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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
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News Article
Patient safety concerns over 'toxic culture' hospital probe
Patient Safety Learning posted a news article in News
An NHS England investigation into claims of a toxic culture at a hospital trust has been described as lacking transparency and undermining trust. The Parliamentary Health Service Ombudsman also said there were "very serious" patient safety issues at University Hospitals Birmingham (UHB). Criticism is contained in letters seen by the BBC between the ombudsman, the trust and NHS England. The inquiries, commissioned by the Birmingham and Solihull Integrated Care Board and the local NHS, were begun in response to an investigation by BBC Newsnight and BBC West Midlands which heard from current and former clinicians from the trust, who accused it of being "mafia-like". One of England's biggest hospital trusts, UHB has been in the spotlight for months after three probes were started following allegations doctors there were threatened for raising safety concerns. The trust denies this and says its "first priority is patient safety". The ombudsman, however, said he was sceptical about the reviews' transparency and independence. His finding of "very serious" patient safety issues at UHB is based on the trust's response to the ombudsman's recommendations and findings, including a case of an avoidable patient death. Read full story Source; BBC News, 14 March 2023 -
News Article
How doctors are exposed and vulnerable due to the current 'blame culture'
Patient Safety Learning posted a news article in News
The patient lay slumped next to a pile of pills and a personally signed note reading: 'do not resuscitate me'. His breathing was agonal, his skin mottled, his pupils fixed, no pulse discernible. The attending doctor, in agreement with both paramedics and family member, decided to respect his wishes. Yet, this GP was placed under investigation for gross negligence manslaughter by the Crown Prosecution Service (CPS) for not resuscitating the patient, setting in motion a sequence of investigations, including by the coroner and the General Medical Council (GMC), that were triggered by the statement of one policeman at the scene. All investigations and allegations were eventually dismissed but not until the GP had been through years of significant physical and mental stress. Still today, questions remain unanswered – in particular, concerning the actions of the police and the CPS. Speaking under the condition of anonymity, the GP spoke to Medscape News UK, and said that now, over 7 years after that fateful home visit, she remained resolute that she made the correct clinical decisions at the time. "It has all been very stressful for me. What was behind this case? What was driving this potential prosecution? And throughout, the patient, the family and their concerns were completely forgotten in the pursuit of so-called justice," she pointed out. Read full story Source: Medscape News, 9 March 2023 -
News ArticleBereaved families are having to report maternity blunders because watchdogs and hospitals are unable to spot failings, an expert has warned. Bill Kirkup said avoidable deaths were "a badge of shame" but would continue without urgent change. Eight years on from his report into the Morecambe Bay maternity scandal, he said the failure of officials to act had needlessly cost more lives. "I am very disappointed – and surprised – that we're still where we are", he said. "That's a terrible badge of shame for the health service that it takes families to come and tell us what's wrong. "Yet just about every tragedy that I've ever been involved with investigating has come to light when there's a group of families who say 'You've got a problem here'. "People are lying, they're not being open and they're concealing what's happening. "If we can't bring this change, I'm not confident that there won't be another East Kent, Morecambe Bay or Nottingham, somewhere else." Read full story Source: Mail Online, 10 March 2023
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News ArticleA review into the culture at Birmingham's biggest hospitals trust amid allegations of bullying and undue pressure on staff has found 'substantial issues' of concern, a brief report has revealed. A short briefing for councillors by NHS Birmingham and Solihull chief executive David Melborne offers the first insight into the findings of Professor Mike Bewick and his review team who were tasked with investigating damning allegations made by current and former staff at University Hospitals Birmingham. More than 50 medics, including some with decades of experience, came forward to criticise a 'toxic' working culture at the trust, many sharing their experiences with MP Preet Kaur Gill (Birmingham Edgbaston). Among the most serious claims that emerged were that whistleblowers concerned about patient safety were silenced with threats of disciplinary action. In a written report to Birmingham and Solihull councils' joint health overview and scrutiny committee, meeting Monday, Mr Melborne says the rapid review into the Newsnight allegations and subsequent complaints has found 'no fundamental safety issues at the Trust'. However, he goes on: "That said, there are substantial issues around culture, behaviour, leadership and governance that will need to be addressed". Read full story Source: Birmingham Live, 10 March 2023
