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News Article
Patients continue to die and be harmed by the failure to learn from unsafe care
Patient Safety Learning posted a news article in News
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. -
News Article
Basildon Hospital blood tests contaminated in 'major failure'
Patient Safety Learning posted a news article in News
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 -
News Article
Police investigating deaths of two babies last year at scandal-hit trust
Patient Safety Learning posted a news article in News
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 -
News Article
NHSE warned of ‘inaccurate’ and ‘unethical’ investigation into man’s death
Patient Safety Learning posted a news article in News
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 -
News ArticleSeaman 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
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News Article
Bullying among top surgeons sparks two national investigations
Patient Safety Learning posted a news article in News
‘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 -
News Article
RCM response to Ockenden review into maternity services at Shrewsbury and Telford
Patient Safety Learning posted a news article in News
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 -
News Article
Guilty verdict for nurse RaDonda Vaught’s dosing mistake could cost lives
Patient Safety Learning posted a news article in News
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 -
News Article
Shrewsbury maternity scandal: Sajid Javid’s statement to the Commons
Patient Safety Learning posted a news article in News
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 -
News Article
Women and babies remain at risk of unsafe NHS care, experts warn
Patient Safety Learning posted a news article in News
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 -
News Article
Baby deaths inquiry: Shrewsbury NHS trust condemned for ‘repeated failures’
Patient Safety Learning posted a news article in News
A damning report into hundreds of baby deaths has condemned the trust at the centre of the biggest maternity scandal in the history of the NHS for blaming mothers while repeatedly ignoring its own catastrophic blunders for decades. The independent inquiry into maternity practices at Shrewsbury and Telford hospital NHS trust uncovered hundreds of cases in which health officials failed to undertake serious incident investigations, while deaths were dismissed or not investigated appropriately. Instead, grieving families were denied access to reviews of their care and mothers were blamed when their babies died or suffered horrific injuries. A combination of an obsession with natural births over caesarean sections coupled with a shocking lack of staff, training and oversight of maternity wards resulted in a toxic culture in which mothers and babies died needlessly for 20 years while “repeated failures” were ignored again and again. Tragically, it meant some babies were stillborn, dying shortly after birth or being left severely brain damaged, while others suffered horrendous skull fractures or avoidable broken bones. Some babies developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries. The report, led by the maternity expert Donna Ockenden, examined cases involving 1,486 families between 2000 and 2019, and reviewed 1,592 clinical incidents. “Throughout our final report we have highlighted how failures in care were repeated from one incident to the next,” she said. “For example, ineffective monitoring of foetal growth and a culture of reluctance to perform caesarean sections resulted in many babies dying during birth or shortly after their birth. “In many cases, mother and babies were left with lifelong conditions as a result of their care and treatment. The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the trust and a culture of not listening to the families involved. “There was a tendency of the trust to blame mothers for their poor outcomes, in some cases even for their own deaths. What is astounding is that for more than two decades these issues have not been challenged internally and the trust was not held to account by external bodies. “This highlights that systemic change is needed locally, and nationally, to ensure that care provided to families is always professional and compassionate, and that teams from ward to board are aware of and accountable for the values and standards that they should be upholding. Going forward, there can be no excuses.” Read full story Source: The Guardian, 30 March 2022 -
News Article
Ex-trust executive to probe NHS manager’s death
Patient Safety Learning posted a news article in News
An ambulance trust has appointed a former senior trust executive to lead an independent investigation into the circumstances surrounding the unexplained death of a staff member, HSJ has learned. East of England Ambulance Service Trust also shared the terms of reference for the investigation withHSJ, which follows the trust being forced to launch a similar probe in 2020 after three young staff members died in 11 days in December 2019. The latest investigation is into the death of Nick Lee, 46, from Ovington in west Norfolk, who died on 3 December 2021. Mr Lee was an operations manager for the trust in the west Norfolk area and had worked for the trust for nearly 20 years. The cause of death is yet to be officially established. Margaret Pratt has been appointed by the trust to lead the investigation. A trust statement issued to HSJ said: “The purpose of the investigation is to look at the events leading up to the death, review the circumstances of the death and consider whether there is anything that the trust can learn to contribute to improving the support provided to staff.” The investigation follows a prolonged period of years in which the trust has been dogged by high-profile and deeply ingrained cultural and bullying problems. Read full story (paywalled) Source: HSJ, 29 March 2022 -
