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News ArticleWhen 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
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News Article
Northern Ireland: Serious adverse incidents 'likely to be repeated'
Patient Safety Learning posted a news article in News
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 -
News Article
‘Innovation put over safety’ at world-famous hospital
Patient Safety Learning posted a news article in News
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 -
News Article
Baby died two days after birth despite mum begging doctors to assess her
Patient Safety Learning posted a news article in News
A two-day old baby died just days after his mother begged doctors to assess her ahead of a c-section despite her pregnancy being deemed high risk. Davi Heer-Do Naschimento was born via emergency caesarean section during the early hours of 29 September 2021, after doctors at Royal London Hospital failed to communicate crucial details during handover meetings. An inquest at Poplar Coroners Court heard that his parents, Ruth Heer and Tiago Do Naschimento, had asked numerous times for assistance and were not seen by the obstetrics team the day before her planned caesarean. Tragically, after becoming "feverish" during the night, she was rushed into theatre with Devi sadly dying two days later. Speaking on behalf of the family, Francesca Kohler said that there had been “multiple occasions” throughout the day when Ms Heer and her partner had called for assistance and had raised concerns, but were not attended. She had also not been seen by the obstetrics team and had not been spoken to about the upcoming caesarean section. Read full story Source: My London, 4 July 2022 -
News Article
Oldham doctor jailed for killing patient in botched procedure
Patient Safety Learning posted a news article in News
A doctor who killed a mother-of-three when he botched a procedure during a routine appointment has been jailed. Dr Isyaka Mamman, now thought to be 85, admitted gross negligence manslaughter over the death of Shahida Parveen, 48, at the Royal Oldham Hospital in 2018. He used the wrong needle and inserted it in the wrong place, piercing the sac holding Mrs Parveen's heart. Mrs Justice Yip at Manchester Crown Court said Mrs Parveen's death was his fault and sentenced him to three years. She also criticised the NHS trust, pointing to the fact that Mamman had both lied about his age and had been involved in two critical incidents similar to that which led to Mrs Parveen's death. The court heard Mrs Parveen attended Royal Oldham Hospital on 3 September, 2018, to give a bone marrow sample. This is usually taken from the hip bone but, after failing in his first attempt, Mamman tried to instead take it from her sternum. This was a "highly dangerous" procedure, the court was told, and one which had led to another of Mamman's patients being permanently disabled three years earlier. Read full story Source: BBC News, 5 July 2022 -
News Article
Doctor admits killing patient in botched routine procedure
Patient Safety Learning posted a news article in News
A mother was killed at her hospital appointment by a doctor who botched a routine procedure, a court has heard. Dr Isyaka Mamman, 85, was responsible for a series of critical incidents before the fatal appointment, Manchester Crown Court heard. Mamman, who admitted gross negligence manslaughter, had already been sacked by medical watchdogs for lying about his age but was re-employed by the Royal Oldham Hospital. He is due to be sentenced on Tuesday. Mother-of-three Shahida Parveen, 48, had gone to hospital with her husband for investigations into possible myeloproliferative disorder on 3 September 2018 and a bone marrow biopsy had been advised, Andrew Thomas QC, prosecuting, told the hearing. Normally, bone marrow samples are taken from the hip bone but Mamman, of Cumberland Drive, Royton, Oldham, failed to obtain a sample at the first attempt, he said. Instead, he attempted a rare and "highly dangerous" procedure of getting a sample from Ms Parveen's sternum - despite objections from the patient and her husband, the court heard. Mamman, using the wrong biopsy needle, missed the bone and pierced her pericardium, the sac containing the heart, causing massive internal bleeding. Ms Parveen lost consciousness as soon as the needle was inserted. She died later that day. Read full story Source: BBC News, 4 July 2022 -
News Article
Baby died after hospital failings starved her of oxygen at birth
Patient Safety Learning posted a news article in News
A baby suffered brain damage and died due to failings at a hospital where her mother spent hours alone in pain and suffered crucial delays, according to her family. Dominic and Ewelina Clyde-Smith told The Independent their daughter, Amelia, was otherwise healthy and poor care led to her being starved of oxygen at birth. The couple said they experienced a series of failings at Jersey General Hospital in 2018, including a lack of a doctor during a difficult labour and staff taking “too long” to resuscitate their child. They believe Amelia suffered further harm when a ventilator was not plugged in properly during a transfer. Amelia was left with brain damage and died aged one month after being put into palliative care. Her parents said they have spent years trying to get justice through official channels but are now speaking out for the first time as they believe the standard of care received should be public knowledge. “It happened nearly four years ago,” Ms Clyde-Smith says, adding: “But the whole maternity unit just failed us completely.” Read full story Source: BBC News, 1 July 2022 -