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News Article
'Unprecedented': Coroner prohibits naming of surgeon in herpes deaths inquest
Patient Safety Learning posted a news article in News
A surgeon who may have infected two new mothers with herpes has been granted anonymity during the inquests into their deaths in an "unprecedented" ruling. Coroner Catherine Wood said she made the decision because the surgeon's "apprehension" about being named when he stands as a witness would "likely impede his evidence in court" and affect his health. Mid Kent and Medway Coroners is investigating the cases of Kimberly Sampson, 29, and Samantha Mulcahy, 32, who both died in 2018 after the same obstetrician conducted their caesareans. They were treated 6 weeks apart in hospitals run by East Kent Hospitals University NHS Trust (EKHUT). On February 26 – the day before the inquest was due to begin and 16 months after it was first announced – EKHUT made a last-minute bid for anonymity covering the surgeon and a midwife also involved in both cases. The trust said they should not be named unless the inquest concluded they had passed on the infection, because of the "reputational damage" they would suffer, and because the surgeon's health was already being impacted by reports. Read full story Source: Medscape, 9 March 2023 -
News Article
Ministers blasted by scandal inquiry chair
Patient Safety Learning posted a news article in News
The government’s response to the East Kent maternity scandal inquiry has been condemned as ‘very disappointing’ by its chair. More than four months on from the inquiry report, ministers this morning issued what they called an “initial response” to it, as a brief written statement to Parliament. It contained few specific proposals, instead saying government was kicking off a series of other reviews, and “working” with various other agencies. Inquiry chair Bill Kirkup, the well-regarded former medic and expert in care failures, told HSJ the response was poor and should have been “wider and deeper”. Dr Kirkup said the response showed government had “not grasped how fundamental” some of the issues outlined in his report were, and “what sort of initiative” was needed to address them. Read full story (paywalled) Source: HSJ, 7 March 2023 -
News Article
Covid inquiry: what stage is it at and what will it look at?
Patient Safety Learning posted a news article in News
The Covid-19 Inquiry is a public inquiry to examine the UK’s response to the pandemic, as well as its wide-sweeping impact. In the UK, at least 216,726 people have had Covid-19 mentioned on their death certificate since the start of the pandemic. Multiple lockdowns, school closures and furloughs later, a public inquiry aims to gauge what lessons can be learned for the future. Two preliminary hearings have already taken place on 28 February and 1 March. The next one will be on 21 March and will cover Scotland, including strategic issues, political governance, lockdowns and restrictions. The inquiry is chaired by Baroness Heather Hallett, a former Court of Appeal judge. The inquiry has been split into three modules: resilience and preparedness, core UK-decision making; political governance, and the impact of Covid-19 on healthcare systems across the UK. In Spring 2022, the inquiry held a public consultation on its draft terms of reference which allowed people to give their opinions on the topics the inquiry would cover. The public inquiry has come under heavy criticism after it was announced that structural racism will not be explicitly considered. Read full story Source: The Independent, 2 March 2023 -
News Article
Misplaced tube contributed to first UK child Covid death, coroner rules
Patient Safety Learning posted a news article in News
A misplaced medical tube contributed to the death of the first child in the UK to die after contracting Covid, a coroner has found. Ismail Mohamed Abdulwahab, 13, of Brixton, south London, died of acute respiratory distress syndrome, caused by Covid-19 pneumonia, on 30 March 2020, three days after testing positive for coronavirus. He had a cardiac arrest before he died. Ismail’s death prompted widespread alarm about the potentially lethal impact of Covid on children. Hours before Ismail died, an endotracheal tube (ET) used to help patients breathe was found to be in the wrong position. A consultant in paediatric intensive care decided to leave it and monitor him. Giving his judgment on Thursday, senior coroner Andrew Harris said: “I am satisfied that he [Ismail] would not have died when he did were it not for the tube misplacement.” On Wednesday, the inquest at London Inner South London coroner’s court heard evidence from Dr Tushar Vince, a consultant in paediatric intensive care at King’s College hospital who treated Ismail on 29 March after he had been intubated. Asked by Harris if it would be reasonable to put the positioning of the ET on the death certificate as one of the causes, Dr Vince said: “I think it would be reasonable to consider it, yes.” She said: “I was so focused on the lungs I just didn’t see how high this tube was and I’m so sorry that I didn’t see it.” Read full story Source: The Guardian, 2 March 2023 -