News Article
Doctor's bid to be removed from register rejected
Patient Safety Learning posted a news article in News
A doctor's bid to be voluntarily removed from the medical register on health grounds has been rejected. It means Dr Heather Steen, who is accused of failings following the death of Claire Roberts in 1996, will still face a fitness to practice tribunal. The tribunal would have been halted if she had been removed from the register, as she would no longer have been a doctor. Claire Roberts died at the Royal Belfast Hospital for Sick Children, where Dr Steen worked, in October 1996. The nine-year-old's death was examined as part of the hyponatraemia inquiry. Her father Alan said his family welcomed the decision to refuse the paediatrician's application. He said the tribunal hearing was "in the public interest" and should proceed "to maintain public confidence in the medical profession, the regulatory process and to ensure that professional standards are upheld". Read full story Source: BBC News, 28 March 2022 -
News ArticleA whistleblower who worked at a hospital trust where hundreds of babies died or were left brain-damaged says there was "a climate of fear" among staff who tried to report concerns. Bernie Bentick was a consultant obstetrician at the Shrewsbury and Telford NHS Trust for almost 30 years. "In Shrewsbury and Telford there was a climate of fear where staff felt unable to speak up because of risk of victimisation," Mr Bentick said. "Clearly, when a baby or a mother dies, it's extremely traumatic for everybody concerned. "Sadly, the mechanisms for trying to prevent recurrence weren't sufficient for a number of factors. "Resources and the institutionalised bullying and blame culture was a large part of that." More than 1,800 cases of potentially avoidable harm have been reviewed by the inquiry. Most occurred between 2000 and 2019. Mr Bentick worked at the Trust until 2020. He said from 2009 onwards, he was raising concerns with managers. "I believe there were significant issues which promoted risk because of principally understaffing and the culture," he said. He also accuses hospital bosses of prioritising activity - the number of patients seen and procedures performed - over patient safety. "I believe that the senior management were mostly concerned with activity rather than safety - and until safety is on a par with clinical activity, I don’t see how the situation is going to be resolved," he said. Read full story Source: Sky News, 27 March 2022
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News Article
Investigation begins into woman's childbirth death
Patient Safety Learning posted a news article in News
An investigation has been launched after a woman died during childbirth at a hospital's maternity unit. It was the third death of a mother in just over three years at Basildon University Hospital in Essex, in addition to a newborn baby's death. The trust that runs the hospital said it could not comment on the case while it was under investigation. Basildon University Hospital is part of Mid and South Essex NHS Foundation Trust, which also runs Southend and Broomfield hospitals. The latest fatality follows the death of 36-year-old Gabriela Pintilie in February 2019. Ms Pintilie died after losing six litres of blood giving birth to her second child at the unit. In separate incidents, a mother died and another woman had a stillborn baby at the unit in March 2019, while the trust was being inspected by the Care Quality Commission (CQC) following Ms Pintilie's death. The unit at Basildon had its rating upgraded from "inadequate" to "requires improvement" in December by the CQC. The hospital also apologised for the death of newborn Frederick Terry after he suffered a brain haemorrhage during a failed forceps delivery in November 2019. Read full story Source: BBC News, 27 March 2022 -
News Article
Three hundred babies lost to a fixation on natural births
Patient Safety Learning posted a news article in News
When Debbie Greenaway was told by doctors that she should try to deliver her twin babies naturally, she was nervous. But the doctor was adamant, she recalls. “He said: ‘We’ve got the lowest caesarean rates in the country and we are proud of it and we plan to keep it that way'." For Greenaway, labour was seemingly endless. She was given repeated doses of syntocinon, a drug used to bring on contractions. By the second day, the midwife was worried for one of the babies, whom the couple had named John. “She was getting really concerned that they couldn’t find John’s heartbeat.” Her husband remembers “the midwife shaking her head”. “She said a number of times that we should be having a caesarean.” By the time doctors finally decided to perform an emergency C-section, it was too late. Starved of oxygen, baby John had suffered a catastrophic brain injury. When he was delivered at 3am, he had no pulse. Efforts to resuscitate him failed. Their son’s death was part of what is now recognised as the largest maternity scandal in NHS history. The five-year investigation will reveal that the experiences of 1,500 families at Shrewsbury and Telford Hospital Trust between 2000 and 2019 were examined. At least 12 mothers died while giving birth, and some families lost more than one child in separate incidents, the report is expected to show. The expert midwife Donna Ockenden and a team of more than 90 midwives and doctors will deliver a damning verdict on the Shrewsbury trust, its culture and leadership — and failure to learn from mistakes or listen to families. At its heart is how a toxic obsession with “normal birth” — fuelled by targets and pressure from the NHS to reduce caesarean rates — became so pervasive that life-or-death decisions on the maternity ward became dangerously distorted for nearly two decades. Read full story (paywalled) Source: The Times, 26 March 2022 -