News Article
CQC prosecutes troubled provider over death of teenage girl
Patient Safety Learning posted a news article in News
A struggling mental health trust is being prosecuted over accusations it failed to protect a teenager at a children’s inpatient unit. Tees, Esk and Wear Valleys Foundation Trust ran the former West Lane Hospital in Middlesbrough until the Care Quality Commission (CQC) closed it in 2019. The CQC is now prosecuting the trust, alleging it breached the Health and Social Care Act 2008 in relation to the death of Christie Harnett, who took her own life at the facility in June 2019. In a statement, the regulator claimed TEWV “failed to provide safe care and treatment” by exposing the patient to a “significant risk of avoidable harm”. A CQC spokeswoman added: “Our main priority is always the safety of people using health and social care services, and if we have concerns we will not hesitate to take action in line with our regulatory powers. We will report further as soon as we are able to do so.” Read full story (paywalled) Source: HSJ, 30 June 2022 -
News Article
Patient safety is not a ‘priority’ for NHSE claims watchdog chief
Patient Safety Learning posted a news article in News
The outgoing chief investigator of the national safety watchdog has described his frustration with the organisation’s ‘ambivalent’ relationship with NHS England. Keith Conradi, who is due to retire from the Health Safety Investigation Branch in July, said he did not think he had “ever really spoken to any of the hierarchy in NHS England”. He added “their priorities are elsewhere”. In an interview with health commentator Roy Lilley for the Institute for Health and Social Care Management, Mr Conradi also described HSIB’s relationship with NHSE as “ambivalent”. “It wobbled along that sort of line and got worse as time has gone on,” he said. “At the very start I had a chat with the permanent secretary of the Department of Health and said we would be better off in the department than NHS England. He disagreed and felt that we’d be too close to [then health secretary] Jeremy Hunt, and particularly at that time that would have a negative effect.” Mr Conradi was also critical of the decision to ask HSIB to take on investigations into maternity care early in its life. He said he was “shocked” that it happened so quickly “when we hadn’t really got going”. He continued: “We hadn’t developed a method of doing normal national investigations and suddenly we were being asked to do maternity ones. There was a huge amount of pressure to do this.” Read full story (paywalled) Source: HSJ, 28 June 2022 -
News Article
Former prime minister calls contaminated blood scandal 'incredibly bad luck'
Patient Safety Learning posted a news article in News
Former prime minister Sir John Major has described the contaminated blood scandal as "incredibly bad luck", drawing gasps from families watching him give evidence under oath to the public inquiry into the disaster. Up to 30,000 people contracted HIV and hepatitis C in the 1970s and 80s after being given blood treatments or transfusions on the NHS. Thousands have since died. Sir John later apologised for his choice of language. He said: "I obviously caused offence inadvertently this morning when I referred to the fact that it was awful that people had been fed infected blood and I referred to it as sheer bad luck. "I can only say to people it wasn't intended to be offensive. I was seeking to express the fact that I was concerned about what happened. "It was intended simply to say that it was a random matter and I perhaps expressed it injudiciously." The UK-wide inquiry was launched after years of campaigning by victims, who claim the risks were never explained and that the scandal was covered up. Campaigners say those infected decades ago are now dying at the rate of one every four days as a result. Read full story Source: BBC News, 27 June 2022 -
News Article
Doctor struck off for ‘repeated dishonesty’ over death of child in 1995
Patient Safety Learning posted a news article in News
A doctor who attempted to cover up the true circumstances of the death in 1995 of a four-year-old patient has been struck off. Consultant paediatric anaesthetist Dr Robert Taylor dishonestly misled police and a public inquiry about his treatment of Adam Strain, who died at the Royal Belfast Hospital for Sick Children, a medical tribunal found. The youngster was admitted for a kidney transplant at the hospital following renal failure but did not survive surgery in November 1995. Six months later an inquest ruled Adam died from cerebral oedema – brain swelling – partly due to the onset of dilutional hyponatraemia, which occurs when there is a shortage of sodium in the bloodstream. Two expert anaesthetists told the coroner that the administration of an excess volume of fluids containing small amounts of sodium caused the hyponatraemia. But Dr Taylor resisted any criticism of his fluid management and refused to accept the condition had been caused by his administration of too much of the wrong type of fluid. In 2004 a UTV documentary When Hospitals Kill raised concerns about the treatment of a number of children, including Adam, and led to the launch of the Hyponatraemia Inquiry. The tribunal found Dr Taylor acted dishonestly on four occasions in his dealings with the the public inquiry, including failing to disclose to the inquiry a number of clinical errors he made and falsely claiming to detectives he spoke to Adam’s mother before surgery. Read full story Source: The Independent, 22 June 2022 -
