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Found 1,566 results
  1. News Article
    An independent review has raised concerns about a mental health trust’s reporting systems and has highlighted a significant number of patient deaths shortly after leaving the trust’s care, including almost 300 who died on the same day they were discharged. However, the review into how Norfolk and Suffolk Foundation Trust collects, processes and reports mortality data made no conclusions on the number of avoidable deaths – the issue which had originally prompted the probe. Local NHS leaders argued the review’s purpose was focused on auditing the trust’s processes, and this had been delivered. But a local MP, Clive Lewis, accused it of “explicitly dodg[ing] the big questions”. The report, which looked at data from between April 2019 and October 2022, has however raised concerns about the number of patients dying soon after being discharged. Read full story (paywalled) Source: HSJ, 28 June 2023
  2. News Article
    Recently Minneapolis-based Allina Health was highlighted by The New York Times for pulling back from its policy of denying nonemergency care to some indebted patients. However, a recent investigation showed it is not the only health system to allegedly have engaged in the practice. According to KFF Health News, about 20% of US nationwide hospitals in a random sample pursued similar policies of care denial. The Lown Institute went further, naming major health systems including Rochester, Minn.-based Mayo Clinic, St. Louis-based Ascension, Indianapolis-based Indiana University Health, Livonia, Mich.-based Trinity Health and Los Angeles-based Cedars-Sinai as operating facilities where the practice is followed. IU Health, Ascension, Trinity Health and Cedars-Sinai denied they have such practices. "We do not restrict medically necessary non-emergency care for patients with unpaid bills," an Ascension spokesperson said. Read full story Source: Becker Hospital Review, 26 June 2023
  3. News Article
    Relatives of a teenage rape survivor who died after failures by mental health services are joining other families to demand a new body to enforce coroners’ recommendations to prevent future deaths. Campaigners claim the failure to act on hundreds of coroners’ recommendations every year, and to learn from the findings of often expensive inquiries into disasters, means the same mistakes are being repeated. Gaia Pope, 19, was diagnosed with post-traumatic stress disorder after revealing that she had been drugged and raped when she was 16. She was found dead in undergrowth on a cliff 11 days after disappearing in Swanage, Dorset, in 2017. After one of the longest inquests in legal history, the coroner, Rachael Griffin, made multiple reports last year to authorities including the NHS and police to prevent future deaths, but Pope’s family says most have not been acted upon. The Inquest campaign, which works with families bereaved by state-related deaths, is calling for a “national oversight mechanism” to collate recommendations and responses in a new national database, analyse responses from public bodies, follow up on progress and share common findings. Read full story (paywalled) Source: The Times, 27 June 2023
  4. News Article
    Shrewsbury and Telford Hospital Trust temporarily suspended admissions to the women’s and children’s centre at Princess Royal Hospital – which houses the provider’s consultant-led maternity services – earlier this week due to an issue with a generator. HSJ understands a power cut occurred and estates chiefs were concerned about running solely on battery power, hence suspending admissions while the problem was fixed. Five inductions of labour were diverted to neighbouring trusts, while fewer than five caesarean sections were rescheduled during the outage. Meanwhile, 56 patients accessing the trust’s telephone triage service were advised by medical chiefs to attend nearby hospitals. Following the incident, a learning review is taking place, and HSJ understands this will investigate whether any women came to harm. HSJ has also been told the generator has been fixed “as good as permanently”. Read full story (paywalled) Source: HSJ, 23 June 2023
  5. News Article
    The midwife leading a review into failings by Nottingham's maternity services said the scope was wider than the UK's biggest maternity scandal. Donna Ockenden previously led the review at Shrewsbury and Telford NHS Trust that found failings led to the deaths of more than 200 babies. The terms of reference for the review in Nottingham were set out on Tuesday. A category of severe maternal harm has been added to include cases that did not lead to a death or injury. Earlier this year Ms Ockenden completed her inquiry into the UK's biggest maternity scandal at Shrewsbury and Telford NHS Trust. She said the scope of the review in Nottingham was wider because an additional category had been added to the investigation. It aims to identify cases of severe maternal harm, like an unexpected admission to intensive care or a major obstetric haemorrhage. Ms Ockenden said: "We felt adding in the category of severe maternal harm would help us to understand women's experiences and help us to learn and help the trust to learn from those cases as well. "So actually there's been a widening of the scope which our review team felt was important and when we tested it out with some families they felt it was important too. "Perhaps there's a mum out there saying 'well I'm ok, and my baby's ok, but x,w,z of my maternity experience really worried me or frightened me' then she can send in her experiences." She said fathers could also send in their experiences. Read full story Source: BBC News, 14 September 2022
