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News Article
Infected blood inquiry: Five things we have learned
Patient Safety Learning posted a news article in News
A long-running public inquiry into what has been called the worst treatment disaster in the history of the NHS will hear its final evidence on Friday. It is thought tens of thousands were infected with HIV and hepatitis between 1970 and 1991 after being given a contaminated drug or blood transfusion. The inquiry, which started in 2018, has reviewed thousands of documents and heard testimony from 370 witnesses. A total of 1,250 people with haemophilia and other bleeding disorders contracted HIV after being given a protein made from blood plasma known as Factor VIII. About half of that group later died of an Aids-related illness. Researchers found that 380 of those infected with HIV - about one in three - were children, including some very young toddlers. One of the key questions the inquiry will now have to answer is whether more could and should have been done to prevent those infections and deaths. Hundreds of victims of the scandal have received annual support payments but - before this inquiry - no formal compensation had ever been awarded for loss of earnings, care costs and other lifetime losses Further recommendations on compensation are expected when the inquiry publishes its final report, which is likely to be around the middle of the year. Read full story Source: BBC News, 3 February 2023 -
News Article
Inquiry head to meet failing maternity bosses
Patient Safety Learning posted a news article in News
Donna Ockenden, who is leading an independent review examining how dozens of babies died or were injured at the Nottingham University Hospitals (NUH) trust, is due to meet with chief executive of NUH, Anthony May, and other members of the NUH executive team. Speaking ahead of the meeting, she said: "The commitment I want to give to the women and families of Nottingham is that real learning, real improvement in maternity safety will happen throughout the life of this review. "It won't be a case of waiting until the end and then presenting the trust with a huge amount of learning that they then have to start putting in place. "Today's meeting with the trust is at executive level. Along with colleagues from NHS England, I'll be meeting with the chief executive and some of his colleagues to talk about how we will ensure that learning reaches the trust on a regular basis and in a timely way so families can be assured that the maternity improvement plan is including learning from our review." Read full story Source: BBC News, 2 February 2023 -
News Article
North East ambulance staff lacked critical medicines, CQC finds
Patient Safety Learning posted a news article in News
Ambulance crews in the North East frequently responded to emergencies without access to life-saving drugs, a damning inspection report has found. The study of North East Ambulance Service NHS Trust (NEAS) concluded patients were potentially put at risk by the poor management of medicines. The Care Quality Commission (CQC) found a deterioration of services and rated NEAS's urgent care as "inadequate". In response, NEAS said it had faced a year of "unprecedented pressures". The damaging assessment follows the launch of a full independent NHS review into numerous "tragic failings" involving patients. Announcing the review, the then health secretary Sajid Javid said he was "deeply concerned" about claims NEAS had covered up mistakes. Whistleblowers have told Newsnight multiple deaths were not investigated properly because information was not always provided to coroners and families. Read full story Source: BBC News, 1 February 2023 -
News Article
Prolific surgeon found guilty of misconduct and dishonesty
Patient Safety Learning posted a news article in News
A prolific surgeon accused of poor care — some with a ‘catastrophic outcome’ — and altering patient notes has been found guilty of misconduct following a tribunal hearing. Jeremy Parker, who performed hundreds of operations at Colchester Hospital and the private Oaks Hospital until his suspension in 2019, faced a misconduct hearing in December and January. The medical practitioners tribunal investigated allegations that between August 2015 and November 2018, Mr Parker failed to provide good clinical care to six patients. It was also alleged he performed surgery in breach of restrictions on his clinical practice between October 2018 and January 2019 and that his actions were dishonest. Richard Holland, opening the tribunal case for the General Medical Council, said Mr Parker’s care of six patients – referred to as patients A-F – was “deficient” in a number of ways, with that provided to patient A leading to a “catastrophic outcome” where their leg was amputated below the right knee following “catastrophic blood loss” caused by severing of an artery during surgery. Read full story (paywalled) Source: HSJ, 1 February 2022 -
News Article
Ian Paterson: Further 1,500 patients to be recalled
Patient Safety Learning posted a news article in News
A further 1,500 patients of convicted breast surgeon Ian Paterson are to be recalled and their treatment investigated. Spire Healthcare, which runs private hospitals, said patients were being contacted after a trawl of IT systems. Paterson was jailed for 20 years in 2017 for 17 counts of wounding people with intent. The healthcare provider said it remained committed to tracking down all "outstanding patients". The former surgeon subjected hundreds of patients to needless and damaging surgery over 14 years. A 2020 independent inquiry ruled "a culture of avoidance and denial" left him free to perform botched operations in NHS and private hospitals in Birmingham and Solihull. The inquiry recommended all 11,000 patients Paterson treated should be recalled for review. Read full story Source: BBC News, 1 February 2023 -
