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Found 1,561 results
  1. News Article
    A senior clinician has raised fundamental concerns about a trust’s probe into dozens of suicide cases, which was sparked by his allegations that staff had tampered with the notes of a patient. Cambridgeshire and Peterborough Foundation Trust announced in July there would be an internal review of 60 suicide cases dating back to 2017. But a key whistleblower told HSJ he fears it could be a “whitewash” and it should be carried by an external, independent investigator rather than led by the trust. The suicides review was prompted by allegations staff had added a care plan into the patient record of Charles Ndhlovu, a day after the 33-year-old had died by suicide in 2017. The allegations, not contested by the trust, were based on the findings of an internal investigation in 2021 of the trust’s conduct around Mr Ndhlovu’s case. Read full story (paywalled) Source: HSJ, 6 September 2023
  2. News Article
    Integrated care systems (ICSs) should factor patient safety into all their operational and financial decisions, the Healthcare Safety Investigations Branch’s chief investigator has urged. Rosie Benneyworth, who was appointed as interim chief investigator last summer, said other safety-critical industries made decisions on the basis of a “triad” of operations, finances and safety. She said the NHS needed to be “more proactive” to take action before things go wrong. Dr Benneyworth said in an interview with HSJ: “I think it’s fundamental that ICSs put safety at the core of everything they do. And I don’t think operational decisions or financial decisions should be made without considering the implications for safety.” Dr Benneyworth – a former GP and commissioner – also spoke about whistleblowing in the wake of the Lucy Letby scandal, saying national organisations should “lead the way” on being proactive over safety and supporting whistleblowers. Major cultural problems were uncovered at HSIB several years ago, while NHSE has been under the spotlight in recent weeks for implementation of the “fit and proper person” test for board members. “I think it’s very difficult as national organisations to tell providers what they should [be] doing, if we’re not doing it ourselves,” Dr Benneyworth said. She added: “What we need is a much more proactive approach to safety, where we actually identify those things that could go wrong and take action before they do go wrong." Read full story (paywalled) Source: HSJ, 5 September 2023
  3. News Article
    The inquiry into how nurse Lucy Letby was able to murder seven babies will now have greater powers to compel witnesses to give evidence. In a significant move, ministers upgraded the independent inquiry after criticism from families of the victims that it did not go far enough. The inquiry, ordered after Letby was found guilty this month, was not initially given full statutory powers. Health Secretary Steve Barclay said he had listened to the families. He said he had decided a statutory inquiry led by a judge was the best way forward and "respects the wishes" of the families. Mr Barclay said the key advantage was the power of compulsion. "My priority is to ensure the families get the answers they deserve and people are held to account where they need to be," he added. He said an announcement about who would chair the inquiry would be made in the coming days - ministers have already said it will be a judge. Richard Scorer, a lawyer who is representing two of the families, welcomed the government's announcement. "It is essential that the chair has the powers to compel witnesses to give evidence under oath, and to force disclosure of documents. Without these powers, the inquiry would have been ineffectual and our clients would have been deprived of the answers they need and deserve," he said. Read full story Source: BBC News, 30 August 2023
  4. News Article
    Hundreds of people across England with drug and alcohol dependencies who have been prescribed Valium long-term, will have their cases reviewed following an Ombudsman investigation. The Local Government and Social Care Ombudsman has found that Change Grow Live (CGL), on behalf of Cambridgeshire County Council, has been prescribing benzodiazepines to people long-term, against national guidance. The company also provides drug and alcohol services for 50 other councils. Benzodiazepines – including diazepam (Valium) - are a class of medicines that can relieve nervousness, tension and other symptoms of anxiety and should usually only be prescribed short-term. CGL’s policy explains people use them for anxiety, insomnia, to enhance opiate effects, to deal with mental health issues, improve confidence and to reduce psychotic symptoms like hearing voices. However, if they are prescribed for too long, they can have significant negative effects including dependence, withdrawal symptoms and drug-seeking behaviour. People on these medicines should have their prescriptions reviewed regularly, and those reviews should consider the benefits and risks of continuing with the current dose, reducing or stopping it, with a management plan put in place after each review. However, the Ombudsman’s investigation found CGL were either not reviewing people’s prescriptions regularly enough or not keeping proper records of those reviews. Nigel Ellis, Local Government and Social Care Ombudsman Chief Executive, said: “Clinicians need to weigh up the benefits and risks for patients who are taking these medicines long-term and should have a clear rationale for continuing to prescribe. “I am pleased that patients in these vulnerable groups will now have their cases reviewed more regularly and comprehensively following my investigation. “Both CGL and the council have co-operated fully with our investigation, and I welcome their ready acceptance of our recommendations.” Read full story Source: Local Government and Social Care Ombudsman, 23 August 2023