  6. News Article
    There was a fair bit of press coverage last week about an employment tribunal case against the Care Quality Commission – in which the regulator was found to have sacked an inspector for making a series of whistleblowing disclosures. However, many of the key details were either skirted over, or missed altogether, in the coverage. The disclosures made by Shyam Kumar related not just to his role as a special adviser for the CQC, but also to his full-time employer, University Hospitals of Morecambe Bay FT, and to understand the case fully, they need to be separated out. The important context (also skirted over) was that Dr Kumar had raised a series of legitimate concerns about another orthopaedic surgeon at UHMB, both internally within the trust, and externally with the CQC, in 2018. This caused major tensions within UHMB, to the extent that Dr Kumar started to be targeted for criticism by a different surgeon, being labelled a ‘traitor’ to Indian doctors in a group email. When challenged by Dr Kumar, the colleague complained to the CQC that Dr Kumar had sought to threaten and intimidate him, along with other accusations. Read full story (paywalled) Source: HSJ, 12 September 2022
  7. News Article
    More than 350 families have already contacted a review team which is examining failings at maternity units in two Nottingham hospitals. The review was opened on 1 September by Donna Ockenden, who previously led an inquiry into the maternity scandal at Shrewsbury and Telford NHS Trust. She will examine how dozens of babies died or were injured in Nottingham. Nottingham University Hospitals NHS Trust has apologised for "unimaginable distress" caused by its failings. More affected families, as well as staff with concerns, have been asked to come forward. Ms Ockenden said: "We are really pleased with the large numbers of families and staff that have already come forward in the first week of the review, and we actively encourage others to do the same." Read full story Source: BBC News, 12 September 2022
  8. News Article
    Dr Ted Baker has been named as the government’s preferred candidate for chair of the Health Services Safety Investigations Body (HSSIB). Steve Barclay, the Secretary of State for Health and Social Care, has today (26 August 2022) invited the Health and Social Care Committee to hold a pre-appointment scrutiny hearing with Dr Baker. Ted Baker was Chief Inspector of Hospitals at the Care Quality Commission between 2017 and 2022. He trained as a paediatric cardiologist. He was in clinical practice for 35 years and has held a range of clinical and academic leadership roles including medical director at Guy’s and St Thomas’ NHS Foundation Trust. He was selected following an open public appointment process. Following the select committee hearing, the committee will set out its views on the candidate’s suitability for the role. The Secretary of State will then consider the committee’s report before making a final decision on the appointment. Read full story Source: HSIB, 26 August 2022
  9. News Article
    A black NHS worker has launched legal action against the health service’s blood and transplant authority after witnessing years of alleged racism within the service. Melissa Thermidor, 40, from Bushey, Hertfordshire, has lodged an employment tribunal claim against NHS Blood and Transplant (NHSBT) and two executives who have since left the authority. Betsy Bassis and Millie Banerjee, who were the chief executive and chairwoman, have denied the allegations and intend to fight the tribunal claims. One colleague allegedly said: “White donors are more likely to shop at Waitrose and black donors at Tesco.” At subsequent meetings, the phrase “Tesco donors” was used. Staff also allegedly referred to “you people” when speaking to black members of the team. Thermidor claims she was constructively dismissed after whistleblowing about racism within NHSBT. The health authority, which supported 3,386 organ donations in the year to March last year as well as collecting blood from 761,000 donors, has been embroiled in allegations of bullying, racism and poor culture under Bassis and Banerjee’s leadership. Read full story (paywalled) Source: The Times, 21 August 2022 Read NHS Blood and Transplant's response to the article.
