessons from incidents of unsafe care and are not taking the action needed to prevent harm recurring. The report focuses on six sources of patient safety insights and recommendations, ranging from inquiry reports into patient safety scandals, such as the recent Ockenden report into maternal and neonatal harm at Shrewsbury and Telford Hospital, to the findings of Coroner’s Prevention of Future Deaths reports. It calls on the Government, parliamentarians, and NHS leaders to take action to address the underlying causes of avoidable harm in healthcare and proposes recommendations in each policy area. Patient Safety Learning is calling for system-wide action in healthcare to transform our approach to learning and safety improvement. Helen Hughes, Chief Executive of Patient Safety Learning, said: “Today’s report highlights the all too frequent examples of where healthcare organisations fail to learn lessons from incidents of unsafe care and not taking the action needed to prevent future harm. 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 learned’ and ‘action will be taken to prevent future avoidable harm to others’. The healthcare system needs to understand and address the barriers for implementing recommendations, not just continually repeat them. Hope is not a strategy.” This report has been published as part of the Safety for All Campaign, which calls for improvements in, and between, patient and healthcare worker safety to prevent safety incidents and deliver better outcomes for all. The campaign is supported by Patient Safety Learning and the Safer Healthcare and Biosafety Network. Notes to editors: Patient Safety Learning is a charity and independent voice for improving patient safety. We harness the knowledge, insights, enthusiasm and commitment of health and social care organisations, professionals and patients for system-wide change and the reduction of avoidable harm. Safer Healthcare and Biosafety Network an independent forum focused on improving healthcare worker and patient safety and has been in existence more than 20 years. It is made up of clinicians, professional associations, trades unions and employers, manufacturers and government agencies with the shared objective to improve occupational health and safety and patient safety in healthcare. COVID-19 pandemic has provided a stark reminder of the vital role healthcare professionals play in providing care to those in our society who need it most and this was recognized in the WHO Patient Safety Day in September 2020: only when healthcare workers are safe can patients be safe. In 2020, the Network launched a campaign called ‘Safety for All’ to improve practice in, and between, patient and healthcare worker safety to prevent safety incidents and deliver better outcomes for all.
  17. News Article
    THE majority of blood tests taken at Basildon Hospital to identify life-threatening illnesses have been contaminated in a “major failure”. An investigation has been launched by health bosses, with staff shortages allegedly causing the issue with “blood cultures”. Blood cultures, which look for germs or fungi in the blood and more deadly bacteria are routinely carried out ahead of operations. However, latest figures show that 70% of tests taken in the year up to January 2022 were found to be contaminated, leading to treatment being delayed as patients are re-tested. The normal limit of contaminated tests would be below 3%. The issue was raised at a joint board meeting of the clinical commissioning groups, which oversee local healthcare, on 24 March. Katherine Kirk, chairman of quality and governance committee at the Basildon and Brentwood group, said: “If I’m understanding this right and it’s about the effectiveness of blood tests, what’s going on? It’s clearly a major failure.” Read full story Source: The Echo, 4 April 2022
  18. News Article
    Detectives have begun an investigation into the deaths of two babies at the hospital trust at the centre of the largest maternity scandal in NHS history. The babies died in separate incidents last year at the Shrewsbury and Telford Hospital NHS Trust, both during birth. One of them was a twin. The cases were among 600 examined by West Mercia police alongside an inquiry by Donna Ockenden, a senior midwife and manager, into failings at the trust. Her report revealed last week that 201 babies had died and 94 suffered brain damage as a result of avoidable mistakes. Nine mothers also died because of errors in care. Detectives are working with prosecutors to determine whether charges should be brought over the two deaths last year, after years of warnings that maternity services were in crisis. West Mercia police said they were investigating the trust as an organisation as well as individuals. The trust could face a charge of corporate manslaughter if it is found that the way the hospital organised and managed its services caused a death that amounted to a “gross breach” of its duty of care. If found guilty, the trust would face an unlimited fine. Individuals charged with gross negligence manslaughter could go to jail if convicted. The move by the police comes amid growing fears that the unsafe care identified in the report could be taking place in maternity services in other parts of the country. Read full story (paywalled) Source: The Times, 3 April 2022