  5. News Article
    Lucy Letby sat with her parents in a meeting with senior managers at the Countess of Chester Hospital, where she worked, waiting patiently for an apology. She had prepared a statement that was read out by her parents to Tony Chambers, the hospital’s chief executive, about being bullied and victimised on the neonatal unit. It was December 22, 2016, and for the previous 18 months, two doctors on the unit had been trying to find an answer for a series of mysterious deaths of babies. Their detective work had led them to a single common denominator: Letby. The neonatal nurse had been on shift for each of the incidents. Rumours of a killer on the ward had spread and Letby had complained about the doctors and their finger-pointing, claiming she was being wrongly blamed. Chambers, who had trained as a nurse, was convinced by Letby’s account, and in front of her parents, John and Susan, offered sincere apologies on behalf of the hospital trust. The doctors in question would be “dealt with’’. Except the doctors were right. By that point Letby had secretly murdered seven babies and tried to kill six more, one of them twice. An investigation by The Sunday Times, based on a cache of internal documents, reveals in detail how the hospital delayed calling the police for months and that senior management, including the board, sided with Letby against doctors after commissioning perfunctory investigations. Read full story (paywalled) Source: The Times, 19 August 2023
  6. News Article
    In September last year, Ebrima Sajnia watched helplessly as his young son slowly died in front of his eyes. Mr Sajnia says three-year-old Lamin was set to start attending nursery school in a few weeks when he got a fever. A doctor at a local clinic prescribed medicines, including a cough syrup. Over the next few days, Lamin's condition deteriorated as he struggled to eat and even urinate. He was admitted to a hospital, where doctors detected kidney issues. Within seven days, Lamin was dead. He was among around 70 children - younger than five - who died in The Gambia of acute kidney injuries between July and October last year after consuming one of four cough syrups made by an Indian company called Maiden Pharmaceuticals. In October, the World Health Organization (WHO) linked the deaths to the syrups, saying it had found "unacceptable" levels of toxins in the medicines. A Gambian parliamentary panel also concluded after investigations that the deaths were the result of the children ingesting the syrups. Both Maiden Pharmaceuticals and the Indian government have denied this - India said in December that the syrups complied with quality standards when tested domestically. It's an assessment that Amadou Camara, chairperson of the Gambian panel that investigated the deaths, strongly disagrees with. "We have evidence. We tested these drugs. [They] contained unacceptable amounts of ethylene glycol and diethylene glycol, and these were directly imported from India, manufactured by Maiden," he says. Ethylene glycol and diethylene glycol are toxic to humans and could be fatal if consumed". Read full story Source: BBC News, 21 August 2023
  7. News Article
    Nurse Lucy Letby has been found guilty of murdering seven babies on a neonatal unit, making her the UK's most prolific child serial killer in modern times. The 33-year-old has also been convicted of trying to kill six other infants at the Countess of Chester Hospital between June 2015 and June 2016. Letby deliberately injected babies with air, force fed others milk and poisoned two of the infants with insulin. Commenting on the verdict, Parliamentary and Health Service Ombudsman Rob Behrens said: “We know that, in general, people work in the health service because they want to help and that when things go wrong it is not intentional. At the same time, and too often we see the commitment to public safety in the NHS undone by a defensive leadership culture across the NHS. “The Lucy Letby story is different and almost without parallel, because it reveals an intent to harm by one individual. As such, it is one of the darkest crimes ever committed in our health service. Our first thoughts are with the families of the children who died. “However, we also heard throughout the trial, evidence from clinicians that they repeatedly raised concerns and called for action. It seems that nobody listened and nothing happened. More babies were harmed and more babies were killed. Those who lost their children deserve to know whether Letby could have been stopped and how it was that doctors were not listened to and their concerns not addressed for so long. Patients and staff alike deserve an NHS that values accountability, transparency, and a willingness to learn. “Good leadership always listens, especially when it’s about patient safety. Poor leadership makes it difficult for people to raise concerns when things go wrong, even though complaints are vital for patient safety and to stop mistakes being repeated. We need to see significant improvements to culture and leadership across the NHS so that the voices of staff and patients can be heard, both with regard to everyday pressures and mistakes and, very exceptionally, when there are warnings of real evil.”