News Article
Los Angeles hospital under investigation accused of ignoring Black woman’s pain
Patient Safety Learning posted a news article in News
April Valentine planned to have a complication-free delivery and to enjoy her life as a first-time parent to a healthy baby girl. Instead, California’s department of health and human services is investigating the circumstances of the April's death during childbirth. April, a 31-year-old Black woman, went to Centinela hospital in Inglewood on 9 January and died the next day. Her daughter Aniya was born via an emergency caesarean section. Her family and friends say that staff at the hospital ignored the pregnant woman’s complaints of pain, refused to let her doula be in the hospital room during the birth and neglected Valentine as her child’s father performed CPR on her. “It’s hard to even sleep, to even look at my child after seeing what I saw in that hospital that night,” said Nigha Robertson, Valentine’s boyfriend and Aniya’s father, to the Los Angeles county board of supervisors during its 31 January meeting. “I’m the only one who touched her, I’m the one who did CPR. Nobody touched her, we screamed and begged for help … they just let her lay there and die.” During the 31 January board of supervisors meeting, people who spoke in support of Valentine said that Centinela hospital is known around the community for being one of the “worst hospitals in the county” for Black and Latina mothers and their infants. Since 2000, the maternal mortality rate in the US has risen nearly 60%, with about 700 people dying during pregnancy or within a year of giving birth each year. More than 80% of the deaths are preventable, according to the US Centers for Disease Control and Prevention. The US has the highest maternal mortality rate among industrialized countries and Black women are three times more likely to die during childbirth than white women. Read full story Source: The Guardian, 3 March 2023 -
News Article
Inquiry exaggerated trust death toll, claims CEO
Patient Safety Learning posted a news article in News
A trust chief executive has suggested an inquiry team looking at 2,000 deaths is lacking in “expertise” and has created a “disproportionate impression” of the problems at his trust. Essex Partnership University Trust is at the centre of a high-profile inquiry into the deaths of patients over a 20-year period, which was sparked after serious concerns were raised over specific cases. The inquiry, led by Geraldine Strathdee, a former national clinical director for mental health, is reviewing the cases of 2,000 people who died while they were patients on a mental health ward in Essex or within three months of being discharged. In a letter to the inquiry, obtained by HSJ through a freedom of information request, trust chief executive officer Paul Scott wrote: “The headline number of c.1,500 or c.2,000 deaths used in publicity by the inquiry is, in my opinion, not a fair reflection of the deaths that would be of interest to the inquiry.” Read full story (paywalled) Source: HSJ, 1 March 2023 -
News Article
Woman died after breathing tube put in food pipe
Patient Safety Learning posted a news article in News
A mother-of-one died after a breathing tube was put into her food pipe, despite staff raising concerns it was inserted incorrectly, an inquest heard. Emma Currell, 32, had just received dialysis and was heading home to Hatfield, Hertfordshire, in an ambulance when she had a seizure. An anaesthetic team was called to sedate her as her tongue had swelled and she was bleeding from the mouth. Dr Sabu Syed, who was a trainee anaesthetist, told the hearing: "I used suction to remove blood and I was able to push the tongue to the side and got a partial view." She said she believed she inserted the tube into the trachea - the windpipe - and had asked her senior colleague Dr Prasun Mukherjee to check the position of the tube. "Dr Mukherjee was busy doing other tasks," she added. Technician Nicholas Healey said he flagged his concerns when there was no carbon dioxide reading on the ventilator, which was not faulty. He said that both he and Dr Syed had raised concerns about the tube being in the wrong place. The court heard the hospital had drawn up a guideline checklist for trachea procedures since Ms Currell's death and staff were due to have "no trace = wrong place" training on the warning signs of incorrect insertion. Read full story Source: BBC News, 27 February 2023 -
News Article
Covid inquiry: Race should be at its core, say campaigners
Patient Safety Learning posted a news article in News
Race should be made a central part of the UK's independent public inquiry into the pandemic, campaigners say. A letter seen by BBC News, sent to the chairwoman of the Covid-19 inquiry, calls for it to look at "racism as a key issue" at every stage. Ethnic minorities were significantly more likely to die with Covid-19, according to official figures. An inquiry spokesperson said the unequal impacts of the pandemic would be at the forefront of its work. People from ethnic minority backgrounds who lost loved-ones during the pandemic also told BBC News they felt "sidelined" by the process so far. The letter to Baroness Hallett, who is chairing the inquiry, has been co-ordinated by the group Covid-19 Bereaved Families for Justice and race equality think tank Runnymede. It calls for ethnic minority communities to be "placed firmly at the centre" of the inquiry. Read full story Source: BBC News, 28 February 2023 -