News Article
1,500 deaths to be investigated at scandal-hit mental health trust
Patient Safety Learning posted a news article in News
More than 1,500 patient deaths are to be investigated in the largest-ever independent inquiry into “unacceptable” mental health care. A probe into the deaths of patients who were cared for by NHS mental health services across Essex has revealed its investigation will cover deaths from 2000 to 2020. All 1,500 people died while they were a patient on a mental health ward in Essex, or within three months of being discharged from one. In 2001, following an investigation into 25 deaths, police criticised the trust for “clear and basic” failings but did not pursue a corporate manslaughter prosecution. And in 2021, the Health and Safety Executive fined the trust £1.5m due to failures linked to the deaths of 11 patients. The regulator said the trust did not manage the risks of ligature points for a period of more than 10 years. In January 2021, following pressures, former patient safety minister Nadine Dorries commissioned former NHS England mental health director Dr Geraldine Strathdee to chair an independent inquiry. While it is not known yet how many of the 1,500 deaths were caused by neglect, Dr Strathdee said evidence had so far shown some “unacceptable” and “dispassionate” care. Melanie Leahy, who has campaigned for change within Essex mental health services since her son died in 2012, has been leading the call for it to become a public inquiry on behalf of the families. Her son, Matthew Leahy, died as an inpatient at the Linden Centre, following multiple failings in his care. A 2018 parliamentary health service ombudsman report on his death, and that of another young man called Richard Wade, identified “systemic” failings on behalf of the trust. These included the failure to manage his risk level, to look after his physical health and to take action when he reported being raped in the unit. Read full story Source: The Independent, 28 March 2022 -
News Article
Covid-19: Public inquiry must include effects on children, say experts
Patient Safety Learning posted a news article in News
The government’s upcoming Covid-19 public inquiry must include the effect of the pandemic on children and young people, a group of leading doctors and scientists have said. The draft terms of reference for the inquiry were published on 15 March but made no specific mention of children or young people other than a single reference to “restrictions on attendance at places of education." “There is no doubt that school closures and broader lockdowns harmed children,” said the letter to the Times signed by 50 people including Russell Viner, former president of the Royal College of Paediatrics and Child Health, and Andrew James, president of the Royal College of Psychiatrists. “Educational losses have been most marked in children from deprived families and in vulnerable children.” They pointed out that mental health problems increased from being experienced by one in nine children and young people before the pandemic to one in six during 2020 and 2021. Childhood obesity rates last year were at least 20% above previous years. One of the signatories to the letter, education committee chair Robert Halfon, has also written directly to the inquiry chair Heather Hallet.3 “The closure of schools and the restrictions placed on education settings has been nothing short of a national disaster for children and young people, not only in terms of their educational attainment but also with regards to their mental health and wellbeing, their life chances, and their safety,” he wrote. Read full story Source: BMJ, 24 March 2022 -
News Article
Trust loses whistleblowing case over ‘pioneering’ procedure
Patient Safety Learning posted a news article in News
A senior medic has won a whistleblowing case after judges ruled she was dismissed after raising concerns about a new procedure her department was using. An employment tribunal found consultant nephrologist Jasna Macanovic was fired from Portsmouth Hospitals University Trust in March 2018 after telling bosses a dialysis technique called “buttonholing”, which had been “championed” there, was potentially dangerous. The trust’s case was that the way she had gone about raising concerns had made for an untenable working environment in the Wessex Kidney Centre. The process saw a Care Quality Commission complaint, an independent investigation and multiple referrals to the General Medical Council. Employment Judge Fowell said: “The plain fact is that after over twenty years of excellent service in the NHS, Dr Macanovic was dismissed from her post shortly after raising a series of protected disclosures about this one issue. It is no answer to a claim of whistleblowing to say that feelings ran so high that working relationships broke down completely, and so the whistleblower had to be dismissed.” Dr Macanovic resigned from the regional renal transplant team in July 2016 when she discovered two incidents had occurred that “had not been reported by either surgeon” and felt that one of the surgeons had misled the medical director over the issue, the tribunal heard. In an email sent after the resignation meeting, Dr Macanovic said the practice was considered inappropriate by the vast majority of experts in the field and that no other renal unit in England was using it. The case exposes some worrying governance, both within the trust and between it and the Care Quality Commission, with which the issues were raised in 2016. When the CQC asked the trust for more information the unit’s clinical director responded that in his view that the deaths and infections were not due to the buttonholing. The CQC made no further enquiries and wrote back saying “they were satisfied that there were no safety concerns and that appropriate governance had been followed”. Read full story Source: HSJ, 24 March 2022 -