  8. News Article
    Patients whose lives were damaged by surgery for bowel problems are calling for a long-awaited report to be published. More than 200 patients underwent mesh bowel operations in Bristol that they might not have needed. The surgery was carried out by Tony Dixon at Southmead Hospital and the private Spire Hospital, in Redland. A review by North Bristol NHS Trust was published in May 2022, but patients are still waiting to hear from Spire. Jill Smith, 69, from Westbury-on-Trym, paid privately to go to Spire. She said she is still in severe pain following her surgery. "Emotionally it has affected me big time. It is just horrible," she said. "The stress and panic I get going anywhere, is, 'will I have an accident or something?'." Read full story Source: BBC News, 18 August 2023
  9. News Article
    The Care Quality Commission (CQC) has published a report on Stoke Mandeville Hospital, part of Buckinghamshire Healthcare NHS Trust following a recent inspection in June. CQC carried out a focused inspection of the trusts children’s emergency department in response to concerns raised about the safety and quality of the service. Inspectors found children and young people received safe care. However, the trust needs to review its systems to make sure potential serious incidents are managed in a way that allows any lessons learned to be shared, to reduce the risk of them happening again. Link to the full report (opens in a new browser window)
  10. News Article
    An 11-year-old boy suffered permanent brain damage after birth because of negligence by hospital midwives who then fabricated notes, a high court judge has ruled. Jayden Astley’s challenges in life include deafness, motor impairments, cognitive difficulties and behavioural difficulties, his lawyers said. After a five-day trial at the high court in Liverpool, Mr Justice Spencer ruled that staff at the Royal Preston hospital in Lancashire were negligent in their treatment of Jayden in 2012. The brain injury was caused by prolonged umbilical cord compression that resulted in acute profound hypoxia – lack of oxygen – sustained during the management of the birth, the court found. Midwives failed to accurately monitor Jayden’s heart rate when he was born and failed to identify his bradycardic, or slow, heart rate during delivery. The judge also found that some entries in notes were fabricated. In his judgment Spencer said it was agreed that all permanent damage to Jayden’s brain would have been avoided if he had been delivered three minutes earlier. Read full story Source: The Guardian, 2 August 2023
  11. News Article
    Every day Sharon Smith has to take a strong morphine tablet to dull the excruciating pain she has lived with for more than a decade. “I am in chronic pain every day. It’s affected our whole family and I’ve lost all my independence,” said Smith, from Leigh, Greater Manchester. Over four years from 2009, she endured three operations on her spine at Salford Royal Hospital, which as an NHS trust was once fêted as England’s safest. But the hospital had a dark secret: an incompetent leading surgeon who, an independent review would later find, had already “contributed” to the death of a girl in 2007. Now a wider investigation has confirmed that dozens of other patients who went under John Bradley Williamson’s knife were harmed or received poor care. Read full story (paywalled) Source: The Times, 30 July 2023
  12. News Article
    Bereaved families in Scotland questioned the credibility of the Covid-19 inquiry on its opening day. Proceedings started with a presentation in Dundee by the public health physician Dr Ashley Croft, who talked about the scientific and medical understanding of the virus as it existed in late 2019 and how it developed up to the end of last year. Members of the Scottish Covid Bereaved group were said to be “bewildered” by the choice of Croft as first speaker of the inquiry, having previously raised concerns about his being used as an expert witness. The lawyer Aamer Anwar, who is representing the group, highlighted a High Court judgment that reportedly described Croft as providing “flawed, unreliable” and “unconvincing” evidence and displaying “a cavalier approach to important evidence”. Pointing out that no respects were paid to the many people who lost their lives during the pandemic during the presentation either, Anwar described the inquiry’s start as “embarrassing” and “deeply disrespectful”. Read full story (paywalled) Source: The Times, 27 July 2023
  13. News Article