  10. News Article
    The midwife leading a review into Nottingham's maternity services has urged families and staff to come forward with their experiences. Donna Ockenden was appointed in May to head the inquiry into the services at Queen's Medical Centre and City Hospital. It was launched after more than 100 families with experiences of maternity failings wrote to former Health Secretary Sajid Javid demanding the action. A much-criticised initial review was subsequently scrapped. Ms Ockenden, who uncovered 200 avoidable baby deaths at Shrewsbury and Telford NHS Trust across two decades, said the review is now open to families, NHS workers and others who wish to contribute. "By September 1 we'll be ready to receive contact from families," she told Nottinghamshire Live. "In the mean time if there are either families or members of the NHS that want to get in touch they can use our new email. And also those who represent communities, whether that's safe communities or women's groups in Nottingham." People can contact the review through the email nottsreview@donnaockenden.com, which was launched last week. Ms Ockenden said that positive steps were being made in putting in place the "building blocks" for the review, which is due to start on 1 September 2022. Read full story Source: Nottinghamshire Live, 17 August 2022
  11. News Article
    Survivors of the contaminated blood scandal have been awarded interim government payments after a 40-year battle, but thousands of parents and children of the victims have still received nothing. Ministers have accepted the urgency of the need to make the £100,000 payments to about 3,000 surviving victims, after being warned that those mistakenly infected with HIV and hepatitis C were dying at the rate of one every four days. But parents and children of the victims accused the government of perpetuating the scandal by failing to recognise their own trauma and loss in today’s announcement. Contaminated blood products administered in the 1970s and 1980s to up to 6,000 people have already led to the deaths of more than 2,400 people in the biggest treatment scandal in NHS history. The government said it intends to make payments to those who have been infected and bereaved partners in England by the end of October. The same payments will be made in Scotland, Wales and Northern Ireland. Announcing the plan, the prime minister, Boris Johnson, said: “While nothing can make up for the pain and suffering endured by those affected by this tragic injustice, we are taking action to do right by victims and those who have tragically lost their partners by making sure they receive these interim payments as quickly as possible. “We will continue to stand by all those impacted by this horrific tragedy, and I want to personally pay tribute to all those who have so determinedly fought for justice.” Read full story Source: The Guardian, 17 August 2022
  12. News Article
    Major reforms have been set out on how NHS organisations should respond to patient safety incidents, which are aimed at ensuring better engagement with patients and families. The Patient Safety Incident Response Framework (PSIRF), published today, replaces the serious incident framework and provides guidance to trusts on how and when they should conduct investigations. According to NHSE, a key aim is to allow trusts to focus resources on where investigations will have the greatest impact, rather than investigating all incidents as they did under the old framework. NHSE said the more flexible approach should make it easier to address concerns specific to health inequalities, as incidents can be learnt from that would not have met the serious incident definition. However, it does not affect the need for a patient safety incident investigation following a never event’ or maternity incident; this is still required. Helen Hughes, chief executive of charity Patient Safety Learning, said the new framework “places an emphasis on individual organisations assessing their patient safety risks”, and provided a “welcome acknowledgement of the importance of engaging patients and families as part of the investigation process”. However, she said there would need to be a “significant training programme for staff in a range of human factors informed approaches”, to ensure reviews lead to safety improvements. She added: “What is being proposed is a complex innovation in the NHS’s approach to incident investigation. Its success to a large part will depend on having the right organisational leadership and resources to support this transition. [NHSE has] now provided a set of tools and a timetable for this. However, ultimately this initiative should be judged on its implementation and effectiveness in reducing avoidable harm.” Read full story (paywalled) Source: HSJ, 16 August 202
  13. News Article