News Article
Minister calls for staff evidence in deaths inquiry
Patient Safety Learning posted a news article in News
A health minister has called for more staff to take part in an inquiry into deaths at a mental health trust. An independent review into 1,500 deaths at the Essex Partnership University Trust (EPUT) over a 21-year period was launched in 2020. It emerged earlier this month that 11 out of 14,000 staff members had come forward to give evidence to an independent inquiry. The trust said it was encouraging staff to take part in the inquiry. During a parliamentary debate, Health Minister Neil O'Brien said the trust was being given a "last chance" before the government intervened and instigated a statutory inquiry. A statutory inquiry would allow staff to be compelled to give evidence. In December, a further 500 deaths were made known to the review chair, Dr Geraldine Strathdee. She said the inquiry could not continue without full legal powers. Chelmsford MP Vicky Ford said she had been told by the chief executive of EPUT that staff were "very scared" to give evidence. Read full story Source: BBC News, 31 January 2023 -
News Article
Hospital doctor accused of sexual assaults on patients
Patient Safety Learning posted a news article in News
The National Crime Agency and Interpol has been drafted in by detectives investigating a junior doctor accused of multiple sexual assaults on children and adults in A&E departments. Last year, Staffordshire police began an investigation into a 35-year-old medic's work at two hospitals, the Royal Stoke University Hospital in Staffordshire and the Russells Hall Hospital in Dudley, West Midlands. Source: Sunday Times Shared by Shaun Lintern Tweet, 29 January 2023 -
News ArticleChildren came to “significant” harm due to chronically low staffing levels at scandal-hit mental health hospitals, whistleblowers have said. In a third exposé into allegations of poor care at private hospitals run by The Huntercombe Group, former employees have claimed that staffing levels were so low “every day” that patients were neglected, resulting in: Patients as young as 13 being force-fed while restrained. Left alone to self-harm instead of being supervised. Left to “wet themselves” because staff couldn’t supervise toilet visits. One staff member, Rebecca Smith, said she was left in tears after having to restrain and force-feed a patient. Following a series of investigations by The Independent and Sky News, 50 patients came forward with allegations of “systemic abuse” and poor care, spanning two decades at children’s mental health hospitals run by the organisation. The government has since launched a “rapid review” into inpatient mental health units across the country following the newspaper’s reporting. Read full story Source: The Independent, 28 January 2023
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News ArticleAn acute trust has been fined a record sum by the Care Quality Commission for failing to provide safe maternity care, which resulted in the death of a baby after 23 minutes. Nottingham University Hospitals must pay a fine of £800,000 within two years. It is only the second time the regulator has brought a case against a NHS maternity service, and the highest fine ever given for failings of this nature. The trust pleaded guilty earlier this week to two charges of failing to provide safe care and treatment to Sarah Andrews and her baby daughter Wynter Andrews at Queen’s Medical Centre in 2019, a short time after her birth by Caesarean section. This guilty plea saw the fine reduced from £1.2m. An inquest in 2020 found the death was a “clear and obvious case of neglect”. It was also found there was “an unsafe culture prevailing within maternity services”, including a “failure to listen and respond to staff safety concerns”. Read full story (paywalled) Source: HSJ, 27 January 2023
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News Article
Shrewsbury maternity scandal: Pay out over boy's brain injury
Patient Safety Learning posted a news article in News
The health trust behind the worst maternity scandal in NHS history has accepted responsibility for a boy's brain injury. Adam Cheshire, 11, contracted a Group B Strep (GBS) infection following his birth at the Royal Shrewsbury Hospital in 2011. A High Court judge approved a pay out from Shrewsbury and Telford Hospitals NHS Trust (SaTH) to provide special care for the rest of his life. His case was examined as part of senior midwife Donna Ockendon's investigation into SaTH which found catastrophic failures might have led to the deaths and life-changing injuries of hundreds of babies, as well as the deaths of nine mothers. Adam, from Newport, Shropshire, was born nearly 35 hours after his mother's waters broke in the afternoon of 24 March 2011. In the hours that followed, he began to show signs of early onset GBS including struggling to feed, crying and grunting. After weeks in intensive care, he was finally diagnosed with the infection and meningitis. Adam is living with multiple conditions including hearing and visual impairments, autism, severe learning difficulties and behavioural problems so he relies on others to care for him. His mum, the Reverend Charlotte Cheshire, said she had expressed concerns about bright green discharge at one of her last antenatal appointments but no action was taken. "From that point I just had a mother's instinct something wasn't right but I was reassured by the midwives so many times that everything was OK," the 45-year-old said. Mrs Cheshire added: "While Adam is adorable and I am so thankful to have him in my life, it's difficult not to think how things could have turned out differently for him if he'd received the care he should have. "Adam will never live an independent life and will need lifelong care. While I'm devoted to him, I'm now raising a severely disabled son, which is extremely challenging and has changed the path of both our lives forever". Read full story Source: BBC News, 23 January 2023 -