    Rishi Sunak says the government will wait for the Infected Blood Inquiry's final report before responding to questions around victim compensation. Bereaved families heckled the prime minister when he told the inquiry the government would act as "quickly as possible". Mr Sunak told the inquiry people infected and affected by the scandal had "suffered for decades" and he wanted a resolution to "this appalling tragedy". But although policy work was progressing and the government in a position to move quickly, the work had "not been concluded". He indicated there was a range of complicated issues to work through. "If it was a simple matter, no-one would have called for an inquiry," Mr Sunak said. Campaign group Factor 8 said Mr Sunak had offered "neither new information not commitments" to the victims and bereaved families, which felt "like a betrayal". Haemophilia Society chief executive Kate Burt said: "This final delay is demeaning, insulting and immensely damaging. "We urge the prime minister to find the will to do the right thing and finally deliver compensation which recognises the suffering that has been caused." Read full story Source: BBC News, 26 July 2023
  14. News Article
    Health officials waited six months to speak to the surgeon Sam Eljamel after a complaint was made about his conduct that eventually led to his suspension. Eljamel, who was head of neurosurgery at NHS Tayside in Dundee between 1995 and 2013, harmed dozens of patients before being suspended in 2013. Even as NHS Tayside commissioned an external review into Eljamel’s conduct, the surgeon was not suspended. Instead, the health board allowed him to continue practising as long as he was monitored. However, a letter sent to Eljamel by NHS Tayside’s clinical director, dated June 21, 2013, reveals that the surgeon was able to negotiate the extent of his own supervision. It was during this period of supervision that Jules Rose attended Ninewells Hospital to have a brain tumour removed by the surgeon. He performed two surgeries on her, in August and December, and she later discovered that he had removed her tear gland instead of the tumour. Since then she has founded and run the Patient’s Action Group, representing 126 of Eljamel’s patients calling for a public inquiry into how he was able to harm so many patients at NHS Tayside. Read full story (paywalled) Source: The Times, 25 July 2023
  15. News Article
    An award-winning hospital consultant says he has been “hunted” out of the NHS after 43 years for flagging patient safety failings. Peter Duffy, 61, performed his final surgical procedure, supervising a bladder cancer removal, earlier this month at Noble’s Hospital on the Isle of Man. He said he had “been looking forward to a good few more years of full-time work — another five, at least”. But the cumulative toll of a long-running whistleblowing dispute with his former employer, Morecambe Bay NHS Trust (UHMBT), instead pushed him into “an abrupt, even savage termination of my calling”. The General Medical Council watchdog recently dropped a 30-month probe into Duffy prompted by emails that he alleges were falsified. The emails, which were apparently sent by Duffy in December 2014 but did not surface until 2020, appeared to implicate him in the string of clinical errors that led to the death of Peter Read, a 76-year-old man from Morecambe. The GMC concluded that it could not attach weight to the emails as evidence. However, Duffy says the ordeal of “having the responsibility for an avoidable death I’d reported being flipped and of having the finger pointed back at me” drove him to contemplate suicide. Read full story (paywalled) Source: The Times, 24 July 2023
  16. News Article
    An ambulance trust accused of hiding information from a coroner about patients that died is keeping a damning internal report about the deaths secret, the Guardian can reveal. A consultant paramedic implicated in the alleged cover-ups continues to be involved in decisions to keep the report from the public. Earlier this month, North East Ambulance Service (NEAS) apologised to relatives after a review into claims it covered up errors by paramedics and withheld evidence from the local coroner about the deceased patients. But a bereaved family left in the dark about mistakes made before their daughter’s death have rejected the apology. Now, it has emerged that a 2020 internal interim report on the alleged cover-up continues to be kept secret by the trust. The damning report by consultants AuditOne has been leaked to the Guardian after first being exposed by the Sunday Times. Paul Aitken-Fell, a consultant paramedic blamed in the report for amending information sent to the coroner and removing crucial passages about mistakes by the trust’s paramedics, remains in post. He also holds the gatekeeper role of FoI review officer, and as such has endorsed decisions to refuse to release the report to members of the public who ask for it. Read full story Source: The Guardian, 24 July 2023