    A scheme handing payments to those affected by the contaminated blood scandal will be announced this week, as ministers scramble to help those harmed by the “historic wrong”. Whitehall sources confirmed that a programme handing interim payments will be confirmed in the coming days, once officials have ironed out issues to ensure that victims are not taxed on the payments or have their benefits affected by them. It is thought that ministers accept recent recommendations that infected people and bereaved partners should get “payments of no less than £100,000”. More than 4,000 people are in line for the payment. Kit Malthouse, the cabinet office minister, has been prioritising the scheme in the last week to ensure payments are made as soon as possible. “The infected blood scandal was a tragedy for everyone involved, and the prime minister strongly believes that all those who suffered so terribly as a result of this injustice should receive compensation as quickly as possible,” said a No 10 source. “He has tasked ministers with resolving this issue so that interim payments can be made to all those infected as soon as possible, and we will set out the full details later this week.” Read full story Source: The Guardian, 6 August 2022
  14. News Article
    A 65-year-old man died after doctors failed to notice serious abnormalities on his X-ray, an investigation by the Parliamentary and Health Service Ombudsman (PHSO) has revealed. The investigation comes a year after a landmark report by the Ombudsman highlighted failings in how X-rays and scans are reported and followed up in the NHS. Mr B, who was admitted to University Hospitals Birmingham NHS Foundation Trust in May 2019, had been unwell for several days. He was admitted to hospital suffering from abdominal pain and vomiting. An X-ray of his abdomen was taken, which two doctors said did not show any apparent abnormalities. The following day the man’s condition deteriorated. He suffered a heart attack and died. A PHSO investigation found the Trust failed to notice a blockage in his intestine on the X-ray. Because of this failure, Mr B did not receive treatment that could have saved his life. Speaking on this case Ombudsman Rob Behrens said: “The case of Mr B highlights the devastating impact mistakes like this can have. If the Trust had picked up the abnormalities on his X-ray sooner, Mr B could still be with his family today. “As the NHS faces the challenge of rebuilding after the pandemic, it must not lose momentum in improving the way X-rays and scans are handled during a patient’s care.” Progress has been made by the NHS in implementing recommendations made by the Ombudsman in the report; however, Rob Behrens has said more needs to be done to protect patients from serious harm. “Attention and buy-in from the NHS’s senior leaders is crucial if we want to see sustained and meaningful change in how X-rays and scans are managed during a patient’s care. We need more collaboration across clinical specialties, looking at the whole patient journey once a scan has been carried out. "I want to see the NHS treating complaints as a source of insight to drive improvements in patient care. Not learning from mistakes will mean missed opportunities to diagnose patients earlier. In the most serious cases, like that of Mr B, it will mean a death which should never have happened.” Read full story Source: PHSO, 20 July 2022
  15. News Article
    Staff at a mental health trust, run by Norfolk and Suffolk NHS Foundation Trust, falsified records that they had checked on a vulnerable patient the night he died, an inquest has heard. Eliot Harris was found dead in his room at Northgate Hospital in Great Yarmouth, Norfolk, in April 2020. A police witness statement detailed how CCTV footage contradicted 19 log entries. Mr Harris, 48, was admitted to hospital after the care home where he was a resident requested an urgent mental health assessment, an inquest into his death at Norfolk Coroner's Court heard. He had been diagnosed with paranoid schizophrenia, had a history of epileptic seizures and had not been taking his medication. Mr Harris was deemed to be high risk and was supposed to be on regular checks four times an hour. In a witness statement read out in court, Det Sgt Nick Appleton described how police had cross referenced logs of his observations with CCTV recordings. Det Sgt Appleton listed 19 instances in which the observation record was signed by a staff member that night, indicating Mr Harris had been checked, but was not backed up by the CCTV record. He identified a number of "points of concern" in his evidence in which falsifying logs was "normal" and "standard practice" on wards. Read full story Source: BBC News, 1 August 2022
  16. News Article