News Article
Ministers order ‘rapid review’ into mental health inpatient care in England
Patient Safety Learning posted a news article in News
Ministers have ordered an inquiry into the quality of care in mental health inpatient units in England after a series of scandals in which vulnerable patients were abused or neglected. Maria Caulfield, the mental health minister, announced the establishment of a “rapid review” in a written ministerial statement in the House of Commons on Monday. The inquiry “is an essential first step in improving safety in mental health inpatient settings”, she said. In recent years, coroners and the Care Quality Commission, the NHS care watchdog, have repeatedly raised concerns about dangerously inadequate care that inpatients have received. It will examine the evidence of “patient safety risks and failures in care” in units that hold and treat patients who have serious conditions including psychosis and personality disorder. It will look in particular at evidence of failings brought forward by patients and their families and how better use of data can help show that care has fallen below acceptable levels. The inquiry will be headed by Dr Geraldine Strathdee, a psychiatrist who used to be NHS England’s national clinical director for mental health. She is likely to look at problems including patients being subjected to controversial restraint techniques, left at risk of being able to take their own lives and segregated from fellow inpatients, and the impact of their experiences on their recovery. Read full story Source: The Guardian, 23 January 2023 -
News ArticleConsultants who blew the whistle at a major teaching trust have raised “grave concerns” about the impartiality of three reviews into the safety and bullying allegations they made. Last month, Birmingham and Solihull Integrated Care Board announced three investigations into University Hospitals Birmingham, following worries about bullying and poor workplace culture. Former trust consultants Manos Nikolousis, John Watkinson and Tristan Reuser have now written to the cross-party reference group holding the investigations to account. Their letter, seen by HSJ, outlines their concerns about potential conflicts of interest. The first investigation is reviewing the trusts’ handling of 12 never events, staff deaths including a recent suicide, and 26 GMC referrals. It is being run by former NHS England deputy medical director Mike Bewick and may report as early as next week. The second and third reveiws will assess trust leadership and broader cultural issues respectively, and will be carried out with UHB and NHSE. Read full story (paywalled) Source: HSJ, 18 January 2023
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News Article
Police and CQC investigate serious incidents at trust
Patient Safety Learning posted a news article in News
A series of concerns about serious incidents at a mental health trust are being investigated by the Care Quality Commission, with a referral also made to the police, HSJ has learned. HSJ understands that various incidents at Black Country Healthcare Foundation Trust have been raised with the Care Quality Commission by whistleblowers. According to a well-placed source, one of the alleged incidents involved alleged inappropriate sexual behaviour, and this has been referred to West Midlands police. Other complaints are understood to include staff using mental health inpatients’ rooms to sleep in, and an information governance breach in which patient information was shared with members of staff who did not need to receive them. It is understood this was in an email raising patient safety concerns. Read full story (paywalled) Source: HSJ, 17 January 2023 -
News ArticleVictims and family members affected by the contaminated blood scandal are calling for criminal charges to be considered as the public inquiry into the tragedy draws to a close. While the inquiry, which will begin to hear closing submissions on Tuesday, cannot determine civil or criminal liability, people affected by the scandal are keen for the mass of documents and evidence accumulated over more than four years to be handed over to prosecutors to see whether charges can be brought. About 3,000 people are believed to have died and thousands more were infected in what has been described as the biggest treatment disaster in the history of the NHS. The inquiry has heard evidence that civil servants, the government and senior doctors knew of the problem long before action was taken to address it and that the scandal was avoidable. But no one has ever faced prosecution. Eileen Burkert, whose father, Edward, died aged 54 in 1992 after – like thousands of others – contracting HIV and hepatitis C through factor VIII blood products used to treat his haemophilia, said the inquiry had shown there was a “massive cover-up”. She said: “In my eyes it’s corporate manslaughter. You can’t go giving people something that you know is dangerous, and they just carried on doing it. As far as my family’s concerned, they killed our dad and they killed thousands of other people and there’s been no recognition for him since he died, there’s been nothing. Read full story Source: The Guardian, 16 January 2023 See UK Infected Blood Inquiry website for further details on the inquiry.