News Article
Nurse who mistreated patient with dementia asks to be removed from register
Patient Safety Learning posted a news article in News
A nurse who admitted she was unfit to practise after dragging a patient with dementia to her room and forcefully attempting to administer a sedative has been suspended for a year by the nursing regulator. Carol Picton was working in the stroke unit at the Western General Hospital in Edinburgh in November 2017 when colleagues raised concerns about her treatment of a vulnerable older woman. Witnesses who gave evidence to an NMC fitness to practice (FtP) panel said they heard the patient screaming in distress after being roughly dragged by her arm back to her room by Ms Picton. The nurse then attempted to forcefully administer the anti-psychotic drug Haloperidol without checking the correct dosage, the hearing was told. She tried to give the drug orally using a 2ml injection syringe rather than an oral syringe. Ms Picton denied forceful mistreatment and panel found no evidence she had shown insight into her misconduct When the patient spat out the drug Ms Picton gave her more without knowing how much she had ingested, risking an overdose, the panel heard. Ms Picton, who was referred to the NMC by her employer following an internal investigation, was also said to have tilted the patient’s bed to prevent her getting out and leaving her room. The panel, which found five charges proven, concluded that Ms Picton’s actions were ‘deplorable’ and amounted to harassment and abuse. Read full story Source: Nursing Standard, 21 March 2022 -
News Article
Women died after ‘gross failings’ by scandal hit mental health trust
Patient Safety Learning posted a news article in News
A young woman died following “gross failings” and “neglect” by a mental health hospital in Essex which is also facing a major independent inquiry into patient deaths. Bethany Lilley, 28, died on 16 January whilst she was an inpatient at Basildon Mental Health unit, run by Essex Partnership University Hospitals. The inquest examined the circumstances of her death this week and concluded that her death was contributed by neglect due to a “plethora of failings by Essex University Partnership Trust”. Following the three week inquest, heard before coroner Sean Horstead, a jury found “neglect” contributed to Ms Lilley’s death and identified “gross failures” on behalf of the trust. The jury identified a number of failings in her care including evidence that cocaine had made its way onto a ward where she was an inpatient. There was evidence of “very considerable problems in the record-keeping at EPUT psychiatric units.” It was also concluded staff failed to carry out a risk assessment of Ms Lilley in the days leading up to her death, and failed to carry out observations. Ms Lilley’s death is one of a series of patients who have died under the care of mental health services in Essex, which have been brought into the light following the campaigning of bereaved families. Read full story Source: The Independent, 19 March 2022 -
News Article
Doctor accused of failings following Claire Roberts' death
Patient Safety Learning posted a news article in News
A paediatrician who was at the centre of one of Northern Ireland's longest running public inquiries will appear before a professional misconduct panel. Dr Heather Steen is accused of several failings following the death of Claire Roberts at the Royal Belfast Hospital for Sick Children in October 1996. The nine-year-old's death was examined by the hyponatraemia inquiry, which lasted 14 years. It examined the role of several doctors. Among his findings, the inquiry's chairman Mr Justice O'Hara said there had been a "cover-up" to "avoid scrutiny." Monday's tribunal will inquire into allegations that, between 23 October 1996 and 4 May 2006, Dr Steen "knowingly and dishonestly carried out several actions to conceal the true circumstances" of the child's death. Also that the doctor provided inappropriate, incomplete and inaccurate information to the child's parents and GP regarding the treatment, diagnosis, clinical management and cause of her death. The tribunal website adds: "It is also alleged that Dr Steen inappropriately recommended a brain-only post-mortem for Patient A (Claire Roberts) when a full post-mortem was necessary. "In addition, it is alleged that Dr Steen failed to refer Patient A's death to the coroner, inappropriately completed the medical certificate of cause of death and inaccurately completed the autopsy request form for Patient A. "Furthermore, it is alleged that during a review of Patient A's notes, Dr Steen failed to consult with the necessary colleagues and medical teams and provided a statement and gave evidence to the coroner's inquest into Patient A's death which omitted key information." Read full story Source: BBC News, 21 March 2022 -