    Three former health secretaries have called on the government to urgently pay compensation to victims of the contaminated blood scandal. The chairman of the public inquiry into the scandal, Sir Brian Langstaff, has recommended that each victim should receive a provisional sum of £100,000. One woman who developed hepatitis C from infected blood told the BBC the news was "incredibly significant". The government has said it will urgently consider any recommendations. Former health secretaries Andy Burnham, Jeremy Hunt and Matt Hancock told the BBC it was important to act quickly because the life expectancy of many victims had been shortened by infections they had contracted. A lawyer representing about 15,000 claimants also argued that victims should receive compensation "immediately". Des Collins said payment must be made within "days or weeks", and he would step up pressure from Monday. Read full story Source: BBC News, 31 August 2022
  17. News Article
    Almost 75 years since its foundation, the NHS is struggling with delays caused by the coronavirus pandemic and the “greatest workforce crisis” in its history. A report from MPs on the health committee this week showed 105,000 vacancies for doctors, nurses and midwives, as thousands quit owing to burnout, bullying, pension rules and low pay. Jeremy Hunt, the committee’s chairman, said that the “persistent understaffing in the NHS poses a serious risk to staff and patient safety”. Lawyers warned that the crisis risked increasing the number of negligence claims. Spending on claims by NHS Resolution rose to £2.5 billion in 2021-22 compared with £2.3 billion in the previous year, according to its annual report published last week. The bill increased despite initiatives to cut the number of cases going to court and foster greater collaboration with claimant lawyers. Claimant lawyers welcomed NHS Resolution’s more collaborative approach and desire to resolve cases sooner. They argued, however, that the defensive culture remained and suggested there should be a greater focus on patient safety and learning from mistakes. John McQuater, president of the Association of Personal Injury Lawyers, said that NHS Resolution’s denials and delays meant that injured patients had to turn to lawyers to find answers. He said that earlier investigation into patient safety incidents and earlier admissions of liability by NHS trusts would speed up the system, cutting costs and human misery. Read full story (paywalled) Source: The Times, 28 July 2022
  18. News Article
    Former Health Secretary Jeremy Hunt has told a public inquiry institutions and the state can sometimes "close ranks around a lie". Giving evidence at the infected-blood inquiry, he said it could be seen as a "huge failing of democracy" that victims had waited so long for justice. At least 5,000 people contracted HIV or hepatitis C in the 1970s and 80s, after being given contaminated blood products and transfusions on the NHS. More than 2,400 have died as a result. Jenni Richards QC asked whether a 2012 briefing for new ministers in the health department - "almost certainly" not shown to Mr Hunt at the time - stating, under a heading "Key facts", hepatitis C and HIV (Human Immunodeficiency Virus) infection had been a problem in the 1970s and 80s, "before it was possible to screen donors and make products safer", suggested the contamination had been an "unavoidable problem". Mr Hunt, health secretary for six years until July 2018, replied: "I mean, that briefing is wrong and it shouldn't say that. "At the very least, ministers should be aware as politicians that this is contentious and disputed by families - but I'm afraid it tries to suggest the issue is closed when it is not." Read full story Source: BBC News, 27 July 2022
  19. News Article
    Families who lost loved ones during the pandemic have demanded to play a central role in the UK’s Covid-19 inquiry, which launches its investigative phase tomorrow. The inquiry has already consulted with different groups, businesses, academics and officials from a variety of sectors involved in the pandemic response to review which areas warrant scrutiny and how to structure proceedings. This includes Covid-19 Bereaved Families for Justice, a campaign group of over 6,000 people who have lost a loved one to coronavirus. The group has repeatedly sought assurances from the inquiry it will be granted a ‘core participant’ status once applications open. This which would allow families to give evidence, ask questions during proceedings, access all disclosed documents, and recommend people to be interviewed. However, Elkan Abrahamson, a lawyer who is representing the group in the inquiry, said it was unclear how the inquiry would select core participants and expressed concern that the bereaved families won’t play a central role. “The feeling from the bereaved at the consultation stage was that the chair was sympathetic. They were happy with how that went,” Mr Abrahamson said. “[But] given we represent the largest group of bereaved in the UK, we’re not experiencing a sense of co-operation that we would normally expect to have reached by this stage. Their lawyers are happy to meet with us, but the questions we ask them aren’t being properly answered.” Read full story Source: The Independent, 20 July 2022