News Article
Birmingham hospital faces criminal probe after death of vulnerable man
Patient Safety Learning posted a news article in News
A hospital and one of its managers are facing a criminal investigation into the death of a vulnerable man who absconded by climbing a fence. An inquest concluded failings amounting to neglect contributed to the death of Matthew Caseby in 2020, after he fled from Birmingham's Priory Hospital Woodbourne and was hit by a train. The investigation will be carried out by the Care Quality Commission (CQC). Priory said it would co-operate fully "if enquiries are raised by the CQC". Mr Caseby, 23, climbed over a 2.3m-high (7ft 6in) courtyard fence on 7 September 2020. He was found dead the following day after being hit by a train near Birmingham's University station. The inquest in April heard other patients had previously climbed the fence and, despite concerns by members of staff, no action was taken to improve security in and around the courtyard until another patient absconded two months after Mr Caseby's death. Following the inquest, coroner Louise Hunt said she was concerned the fence and courtyard area may still not be safe and urged health chiefs to consider imposing minimum standards for perimeter fences at mental health units. She also criticised record-keeping and how risk assessments were carried out. Read full story Source: BBC News, 23 June 2022 -
News Article
Watchdog warns over medication risk to vulnerable
Patient Safety Learning posted a news article in News
Vulnerable patients cared for in secure mental health units across England could miss out on vital medications due to a shortage of learning disability nurses, the Healthcare Safety Investigation Branch (HSIB) has warned. The report into medication omissions in learning disability secure units across the country highlights problems with retaining learning disability nurses, with the number recruited each year matching those leaving. Figures quoted in the report suggest the number of learning disability nurses in the NHS nearly halved from 5,500 in 2016 to 3,000 in 2020. The HSIB launched a national investigation after being alerted to the case of Luke, who spent time in NHS secure learning disability units but was not administered prescribed medication for diabetes and high cholesterol on several occasions. At Luke’s facility, which included low and medium secure wards, HSIB investigators considered that the quality and style of care provided to patients had been directly impacted by a lack of nurses with required skill sets. Findings from HSIB’s wider national investigation link a shortfall of learning disability nurses to instances of patients missing their medication, with the report’s authors describing a “system in which medicines omissions were too common and prevention, identification and escalation processes were not robust”. Read full story (paywalled) Source: HSJ, 23 June 2022 -
News Article
NHS hospital failed to disclose babies’ deadly bacteria infections
Patient Safety Learning posted a news article in News
A leading NHS hospital failed to publicly disclose that four very ill premature babies in its care were infected with a deadly bacterium, one of whom died soon after, the Guardian has revealed. St Thomas’ hospital did not admit publicly that it had suffered an outbreak of Bacillus cereus in the neonatal intensive care unit (NICU) of its Evelina children’s hospital in late 2013 and early 2014. It occurred six months before a well publicised similar incident in June 2014 in which 19 premature babies at nine hospitals in England became infected with it after receiving contaminated baby feed directly into their bloodstream. Three of them died, including two at St Thomas’. Leaked documents show that both the first outbreak and newborn baby’s death were investigated but never publicly acknowledged by the NHS trust that runs the hospital. GSTT insists that it did not acknowledge the baby’s death publicly in any reports because it believed the child had died of other medical conditions, not the bacteria. However, it declined to say if it had told the baby’s parents that it had become infected with Bacillus cereus. Read full story Source: The Guardian, 23 June 2022 -
News Article
Systems and processes failed neurologist’s patients, inquiry finds
Patient Safety Learning posted a news article in News