  19. News Article
    An independent investigation into the death of a man with autism and learning difficulties in NHS care may never be published in full as his sister has rejected several drafts as inaccurate, telling NHS England they were ‘totally unethical’. Anthony Dawson died from a burst gastric ulcer in Ashmount, a residential care home run by Surrey and Borders Partnership Foundation Trust, in May 2015. The jury at an inquest into his death found there were gross failings in his care and his death was contributed to by neglect. NHS England commissioned an independent investigation into the incident from Sancus Solutions in June 2017. But seven years after Mr Dawson’s death the investigation’s report has yet to be published, despite several reports being submitted. His sister, Julia Dawson, has written to NHS chief executive Amanda Pritchard in recent weeks saying: “The investigation has not had my brother at its heart which we were assured would be the case” and that its reports had been “totally unethical”. Ms Dawson has asked that only the executive summary of the latest draft of the investigation be published, alongside a statement saying that she feels it has inaccuracies and misses out important points. She says that successive drafts have misrepresented her brother’s situation and failed to address what she believes was the real cause of his death – the frequent use of NSAIDs (ibuprofen) without any measures taken to protect his stomach. This ultimately led to the undiagnosed gastric ulcer bursting. An expert witness told the inquest into his death that treatment with proton pump inhibitors and stopping NSAIDs would have eradicated the ulcer. Read full story (paywalled) Source: HSJ, 4 April 2022
  20. News Article
    Seaman Danyelle Luckey “didn’t die in combat or any military operation. She died from gross negligence of the medical providers on the ship she served, the USS Ronald Reagan,” said her father, Derrick Luckey. Danyelle Luckey died from sepsis on 10 October 2016. The 23-year-old had been on the ship for two weeks, and had been going back and forth to medical from 3 to 9 October with worsening symptoms. “Her death was very preventable. She died in excruciating pain, instead of being properly treated,” Derrick Luckey told lawmakers during a hearing about patient safety and the quality of care in the military medical system. “If the medical providers had given her a simple treatment of antibiotics instead of turning her away, she would be alive today,” he said. Luckey and Army veteran Dez Del Barba, who said he lost part of his left leg and suffered 70% muscle and tissue damage after his strep infection went untreated, urged lawmakers to make changes so others in the military community don’t have to suffer.Both contend this could have been avoided if proper medical care, such as antibiotics, had been provided. And both said they haven’t been able to get any information on investigations, or any actions to hold anyone accountable.Read full story Source: Yahoo News, 31 March 2022
  21. News Article
    ‘Horrifying and upsetting’ reports of bullying in prestigious heart units are being probed by national officials and professional leaders, HSJ can reveal. Health Education England told HSJ it was “undertaking a national thematic review of training in cardiothoracic surgery”, while the Society for Cardiothoracic Surgery separately revealed it was investigating concerns about “bullying, harassment and undermining behaviour” in the specialty following high-profile recent cases in Newcastle and Wales. Society president consultant surgeon Simon Kendall, who is based at James Cook University Hospital in Middlesbrough, told HSJ he has been made aware of wider problems beyond those identified in the North East and Wales. Mr Kendall revealed allegations reported to the society have included people being shouted at in public, problems resulting from a “legacy culture of sarcasm and public humiliation”, and more personal disputes between individuals. The consultant surgeon told HSJ: “The job is hard enough for all of us, without picking on each other and making it worse." He added: “It’s the extended team that is affected by these behaviours and it will have an impact on patient safety and patient care. Read full story (paywalled) Source: HSJ, 1 April 2022
  22. News Article
    Poor culture and leadership must be addressed if we are to make our maternity services the safest place to give birth. This statement from the Royal College of Midwives (RCM) came as the final report of the largest ever review of NHS maternity services was published. The RCM acknowledged that the pain and suffering of the families had been worsened by having to fight for answers and vowed to work with NHS bodies and other professional organisations to ensure lessons are learned from these tragic failings. Today the RCM has pledged to continue its work to be part of the solution to safety improvements and support its members to do the same not only at Shrewsbury and Telford NHS Trust, but throughout all maternity services across the UK. Commenting, the Royal College of Midwives’ (RCM) Chief Executive, Gill Walton said: “It is heartbreaking that this report only came about because of the determination of the families. We owe them a debt that I fear can never be