  17. News Article
    A trust breached its own internal illness policy when managers sacked a doctor who had PTSD and had been drunk at work, an employment tribunal has ruled. Judges criticised the move as a “complete failure” by East and North Hertfordshire Trust when Vladimir Filipovich was dismissed in July 2019. Dr Filipovich was summoned to a hearing following allegations he had been drunk at work, did not disclose a diagnosis of post-traumatic stress disorder to his employer, and failed to take a recommended prescription of Citalopram. In a decision published this month, the tribunal sharply criticised how the trust’s investigator handled the Citalopram claim, concluding he “did nothing to investigate the matter whatsoever”, and found ENHT had “appeared to simply take legal advice” on how to dismiss Dr Filipovich. The tribunal also concluded ENHT “stopped following” its own illness policy, which aimed to get practitioners to return to work, and “abandoned” its requirement to obtain the latest occupational advice. Read full story (paywalled) Source: HSJ, 21 July 2023
  18. News Article
    The government has admitted that many ‘vulnerable’ hospitals ‘suffer with a lack of permanence of leadership’, but said that chiefs are only sacked by NHS England ‘in extreme and exceptional circumstances’. The comments were included in the government’s response to the independent investigation into major maternity care failures at East Kent Hospitals University Foundation Trust, which highlighted how the practice of repeatedly hiring and firing leaders had contributed to its problems. The investigation said successive chairs and CEOs at the FT were “wrong” to believe it provided adequate care, and urged that they be held accountable. But it said senior management churn had been “wholly counterproductive”, and that it had “found at chief executive, chair and other levels a pattern of hiring and firing, initiated by NHS England” which would “never have been an explicit policy, but [had] become institutionalised”. Read full story (paywalled) Source: HSJ, 21 July 2023
  19. News Article
    The bodies of people who died with Covid were treated like "toxic waste" and families were left in shock, a bereaved woman has told the inquiry. Anna-Louise Marsh-Rees said her father Ian died "gasping for breath" after catching the virus while in hospital. Ms Marsh-Rees, who leads Covid-19 Bereaved Families for Justice Cymru, said he was "zipped away", and his belongings put in a Tesco carrier bag. Ian Marsh-Rees died after catching the virus while in hospital, aged 85. His daughter said finding information regarding his care in hospital and how he became infected was "almost like an Agatha Christie mystery". She said no GP ever suggested he might have Covid, although she now knows his discharge notes said he had been exposed to Covid. "It wasn't until we saw his notes some months later that we saw the DNA CPR (do not attempt CPR) placed on him, and this was without consultation with us," she said. "It kind of haunts us all that… people used to say 'well they're in the right place' when they go to hospital. I'm not sure they would say that any more," Ms Marsh-Rees said. She now wants to change the way deaths are handled by health boards. She said it was important to prepare families before and support them after the death of a loved one, from palliative care to dignity in death. Read full story Source: BBC News, 18 July 2023
  20. News Article
    Just one in five staff who were approached in a trust’s internal inquiry – prompted by an undercover broadcast raising serious care concerns – engaged with the process, a report has revealed. Essex Partnership University Foundation Trust said it took “immediate action” to investigate issues highlighted in a Channel 4 Dispatches programme into two acute mental health wards last year. This included speaking to staff identified as a high priority in the investigation. However, a new Care Quality Commission report has revealed, of the 61 staff members the trust approached, only 12 engaged with the process. Read full story (paywalled) Source: HSJ, 19 July 2023
  21. News Article