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News Article
Deaths inquiry thrown into doubt as only 11 staff agree to give evidence
Patient Safety Learning posted a news article in News
The chair of an inquiry into hundreds of deaths at a mental health trust has revealed she may not be able to deliver it in its current form following a ‘hugely disappointing’ lack of staff coming forward to give evidence. Former national clinical director for mental health, Geraldine Strathdee, chair of the non-statutory inquiry into deaths at Essex Partnership University Trust, has penned an open letter warning just 11 of 14,000 staff contacted said they will attend evidence sessions. It was meant to report in spring 2023. However, after raising concerns with ministers, Dr Strathdee said she believes the inquiry will not be able to meet its terms of reference with a non-statutory status. The inquiry was announced in 2021 and last year chiefs revealed they were probing 1,500 deaths of people in contact with Essex mental health services between 1 January 2000 and 31 December 2020. However, without statutory powers, staff are not compelled to give evidence under oath. Many bereaved families, of which just one in four has engaged with the current probe, are campaigning for a statutory inquiry into deaths. Read full story (paywalled) Source: HSJ, 13 January 2023 -
News Article
Birmingham hospital trust declared war on me - surgeon
Patient Safety Learning posted a news article in News
John Watkinson was one of the country's top ear, nose and throat surgeons. But Mr Watkinson's life and career were turned upside down when he was accused of shortening the lives of three patients, suspended and investigated. General Medical Council investigators would eventually close his case, taking no further action, and Mr Watkinson would receive an apology for what he had experienced from his employer University Hospitals Birmingham (UHB) NHS Trust. But that was six years after he was first suspended - six years that would see him pushed to the brink. "As doctors, we're trained in communication skills, we have appraisals, mandatory training," he says. "But the one thing we're not trained to cope with is when somebody declares war on you." The hospital trust stands by its decision to suspend Mr Watkinson and says its referral to the General Medical Council was "appropriately made following a clinical colleague raising significant concerns" about patient care. UHB has been in the spotlight in recent weeks, with reviews launched into its culture, leadership, and allegations of poor patient care aired in a Newsnight investigation late last year. It says a review into patient care is now well under way. Mr Watkinson says he was at the sharp end of this culture when he was suspended and suddenly went "from hero to zero". He accepts mistakes were made, but not just by him and not ones that would have affected the patients' outcomes. Read full story Source: BBC News, 13 January 2023 -
News Article
Inquiry into deaths after Northern Ireland ambulance delays
Patient Safety Learning posted a news article in News
The Northern Ireland Ambulance Service (NIAS) is investigating whether a delayed response contributed to the deaths of eight people in recent weeks. All eight deaths occurred between 12 December and the start of January. The NIAS is treating four of the deaths as serious adverse incidents, which is defined as an incident that led to unintended or unexpected harm. The remaining four deaths are being investigated to see whether they meet that criteria. The patients' identities have not been disclosed, but it is understood one of the eight people was a man who waited more than nine hours for an ambulance in mid-December. The man's condition deteriorated and he died before paramedics arrived. The delays are a cause of "great concern," but there is "no end in sight to the pressures we are facing," according to the ambulance service's medical director Nigel Ruddell. He said the ambulance service conducts an internal review whenever "there is a delayed response to the call and a poor outcome from the call" to see whether delays contributed to a death. "That process involves liaising with the family and being open and clear with them about what happened on the day - whether it was because of pressures and demand on the day or whether there was something that, potentially, we could have done better." Read full story Source: BBC News, 4 January 2022 -
News Article
Thousands of patients go missing from NHS care
Patient Safety Learning posted a news article in News