News Article
Eating disorder patients ‘repeatedly failed’, says England watchdog
Patient Safety Learning posted a news article in News
Urgent action is needed to prevent people dying from eating disorders, the parliamentary and health service ombudsman for England has warned, as he said those affected are being “repeatedly failed”. The NHS needs a “complete culture change” in how it approaches the condition, while ministers must make it a “key priority”, according to Rob Behrens. Little progress has been made since the publication of a devastating report by his office in 2017, which highlighted “serious failings” in eating disorder services, he said. Lives continue to be lost because of “the lack of parity between child and adult services”, and “poor coordination” between NHS staff involved in treating patients. There remain issues with the training of medical professionals, Behrens added. “We raised concerns six years ago in our ignoring the alarms report, so it’s extremely disappointing to see the same issues still occurring,” he said. “Small steps in improvements have been taken, but progress has been slow, and we need to see a much bigger shift in the way eating disorder services are delivered." Read full story Source: The Guardian, 27 February 2023 -
News Article
Tees, Esk and Wear Valley NHS Trust prosecuted after three patients died
Patient Safety Learning posted a news article in News
A mental health trust is to be prosecuted after three patients died in its care. The Care Quality Commission (CQC) is bringing charges against the Tees, Esk and Wear Valleys (TEWV) NHS Trust. It is thought they relate to the deaths of Christie Harnett, 17, Emily Moore, 18, and a third person. The trust is said to have failed "to provide safe care and treatment" which exposed patients to "significant risk of avoidable harm". Both Christie Harnett and Emily Moore had complex mental health issues and took their own lives. The CQC said the trust "breached" the Health and Social Care Act, which relates to healthcare providers' responsibility to "ensure people receive safe care and treatment". In response, a spokesperson for the trust said: "We have fully cooperated with the Care Quality Commission's investigation and continue to work closely with them. "We remain focused on delivering safe and kind care to our patients and have made significant progress in the last couple of years." Read full story Source: BBC News, 25 February 2023 -
News Article
USA: Investigation spotlights rise of for-profit ethics boards in research
Patient Safety Learning posted a news article in News
A US government watchdog called for greater federal oversight of ethics boards that sign off on scientific studies, finding that for-profit companies have taken an outsize role in approving certain research and questioning whether financial motivations could put human subjects at risk. Federal regulations require that certain research on human subjects — including those testing the safety of new drugs — first get approval from a registered institutional research board. These boards, which are made up of at least five members and can include researchers and academics, are designed to make sure that a study poses as little risk as possible and that participants have enough information to give consent. While the majority of these boards are affiliated with universities, a small number have no affiliation with institutions conducting research. But according to a new report from the U.S. Government Accountability Office (GAO), these independent boards now account for the largest share of reviews of studies involving new drugs and biologics. The GAO found that federal agencies overseeing the ethics panels inspect relatively few of them and lack ways to evaluate how well they protect people participating in research. Read full story (paywalled) Source: The Washington Post, 16 February 2023 -
News Article
Derby maternity deaths may have been prevented
Patient Safety Learning posted a news article in News
Three women who died under the care of a hospital's maternity unit may have survived if earlier recommendations had been implemented, a report has said. The cases occurred at University Hospitals of Derby and Burton (UHDB) NHS Foundation Trust over 16 months. A review by the Healthcare Safety Investigation Branch (HSIB) also found a culture of intimidation and bullying. The report found that although there was no common theme to the deaths - and four other life-threatening cases that occurred in the same period - processes and leadership had been inconsistent and fragmented. HSIB said "robust action planning and prompt addressing of the learning" from previous recommendations from other investigations "may have had an impact on the outcome for the women who received care during the seven events included in this thematic review". Read full story Source: BBC News, 22 February 2023