    The trust at the centre of a maternity scandal insists it has been providing immediate anaesthetic cover for obstetric emergencies, contrary to an NHS England report suggesting it had not and had been potentially breaching safety standards. Health Education England – now part of NHSE – visited William Harvey Hospital in March and was told senior doctors in training who were covering obstetrics could also be covering the cath lab – which deals with patients who have had a heart attack, and could receive trauma, paediatric emergency and cardiac arrest calls. This suggested the trust was in conflict with Royal College guidelines which state an anaesthetist should always be “immediately available” for obstetrics. East Kent Hospitals University Foundation Trust, which runs the hospital, originally told HSJ its rota had very recently been changed and that an anaesthetist with primary responsibility for maternity could leave any other work to attend to a maternity emergency immediately. However, it has since said it has been the case for a long time that an anaesthetist is available to return to maternity in case of an emergency. Read full story (paywalled) Source: HSJ, 17 June 2023
  22. News Article
    A coroner has criticised an NHS trust over the deaths of two new mothers with herpes. Kimberley Sampson, 29, and Samantha Mulcahy, 32, died in 2018 after having caesarean sections six weeks apart by the same surgeon at hospitals in Kent. Their families have been waiting five years for answers on how they came to be infected with the virus, which can cause sores around the mouth or genitals. Catherine Wood, Mid Kent and Medway coroner, said Sampson could have been given an anti-viral treatment sooner. Wood added that in Mulcahy’s case “suspicion should have been raised” given the knowledge among staff from Sampson’s earlier death. The coroner ruled out human culpability of any of the medical staff involved in the case and said it was “unlikely” for the surgeon to be the cause of the herpes infection found in both women. Read full story Source: The Guardian, 14 July 2023
  23. News Article
    More families have been told by a health board that their relatives' deaths may have been linked to treatment by vascular services. Betsi Cadwaladr University Health Board (BCUHB) has written to families who were part of a review after concerns were raised last year. Four cases had already been reported to a coroner and the health board says it has been "very open" with relatives of other patients. The service has recently been described by inspectors as making "satisfactory progress", but the health board admit it is still on a "long journey". A report by the Royal College of Surgeons England (RCSE) in January 2022 found risks to patient safety due, in part, to poor record keeping. It recommended to the health board that it investigate fully what happened to the 47 patients its report focused on. Read full story Source: BBC News, 13 July 2023
  24. News Article
    An ambulance service has apologised to families following a review into claims it covered up errors by paramedics and withheld evidence from coroners. The families of a teenager and a 62-year-old man were not told paramedics' responses were being investigated by North East Ambulance Service (NEAS). The deaths, in 2018 and 2019, were raised by a whistleblower last year. Among the findings of the independent review carried out by Dame Marianne Griffiths, were inaccuracies in information provided to the coroner, employees who were "fearful of speaking up" and "poor behaviour by senior staff". The study, commissioned by the former health secretary Sajid Javid in August, examined four of the five cases that were highlighted by the whistleblower, initially in The Sunday Times. It found two bereaved families were left in the dark about investigations into the response of paramedics called to help their loved ones. Read full story Source: BBC News, 12 July 2023
  25. News Article
    A further 11 inquests are to be opened this week as part of an investigation into dozens of deaths linked to jailed breast surgeon Ian Paterson. Paterson is currently serving a 20-year sentence after he carried out unnecessary or unapproved procedures on more than 1,000 breast cancer patients. Judge Richard Foster said 417 cases of former patients had been reviewed. The inquests will open and be adjourned on Friday. More than 30 deaths are already the subject of an inquest. Paterson worked at Spire Parkway Hospital and Spire Little Aston Hospital in the West Midlands between 1997 and 2011, as well as NHS hospitals run by the Heart of England NHS Foundation Trust. Paterson was jailed in 2017 after being convicted of 17 counts of wounding with intent. An independent inquiry found he had been free to perform harmful surgery in NHS and private hospitals due to "a culture of avoidance and denial" in a healthcare system where there was "wilful blindness" to his behaviour. Read full story Source: BBC News, 10 July 2023
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