Police have carried out more than 5,500 investigations into patients who have been reported missing from NHS facilities in Scotland since 2019. The figures were outlined in a written response from Keith Brown, the justice secretary, to Jamie Greene, the Conservative MSP. Greene, who is the justice spokesman for the Conservatives, said the figures gave serious cause for concern. He said that the complete figure could be much higher because the data provided only included those reported to police. He urged Brown and Humza Yousaf, the health secretary, to provide adequate resources for policing and the health sector to ensure vulnerable patients were not slipping through the cracks. Greene said: “These figures are deeply alarming. Relatives expect their loved ones to be safe while they are staying, or being treated in, an NHS facility. It gives serious cause for concern that over 200 investigations have had to be launched in just the last few years to determine the whereabouts of young people who went missing from NHS grounds.” Read full story (paywalled) Source: The Times, 3 January 2023 -
News ArticleThe Birmingham MP Preet Gill has called on the UK health secretary to launch a major public inquiry into allegations that a bullying and a toxic culture is risking patient safety at University Hospitals Birmingham (UHB). The MP for Edgbaston, where UHB is based, said she had received complaints from staff alleging elderly patients had been left on beds in corridors outside wards due to mismanagement, and medics were discouraged from speaking out about problems. In a letter to Steve Barclay, seen by the Guardian, Gill said: “I have been inundated by messages from UHB staff, past and present, who have contacted me to share their experience of what has been repeatedly described as a toxic culture that has had an alarming impact on staff and patient care.” After an investigation by BBC Newsnight earlier this month, which found that doctors at the trust were “punished” for raising safety concerns, the Birmingham and Solihull Integrated Care Board (ICB) announced a three-part review into the culture at UHB. The first report is expected at the end of January. But Gill criticised the plans, saying she did not think it would “be sufficient to adequately investigate this scandal”, and instead called for a major independent public inquiry, similar to the 2013 Francis inquiry into the Stafford hospital scandal. “We cannot rely on an ICB investigation to solve this issue. Many of those on the ICB are former members of the senior leadership team from UHB and would not offer the independence required to recommend the changes that are so needed or give confidence to whistleblowers,” she said. Read full story Source: The Guardian, 19 December 2022
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News Article
Police investigating ‘rape of child’ at scandal-hit mental health hospital
Patient Safety Learning posted a news article in News
Police are investigating allegations of rape of a child involving two staff members at a scandal-hit mental health hospital, The Independent can reveal. Thames Valley Police confirmed it has launched an investigation after a report last month of rape made by a former patient of Taplow Manor, a private hospital in Maidenhead, Berkshire, run by The Huntercombe Group. The incident was reported to have taken place in 2019. Mark McGhee, a solicitor for Hutcheon Law, who is representing the family of the patient in a clinical negligence claim, said the allegation had been raised to the police about the patient who was a child and that the allegation involves two staff members at the time. In October, The Independent and Sky News revealed allegations of “systemic abuse” from 20 patients across The Huntercombe Group’s children’s mental health hospitals – Taplow Manor, Ivetsey Bank near Stafford, Watcombe Hall in Torquay, and The Huntercombe Hospital Norwich. Since the report, 30 more patients have come forward with allegations of poor treatment and the provider now also faces nine legal claims from former patients. Thames Valley Police are also investigating an incident involving the death of a child at the Maidenhead hospital in February. The CQC is conducting a separate criminal investigation into the serious incident which resulted in the death of the young person. Read full story Source: The Independent, 19 December 2022 -
News Article
The mental health patients dying on NHS wards from starvation and neglect
Patient Safety Learning posted a news article in News
Asystemic failure to provide basic physical care on NHS mental health wards is killing patients across the country, despite scores of warnings from coroners over the past decade, The Independent can reveal. An investigation has uncovered at least 50 “prevention of future death” reports – used by coroners to warn health services of widespread failures – since 2012, involving 26 NHS trusts and private healthcare providers. Cases include deaths caused by malnutrition, lack of exercise, and starvation in patients detained in mental health facilities. Experts warn that poor training and a lack of funding are factors in the neglect of vulnerable patients. The Independent investigation uncovered: Staff failing to carrying out basic health checks, such as assessment for risk of blood clots. Cases of nurses and care assistants without adequate CPR training. Doctors unable to carry out emergency response procedures. Patients not treated for side effects of antipsychotic medication. Rapidly deteriorating health going unnoticed and untreated. Coroners have exposed multiple cases of mental health patients receiving inadequate treatment in general hospitals, with their illness being mistaken for a psychiatric problem. Read full story Source: The Independent, 18 December 2022 -