  20. News Article
    A paediatrician has been struck off for falsely diagnosing children with cancer to scare their parents into paying for expensive private treatment. Dr Mina Chowdhury, 45, caused "undue alarm" to the parents of three young patients - one aged 15 months - by making the "unjustified" diagnoses so his company could cash in by arranging tests and scans, a medical tribunal found. Chowdhury, who worked as a full-time consultant in paediatrics and neonatology at NHS Forth Valley, provided private treatment at his Meras Healthcare clinic in Glasgow. But the clinic made losses, despite "significant" potential income from third-party investigations and referrals for treatment – with patients charged a mark up fee of up to three times the actual cost. In all three cases, Chowdhury gave a false cancer diagnosis, without proper investigation, before recommending “unnecessary and expensive” private tests and treatment in London. Parents previously told the tribunal of their shock and upset at receiving Chowdhury’s diagnoses during consultations between March and August 2017. He told the parents of a 15-month-old girl - known as Patient C - that a lump attached to the bone in her leg was a "soft tissue sarcoma" and a second lump had developed. Chowdhury urged them to see a doctor in London who could arrange an ultrasound scan, a MRI scan and biopsy in a couple of days, saying: "If things are happening it is best to get on top of them early." He also warned that it would be "confusing" to return to the NHS for treatment. But the parents spoke to an A&E doctor and an ultrasound scan revealed that the lumps were likely fat necrosis. Patient C later was discharged after her bloods tests came back as normal. The child’s mother told the tribunal that she and her husband had been "very upset" at Chowdhury’s diagnosis. She was also left "angry" after she later read Dr Chowdhury’s consultation notes and realised they were a "total falsification" of what was discussed. Read full story Source: Medscape, 18 July 2022
  21. News Article
    Catherine O’Connor, who was born with spina bifida and used a wheelchair all her life, was looking forward to the surgery to fix her twisted spine. Tragically, after a catastrophic loss of blood, she died on the operating table at Salford Royal Hospital in Manchester. She died in February 2007 but only now has an NHS-commissioned report concluded the “unacceptable and unjustifiable” actions of her surgeon, John Bradley Williamson, “directly contributed” to her death. Williamson pressed on with the surgery despite being explicitly told he needed a second consultant surgeon. Her case is one of more than a hundred of Williamson’s being reviewed by Salford Royal Hospital amid allegations by whistleblowers of a cover-up by managers and a “toxic culture” within his surgery team. An internal list produced by concerned clinicians as long ago as 2014 describes some of Williamson’s patients being left paralysed or in severe pain as a result of misplaced spinal screws and others being rushed back to theatre for life-saving surgery. Separately, leaked minutes of a meeting between staff and the hospital’s new chief executive in December 2021 described a “snapshot” of five of Williamson’s patients which “clearly identified significant areas of clinical care, avoidable harm and avoidable death”. They added: “Concerns around Mr Williamson continue to be raised and remain unaddressed.” Read full story (paywalled) Source: The Times, 17 July 2022
  22. News Article
    A couple whose baby died in Nottingham say they are "furious" at a memo to hospital staff criticising media coverage of the city's maternity units. Jack and Sarah Hawkins, whose daughter Harriet died in 2016, have led calls for an inquiry into failings. Nottingham University Hospitals NHS Trust (NUH) is at the centre of a review into failings at the city's maternity units. After years of campaigning and an earlier review which was abandoned, experienced midwife Ms Ockenden was appointed in May. On Tuesday it emerged Ms Wallis had sent a memo to NUH maternity staff which read: "Yesterday, (Monday 11th) Donna Ockenden met with families as part of the new independent review process. "Some of you will no doubt have seen some of the media fall out." "Yet again they painted a damning picture of our maternity services, leaving out of their reports the great work that has been done, the improvements that have been introduced and the passion and commitment of all of the staff." Mr and Mrs Hawkins told the Local Democracy Reporting Service: "It's not just the families and the press ganging up - there is very real concern about safety. For senior leadership to not be saying that they have a problem is beyond us." Hospital bosses have "wholeheartedly apologised" for offence caused. Read full story Source: BBC News, 13 July 2022