News Article
Archie Batten: Inquest hears baby's mother was turned away from maternity unit
Patient Safety Learning posted a news article in News
The parents of a baby boy who lived for just 27 minutes have told an inquest they were "completely dismissed" throughout labour. Archie Batten died on 1 September 2019 at the Queen Elizabeth the Queen Mother Hospital (QEQM) in Margate, Kent. His inquest began on Monday at Maidstone Coroner's Court. The East Kent Hospitals University NHS Foundation Trust has already admitted liability and apologised for Archie's death. The coroner heard Archie's mother Rachel Higgs was frustrated at being turned away from the maternity unit in the morning, when she had gone to complain of vomiting and extreme pain. She was told she was not far enough into labour to be admitted. She returned home to Broadstairs with her partner Andrew Batten, but continued to feel unwell so phoned the hospital. She was told the unit was now closed. Instead, two community midwives were sent to their home, where they attempted to deliver the baby but could not find a heartbeat. Andrew Batten told the inquest the midwives looked "terrified," and that there was "an air of panic", with the midwives whispering in the hallway instead of telling him and Ms Higgs what was happening. Under examination from the family's barrister Richard Baker, Victoria Jackson, the midwife who had originally seen Ms Higgs, admitted the high number of patients she was having to deal with had affected her ability to spend time with her. Read full story Source: BBC News, 14 March 2022 -
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Midwife struck off over Shropshire baby's death
Patient Safety Learning posted a news article in News
A midwife found guilty of misconduct over the death of a baby six years ago is to be struck off. Claire Roberts was investigated by the Nursing and Midwifery Council (NMC) for failures in the care she gave to Pippa Griffiths - who died a day after being born at home in Myddle, Shropshire. An independent disciplinary panel described the midwife as "a danger to patients and colleagues". Ms Roberts and fellow midwife Joanna Young failed to realise the "urgency" of medical attention needed, following the birth, the panel said. They had failed to carry out a triage assessment, after Pippa's mother called staff for help because she was worried about her daughter's condition. The panel concluded Ms Roberts's fitness to practise was impaired. Inaccurate record-keeping by Ms Roberts represented "serious dishonesty", panel chair David Evans said, adding she had carried it out "in order to protect herself from disciplinary action". Her failures had represented a "significant departure from standards expected by a registered midwife," he added. Her colleague Ms Young, whose case was also heard by the panel, faced strong criticism on Wednesday, but was told she would face no sanction after the hearing concluded she had shown remorse and undergone extra training since 2016. Kayleigh Griffiths said she and her husband welcomed the findings and sanctions. "We're really relieved that one of the midwives has been struck off and actually we're also relieved to find that the other midwife has learnt and feels significant remorse for the event that took place," she said. "We realise people do make mistakes and I think how you deal with those mistakes is really important. "All we do ask is that learning was made from those and I think in one of the instances it did occur and in the other it didn't - so I think the right outcome has been found." Read full story Source: BBC News, 10 March 2022 -
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UK Covid inquiry draft terms of reference set out
Patient Safety Learning posted a news article in News
The draft terms of reference for the UK public inquiry into the government's handling of the Covid-19 pandemic have been published. The inquiry, due to start in the spring, will play a key role in "learning lessons" from the pandemic and for the future, it said. The terms of reference were published after a consultation with inquiry chairwoman and former High Court judge Baroness Hallett, and with ministers in the devolved nations. The Scottish government has already published the terms of reference for its own Covid-19 inquiry, to be led by Judge Lady Poole. The UK-wide inquiry proposes examining a broad range of issues including: the UK's preparedness for the pandemic the use of lockdowns and other 'non-pharmaceutical' interventions such as social distancing and the use of face coverings the management of the pandemic in hospitals and care homes the procurement and provision of equipment like personal protective equipment and ventilators support for businesses and jobs, including the furlough scheme, as well as benefits and sick pay. The inquiry aims to produce "a factual, narrative account" covering decision-making at all levels of government and the response of the health and care sector as well as identifying the "lessons to be learned". Becky Kummer, spokesperson for Covid-19 Bereaved Families for Justice, said the publication was a "huge step forward" and the organisation looked forward to contributing to the consultation on the terms. Chris Hopson, chief executive of NHS Providers, which represents hospital trusts, said there was much the NHS did well during the pandemic but: "It is right the inquiry looks at areas where there were major challenges - such as infection prevention and control, access to PPE, testing, and robust epidemiological modelling." Read full story Source: BBC News, 11 March 2022