repaid. What we can do - all of us who are involved in maternity services – is work together to ensure we listen, and we learn from this and ensure that women and families have trust in their care." “This review must be a turning point for all those working in maternity services. The actions recommended are measured and sensible and reflect much of what the RCM has been calling for. We hope that those in a position to enact them – NHS England and the Department for Health & Social Care – will do so in partnership with organisations like ours and with haste.” "A poor working culture, where staff were afraid to raise concerns, has been cited by the report as a key factor in many of the cases. Earlier this year the RCM called for a seismic NHS cultural shift to improve maternity safety as it published guidance for its members to raise concerns about maternity care which outlined steps staff can take and what to do if they feel they are not being listened to or their concerns are ignored." Read full story Source: Royal College of Midwives, 30 March 2022
  23. News Article
    Patient safety and nursing groups around the country are lamenting the guilty verdict in the trial of a former nurse in Tennessee, USA. The moment nurse RaDonda Vaught realised she had given a patient the wrong medication, she rushed to the doctors working to revive 75-year-old Charlene Murphey and told them what she had done. Within hours, she made a full report of her mistake to the Vanderbilt University Medical Center. Murphey died the next day, on 27 December 2017. On Friday, a jury found Vaught guilty of criminally negligent homicide and gross neglect. That verdict — and the fact that Vaught was charged at all — worries patient safety and nursing groups that have worked for years to move hospital culture away from cover-ups, blame and punishment, and toward the honest reporting of mistakes. The move to a “Just Culture" seeks to improve safety by analyzing human errors and making systemic changes to prevent their recurrence. And that can't happen if providers think they could go to prison, they say. “The criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent,” the American Nurses Association said. “Health care delivery is highly complex. It is inevitable that mistakes will happen. ... It is completely unrealistic to think otherwise.” Read full story Source: The Independent, 31 March 2022
  24. News Article
    Sajid Javid has issued an apology for the maternity service failings reported at Shrewsbury and Telford Hospital NHS Trust. The health secretary spoke in the Commons on Wednesday after an independent inquiry into the UK’s biggest maternity scandal found that 201 babies and nine mothers could have - or would have - survived if the NHS trust had provided better care. Speaking in the Commons, the health secretary said Donna Ockenden - a maternity expert who led the report - told him about “basic oversights” at “every level of patient care” at the trust. He said the report “has given a voice at last to those families who were ignored and so grievously wronged”. Javid said the report painted a tragic and harrowing picture of repeated failures in care over two decades which led to unimaginable trauma for so many people. Rather than moments of joy and happiness for these families their experience of maternity care was one of tragedy and distress and the effects of these failures were felt across families, communities and generations. The cases in this report are stark and deeply upsetting. Mr Javid offered reassurances that the individuals who are responsible for the “serious and repeated failures” will be held to account. Read full story and Sajid Javid's statement Source: The Independent, 30 March 2022
  25. News Article
    A shortage of more than 2,000 midwives means women and babies will remain at risk of unsafe care in the NHS despite an inquiry into the biggest maternity scandal in its history, health leaders have warned. A landmark review of Shrewsbury and Telford hospital NHS trust, led by the maternity expert Donna Ockenden, will publish its final findings on Wednesday with significant implications for maternity care across the UK. The inquiry, which has examined more than 1,800 cases over two decades, is expected to conclude that hundreds of babies died or were seriously disabled because of mistakes at the NHS trust, and call for changes. But NHS and midwifery officials said they fear a growing shortage of NHS maternity staff means trusts may be unable to meet new standards set out in the report. “I am deeply worried when senior staff are saying they cannot meet the recommendations in the Ockenden review which are vital to ensuring women and babies get the safest possible maternity care,” said Gill Walton, chief executive of the Royal College of Midwives (RCM). The number of midwives has fallen to 26,901, according to NHS England figures published last month, from 27,272 a year ago. The RCM says the fall in numbers adds to an existing shortage of more than 2,000 staff. Experts said the shortage was caused by the NHS struggling to attract new midwives while losing existing staff, who felt overworked and fed up at being spread too thinly across maternity wards. Read full story Source: The Guardian, 29 March 2022
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