  23. News Article
    When Susan Sullivan died from Covid-19, her parents’ world fell quiet. But as John and Ida Sullivan battled the pain of losing their eldest, they were comforted by doctors’ assurance that they had done all they could. It was not until more than a year later, when they received her medical records, that the family made a crushing discovery. These suggested that, despite Susan being in good health and responding well to initial treatments, doctors at Barnet hospital had concluded she wouldn’t pull through. When Susan was first admitted on 27 March 2020, a doctor had written in her treatment plan: “ITU (Intensive therapy unit) review if not improving”, indicating he believed she might benefit from a higher level of care. But as her oxygen levels fell and her condition deteriorated, the 56-year-old was not admitted to the intensive unit. Instead she died in her bed on the ward without access to potentially life-saving treatment others received. In the hospital records, seen by the Observer, the reason Susan was excluded is spelled out: “ITU declined in view of Down’s syndrome and cardiac comorbidities.” A treatment plan stating she was not to be resuscitated also cites her disability. For John, 79, a retired builder, that realisation was “like Susan dying all over again”. “The reality is that doctors gave her a bed to die in because she had Down’s syndrome,” he said. “To me it couldn’t be clearer: they didn’t even try.” Susan is one of thousands of disabled people in Britain killed by Covid-19. Last year, a report by the Learning Disabilities Mortality Review Programme found that almost half those who died from Covid-19 did not receive good enough treatment, including problems accessing care. Of those who died from Covid-19, 81% had a do-not-resuscitate decision, compared with 72% of those who died from other causes. Read full story Source: The Guardian, 10 July 2022
  24. News Article
    Health Minister Robin Swann has announced plans to improve the review process for serious adverse incidents (SAI) in Northern Ireland's health and social care system. The reviews take place after unintended incidents of harm and ensure improvements are made. The Regulation and Quality Improvement Authority (RQIA) was commissioned to examine the system's effectiveness. It found the process was not "sufficiently robust". In the RQIA report, the independent body found that "neither the SAI review process nor its implementation is sufficiently robust to consistently enable an understanding of what factors, both systems and people, have led to a patient or service user coming to harm". It added: "The reality is that similar situations, where events leading to harm have been inadequately investigated and examples of recognised good practice have not been followed, have been and are likely to be repeated in current practice." It identified failures in the SAI procedure, including failures to: Answer patient and family questions. Determine where safety breaches have occurred. Achieve a systemic understanding of those safety breaches. Design recommendations and action plans to reduce the opportunity for the same or similar safety breaches in future. Read full story Source: BBC News, 7 July 2022
  25. News Article
    A world-famous hospital has a culture where some staff may put research interests above patient safety, according to an external investigation. A report published yesterday cited some employees at Great Ormond Street Hospital for Children Foundation Trust as saying “they feel that the hospital sometimes put too much emphasis on pushing the boundaries of science” and “are concerned [this] may lead to a culture where some prioritise innovation over safety in their practice”. The trust’s medical director Sanjiv Sharma commissioned the report into the effectiveness of its safety procedures, from consultancy Verita, in 2020, after families of several patients who died at the hospital raised concerns in the media about how it responded to safety incidents. The report said: “We believe that it is sometimes culturally difficult within Great Ormond Street to accept that things can go wrong and to respond appropriately. We were told that some see the organisation as ‘bullet-proof’ in the face of criticism." “There is also a view outside the trust that some clinicians at Great Ormond Street can find it difficult to accept that something had gone wrong. Some believe that this reflex is deeply ingrained. This is potentially indicative of a culture of defensiveness. Acknowledging this trait is the first step on the road to changing it.” Dr Sharma said in a statement yesterday that GOSH had already taken steps to improve its culture and systems, appointing patient safety educators and patient safety leads in each directorate. Read full story (paywalled) Source: HSJ, 7 July 2022
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