Systems and processes in place around patient safety failed in terms of the work of a Belfast-based neurologist, an inquiry has found. Dr Michael Watt was at the centre of Northern Ireland’s largest ever recall of patients, which began in 2018, after concerns were raised about his clinical work. More than 4,000 of his former patients attended recall appointments. Almost a fifth of patients who attended recall appointments were found to have received an “insecure diagnosis”. The final report following the Independent Neurology Inquiry found that problems with Dr Watt’s practice were missed for years and opportunities to intervene were lost. It makes 76 recommendations to the Department of Health, healthcare organisations, General Medical Council and the independent sector. “While one process or system failure may not be critical, the synergistic effect of numerous failures ensured that a problem with an individual doctor’s practice was missed for many years and, as this inquiry finds, opportunities to intervene, particularly in 2006/2007, 2012/2013, and earlier in 2016 were lost,” the inquiry found. Read full story Source: The Independent, 21 June 2022 -
News Article
Epilepsy drug that harms babies may damage their children too
Patient Safety Learning posted a news article in News
An epilepsy drug that caused disabilities in thousands of babies after being prescribed to pregnant women could be more dangerous than previously thought. Sodium valproate could be triggering genetic changes that mean disabilities are being passed on to second and even third generations, according to the UK’s medicines regulator. The Medicines and Healthcare Products Regulatory Agency (MHRA) has also raised concerns that the drug can affect male sperm and fertility, and may be linked to miscarriages and stillbirths. Ministers are already under pressure after it emerged in April that valproate was still being prescribed to women without the legally required warnings. Six babies a month are being born after having been exposed to the drug, the MHRA has said. It can cause deformities, autism and learning disabilities. Cat Smith, the Labour chairwoman of the all-party parliamentary group on sodium valproate, said: “This transgenerational risk is very concerning. There have been rumours that this was a possibility, but I had never heard it was accepted until last week by the MHRA." “The harm from sodium valproate was caused by successive failures of regulators and governments, and this news means it could be an order of magnitude worse than we first thought. It underlines the need for the Treasury to step up to their responsibilities around financial redress to those families.” Read full story (paywalled) Source: Sunday Times, 19 June 2022 -
News Article
Coeliac patient died after being fed Weetabix in hospital, inquiry hears
Patient Safety Learning posted a news article in News
An 80-year-old woman with coeliac disease died within days of being fed Weetabix in hospital, an inquest has heard. Hazel Pearson, from Connah’s Quay in Flintshire, was being treated at Wrexham Maelor hospital and died four days later on 30 November from aspiration pneumonia. Although her condition was recorded on her admission documents, there was no sign beside her bed to alert healthcare assistants to her dietary requirements. Coeliac disease is a condition where the immune system attacks the body’s own tissues after consuming gluten, a type of protein found in wheat, rye and barley, causing damage to the small intestine. The hospital’s action plan to avoid similar fatal incidents lacked detail and had “narrow vision”, the coroner said. The hospital’s matron, Jackie Evans, told the inquest that changes, including placing signs above the beds of patients with special dietary requirements, had been implemented since Pearson’s death. But Sutherland raised concerns that the hospital had yet to carry out a formal investigation into what went wrong. She said: “The action plan lacks detail. What has happened locally is commendable, but it lacks detail and it has narrow vision.” She added that the plan that had been put in place was “amateurish with no strategic vision”. The assistant coroner said she would be unable to make a decision on a prevention of future deaths report until the Betsi Cadwaladr University Health Board (BCUHB) provided a witness to answer further questions about changes. Read full story Source: The Guardian, 17 June 2022 -
News Article
Covid care home restrictions in Scotland caused harm, says report
Patient Safety Learning posted a news article in News
Severe restrictions imposed on care home residents in Scotland during the Covid pandemic caused "harm and distress" and may have contributed to some deaths, academics have said. A 143-page report has been produced by Edinburgh Napier University. It had been commissioned by the independent inquiry into the country's handling of the pandemic. The report says that the legal basis for confining residents to their rooms and banning visitors was "unclear". And it said care home residents were arguably discriminated against compared to other citizens. The report is 1 of 14 that have been published by the Scottish Covid-19 Inquiry, which is chaired by Lady Poole. It found that in the early months of the pandemic there was "little evidence" that the human rights of residents and their families had been considered. It said: "There is substantial evidence of the harm and distress caused to residents and their families by the restrictions imposed in care homes. "This includes concerns that, particularly for people with dementia, being unable to maintain contact with their family exacerbated cognitive and emotional decline, potentially hastening their death." Read full story Source: BBC News, 16 June 2022 -
News Article
USA: Four-year-old accidentally given vasectomy
Patient Safety Learning posted a news article in News