News Article
No timetable for infected blood victims' compensation
Patient Safety Learning posted a news article in News
There is a "moral case" for compensation to be paid to people affected by the contaminated blood scandal, the government has said. But Paymaster General Jeremy Quin told MPs he could not commit to a timetable. In August, the government announced that 4,000 UK victims would receive interim payments of £100,000. Tens of thousands of people contracted HIV or hepatitis C in the 1970s and 80s after being given infected blood. In September, modelling by a group of academics commissioned by the public inquiry estimated that 26,800 people were infected after being given contaminated transfusions between 1970 and 1991. The study calculated that 1,820 of those died as a result, but that the number could be as high as 3,320. The inquiry, chaired by retired High Court judge Sir Brian Langstaff, began taking evidence in 2018. The interim compensation announcement in August came after Sir Brian argued there was a compelling case to make payments quickly - saying victims were on borrowed time because of their failing health. Payments have been made to those whose health is failing after developing hepatitis C and HIV, and partners of people who have died. But families have complained that many people affected, such as bereaved parents, missed out. Read full story Source: BBC News, 15 December 2022 -
News ArticleLucy Letby used a plunger to force milk and air into one of the babies she is accused of attempting to murder, a medical expert has told a court. The alleged attack caused the infant’s stomach to distend to such a degree that she then projectile vomited a “massive” amount of milk so violently that the material left her cot and splashed over a chair several feet away. Staff at the Countess of Chester Hospital managed to save Baby G’s life but the incident was so catastrophic that it caused the child severe brain damage. Seven years later she still suffers from quadriplegic cerebral palsy. Dr Dewi Evans, a consultant paediatrician called in by the prosecution, said the use of a plunger on the end of a syringe was the only explanation for the baby’s sudden collapse in the early hours of 7 September 7 2015. Letby, 32, of Hereford, is accused of murdering seven children in the neonatal unit of the hospital in Cheshire, and of ten attempted murders, between June 2015 and June 2016. She denies all the charges. Read full story (paywalled) Source: The Times, 13 December 2022
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News Article
Hospital apologises after hiding surgeon's error for seven years
Patient Safety Learning posted a news article in News
A hospital trust has apologised to a woman for failing to admit a surgeon had been responsible for a massive haemorrhage that almost killed her after a Caesarean section. For seven years, East Kent Hospitals Trust maintained the size of Louise Dempster's baby was to blame. "It was just continuous lies," the 34-year-old told BBC News. East Kent Hospitals chief executive Tracy Fletcher promised "to ensure lessons are learned". Louise Dempster gave birth in May 2015 but the surgeon's error only emerged during an inquiry into poor maternity care at East Kent Hospitals Trust which reported this year. Read full story Source: BBC News, 9 December 2022 -
News ArticleThe family of a man who died after being given infected blood have called on the UK government to pay their compensation immediately. Randolph Peter Gordon-Smith, who had haemophilia, learned in 1994 that he had been infected with hepatitis C. His daughter said the family were "abandoned" to care for him without support before his death in 2018. The chairman of the UK infected blood inquiry has said parents and children of victims should receive compensation. Sir Brian Langstaff wants to see a final compensation framework set up by the end of the year. Ms Gordon-Smith, who lives in Edinburgh, says compensation would provide an acknowledgement of "what they did to our family" as his daughters cared for him when he was dying. "I think the government needs to get their chequebook out, do the right thing and pay [the compensation]," she added. "Not when the inquiry rules, but now." Read full story Source: BBC News, 22 June 2023