A family in Texas is suing a Houston-based doctor after their 4-year-old on son underwent an "unintended vasectomy" during a surgery. The child was reportedly in the hospital for a hernia surgery at the time of the incident, according to Randy Sorrels, the family's personal injury attorney. He told Fox4 that part of the procedure involved work near the child's groin. The attorney claimed the surgeon "cut the wrong piece of anatomy." “The surgeon, we think, cut accidentally the vas deferens, one of the tubes that carries reproductive semen in it. It could affect this young man for the rest of his life,” Mr Sorrels told the broadcaster. The surgeon who operated on the boy has no history of malpractice and has otherwise never received any negative reports on their work. Mistakes like the one made on the toddler are generally very rare due to safety precautions built into the surgery process. “It’s not a common mistake at all,” Mr Sorrels said. “Before a doctor transects or cuts any part of the anatomy, they are supposed to positively identify what that anatomy is and then cut. Here, the doctor failed to accurately identify the anatomy that needed to be cut. Unfortunately, cut his vas deferens. That wasn’t found out until it was sent in for pathology.” The attorney said his and the family’s top concern is for the boy’s health. They are considering options for reversing the procedure, but the attorney noted that doing so would require the boy to undergo more surgery. Read full story Source: The Independent, 15 June 2022 -
News ArticleA review intended to drive ‘rapid improvements’ to maternity services in Nottingham has been scrapped after just eight months – with some bereaved families saying instead it did ‘irreparable’ damage to their mental health and trust in the system. It was hoped the process would lead to rapid change, restore families’ faith in maternity in Nottingham, and provide a voice for parents who wanted to share both positive and negative experiences. Instead, some families said they found the review process slow, unprepared for the number of people who came forward and lacking the impact needed to improve a maternity service rated ‘inadequate’ by health inspectors. The growing frustration that followed would turn to anger for some families, leading to the direct involvement of a Government minister, the arrival and rapid departure of a new chair, and the eventual disbanding of the review altogether in favour of a fresh start with one of the country’s top advisers on midwifery, Donna Ockenden – who led an in-depth review into Shrewsbury and Telford NHS Trust’s maternity services. The U-turn came after pressure from a group of more than 100 people named ‘Families Harmed by Nottingham Maternity’ – which includes parents whose babies have died or been injured while being cared for at Nottingham’s two main hospitals. Local Democracy Reporter Anna Whittaker looks at what led to so many families turning on a system which the NHS said was set up to bring about major changes. Read full story Source: Notts, 14 June 2022
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News Article
Breast surgeon's victim wants faster improvements
Patient Safety Learning posted a news article in News
Victims of breast surgeon Ian Paterson said independent inquiry improvements are not being implemented fast enough. Paterson was jailed in 2017 after he was found to have carried out needless operations on patients across Birmingham and Solihull. The 2020 report's recommendations include the recall of his 11,000 patients to assess their treatment. The Department of Health and Social Care (DHSC) said it is working to stop future patients facing similar harm. On Sunday, ITV screened a documentary 'Bodies of Evidence: The Butcher Surgeon' which featured victim and campaigner Debbie Douglas, who was instrumental in getting the inquiry established. She said the government needs "to put pace behind" the work to implement the 15 recommendations it made. "It is important those recommendations are embedded in legislation, it is important there is governance over those recommendations to stop another Paterson, it is important that there is a proper consent procedure," she said. The recommendations called for consultants to write directly to patients to explain proposed surgical treatment as standard practice, a public register to detail which types of operations surgeons are able to perform and for patients to be given time to reflect on their diagnosis and treatment options before they are asked to consent to surgery. Read full story Source: BBC News, 14 June 2022 -
News Article
Trust failed for months to give vital medication to vulnerable inmate
Patient Safety Learning posted a news article in News
A troubled NHS trust failed for months to give vital medication to a prison inmate who had a long-standing diagnosis of HIV, an inquest has found. A jury at Essex Coroner’s Court concluded that a series of failures and neglect by Essex Partnership University Trust (EPUT) contributed to the death of Thokozani Shiri in April 2019. The 21-year-old spent two spells as a prisoner at HMP Chelmsford, where EPUT provided some services at the time. He was considered vulnerable due to a long-standing diagnosis of HIV for which he was receiving treatment before he went to prison, and the trust was aware he had HIV throughout both stays, the inquest heard. The inquest jury identified that five separate failings had “probably caused” Mr Shiri’s death. These included: a failure to provide antiretroviral medication to Mr Shiri during both periods of imprisonment; a failure to refer him to an HIV clinic; the absence of an appropriate care plan and engagement with a multidisciplinary team; and inadequate management of records. Each failing on behalf of the trust was considered by the jury to have amounted to neglect. Read full story (paywalled) Source: HSJ, 9 June 2022 -
News ArticleTwo years ago, it seemed that thousands of British women afflicted with crippling pain, ruined sex lives, shattered relationships and wrecked careers would finally get justice and practical redress. A government-commissioned report, following a campaign backed by Good Health, recognised that the plastic mesh tape surgeons had used to treat their incontinence and prolapse had caused some women catastrophic harm. How many women’s lives have been ruined by this mesh is unknown, but Baroness Cumberlege, who led the official review, estimated it to be ‘tens of thousands’. The use of the mesh for stress urinary incontinence was paused in July 2018 as recommended by the inquiry’s preliminary report — then the concluding report, in July 2020, said that this pause should continue until strict requirements on safety and recompense are met. These include the establishment of specialist centres to remove mesh from afflicted women, and financial compensation from government and mesh manufacturers for women affected, as well as the setting up of a database of victims to ascertain the numbers involved and their injuries. The final report also urged that the watchdog, the Medicines and Healthcare products Regulatory Agency (MHRA), which had approved the use of mesh tape in the 1990s, should be reformed to improve its vigilance on such problems. Matt Hancock, then Health Secretary, apologised for the women’s pain. ‘We are going to look carefully at the recommendations,’ he told reporters in July 2020. ‘We need to take action.’ But words can be cheap: a Good Health investigation has found none of the recommendations has been implemented properly and the use of mesh in women is continuing. Read full story Source: MailOnline, 6 June 2022
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News Article
Inquiry opens into alleged patient abuse at Muckamore Abbey
Patient Safety Learning posted a news article in News
A public inquiry has opened into allegations of extensive and repeated abuse of patients at Muckamore Abbey, a hospital for vulnerable adults in Northern Ireland. The inquiry’s chair, Tom Kark, said at the first hearing on Monday that the allegations of abuse and neglect at the psychiatric facility outside Belfast, in County Antrim, brought the medical, nursing and care professions into disrepute. “Many of the parents and relatives and carers who trusted the hospital have been let down and they are understandably furious and some feel guilty,” he said. Kark, a QC, said a civilised society had a duty to care for people with learning disabilities and mental illness. Police have arrested 34 people and more than 70 staff have been suspended as a precaution since the alleged abuse came to light in 2017. The police investigation will proceed in parallel to the inquiry. Detectives have viewed about 300,000 hours of CCTV footage from the hospital. Relatives of patients hope the inquiry will shed light on accounts of mental and physical abuse and neglect at what used to be considered one of the best facilities of its kind in Northern Ireland. The hospital currently has about 60 patients, down from about 1,500 in the 1980s. “Without pre-determining any issues, it’s quite obvious that bad practices were allowed to persist at the hospital to the terrible detriment to a number of patients,” Kark told the inquiry. Read full story Source: The Guardian, 6 June 2022 -
News ArticleA woman who suffered six miscarriages lost her seventh baby after doctors delayed her caesarean section, a report has found. Chyril Hutchinson was admitted to hospital in February 2021 with high blood pressure when she was 37 weeks pregnant with her daughter Ceniyah Cienna Carter, and was told by doctors at Mid and South Essex NHS Foundation Trust she would need a caesarean. But the procedure was delayed as a result of staffing pressures and because Ms Hutchinson’s blood pressure stabilised. She was then told she would have to wait another two weeks for it to be carried out. Given her previous miscarriages, Ms Hutchinson said she pleaded for her baby to be delivered earlier, but her concerns were “dismissed” and she was sent home. Days later, a scan revealed that her baby had died. A trust investigation into Ms Hutchinson’s care found that staff had failed to properly monitor the growth of her baby, which could have indicated the need for an earlier delivery. The internal report, seen by The Independent, also revealed that on the day Ms Hutchinson was told she should have a casaerean, the hospital was six midwives short and the department was busy - a situation the trust said “places additional pressures and possible overload on medical staff”. However, the report concluded that staffing levels did not affect Ms Hutchinson’s care, and it did not state whether the wider failings had led directly to her child being stillborn. Read full story Source: The Independent, 5 June 2022
