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Showing results for tags 'Investigation'.
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News Article
NHS 'corrected mistakes' after son's suicide
Patient Safety Learning posted a news article in News
An NHS trust has been accused of adding to the records of a man the day after he took his own life to "correct their mistakes". Charles Ndhlovu, 33, died under the care of Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) in 2017. Mr Ndhlovu, who was diagnosed with paranoid schizophrenia and substance misuse, had been under CPFT's care two months when he died. He had been transferred from a neighbouring trust after moving to Ely and then been taken off a community treatment order. His mother, Angelina Pattison, told the BBC that despite being heavily involved in her son's care, she was "shocked that they transferred him without even telling me". A trust serious untoward incident (SUI) review acknowledged that when he was transferred no-one from CPFT had asked about whether his family had been involved in his care. Ms Pattison said: "They didn't have any address of [my home] in his care plan and the care plan was done when he died - when they were running around to correct their mistakes, which they have done" The BBC has separately spoken to consultant nurse and psychotherapist Des McVey, who was asked by the trust to investigate a complaint in July 2021, understood to be the one from Ms Pattison. Mr McVey said: "I noticed that the deceased did have care plans, but they were written the day after his death and they were also evaluated the day after his death and I was concerned that this wasn't picked up by the SUI." He said this "really alarmed me", adding: "Surprisingly, there was no care plan to address his suicidal ideation and he had... an extensive history of trying to kill himself." Read full story Source: BBC News, 15 June 2023 . -
News Article
New triage policy implicated in 44-year-old’s death
Patient Safety Learning posted a news article in News
An ambulance service says it has sped up clinical review of lower-priority calls, after a coroner said the new triage process — introduced in response to recent waiting time pressures — ‘will lead to further deaths’. The coroner raised concerns with West Midlands Ambulance Service after a type 1 diabetic patient died following a long delay in deciding whether to send an ambulance. Following a pilot in July 2021, all category 3 and 4 incidents at WMAS, except for a predefined list of exceptions, are sent directly to the trust’s “clinical validation team” to triage patients, with the aim of reducing the need for ambulance call-outs. It is thought a similar approach has been introduced across England since covid, as there have been huge pressures on ambulance capacity. But coroner Emma Serrano has raised concerns about the process in a prevention of future deaths report published this week. The inquest was told that Ms Finch waited 10 hours for her call to be “clinically assessed” and an ambulance call-out approved as the validation team was “under-staffed”. The PFD report also said that there was “no time limit” for assessments to take place, and no prioritisation system. Read full story (paywalled) Source: HSJ, 14 June 2023 -
News Article
Lords to investigate private health firms used to deliver NHS drugs
Patient Safety Learning posted a news article in News
Peers are launching an inquiry into private health companies paid millions of pounds to courier NHS medicines in England, after the Guardian exposed how sick children and adults were being harmed by botched, delayed or missed deliveries. The House of Lords public services committee will examine “the extent of the problems in homecare medicine services”, and the impact on patients, clinicians and the wider health service. More than 500,000 patients and their families rely on private companies contracted by the NHS to deliver essential medical supplies and care to their homes. A Guardian investigation revealed how Sciensus, Britain’s biggest provider of homecare medicines services, has struggled to provide a safe or reliable service. Seriously ill children as young as four have been let down, with some becoming sicker because of failings by the company. Patients and medics have complained to Sciensus and to regulators, but little has changed. Read full story Source: The Guardian, 13 June 2023 -
News Article
Health officials ‘ignored evidence of non-Covid deaths’ during lockdown
Patient Safety Learning posted a news article in News
The Covid inquiry is being urged to investigate if health officials dismissed evidence of collateral deaths during lockdown after a whistleblower claimed that pathologists’ concerns were shut down. As the inquiry prepares to hold its first full public hearing this week, Prof Sebastian Lucas, who worked as a consultant pathologist at St Thomas’ Hospital in London, claimed that PHE was not interested in what he described as “collateral deaths”. Prof Lucas wrote to Prof Kevin Fenton, the director of PHE London, on behalf of the London Inner South Jurisdiction Pathology Advisory Group. He approached the agency in January 2021 as the UK entered its third lockdown, warning that collateral deaths as a result of the pandemic had not been recorded properly. The group, which was headed up by a coroner, had identified several deaths that would not have happened had the NHS been functioning as normal. This included people who did not want to bother the doctor or who took their own lives because of lockdowns. Read full story (paywalled) Source: The Telegraph, 10 June 2023 -
News Article
Maternity failures behind most big NHS payouts
Patient Safety Learning posted a news article in News
More than three quarters of all multimillion-pound NHS medical negligence payouts are the consequences of failures in maternity care, new figures show. In total, 364 patients or families received the highest-value compensation payments of at least £3.5 million after suing the NHS last year. Of those, 279 (77%) were maternity-related damages, according to figures from NHS Resolution. The large payouts have been offered to parents whose babies were stillborn or suffered avoidable life-changing disabilities or brain injuries. Maternity makes up the bulk of NHS compensation payments. There were more than 10,000 clinical negligence claims brought against the NHS in 2021-22, with a total value of more than £6 billion. Maternity accounted for 62% of payments, or £3.74 billion. When taking into account all cost of harm, including future periodic payments and legal costs, the cost of compensating mothers and their families rises to £8.2 billion a year. Analysis by The Times Health Commission found that this is more than twice the £3 billion spent by the NHS annually on maternity and neonatal services. Maternity claims have increased during the past decade amid a string of high-profile scandals and a shortage of midwives. Read full story (paywalled) Source: The Times, 12 June 2023 -
News Article
Covid inquiry prepares for first hearing after 220,000 deaths
Patient Safety Learning posted a news article in News
More than three years after Boris Johnson announced a nationwide lockdown, the Covid investigation will cover every aspect of the UK’s pandemic response. More than three years after the first lockdown began, two years after the last one ended, the public hearings are at last starting. Over the months that come the inquiry will have many questions to answer. Should we have locked down earlier? Should we have not locked down at all? Did we eat out to help restaurants out, or eat out to help the virus out? Could more have been done to protect care homes from infection? Should more have been done to protect residents from loneliness? Baroness Hallett, the judge presiding, said her chief role is “to determine whether [the] level of loss,” in the broadest sense of the word, “was inevitable or whether things could have been done better”. Read full story (paywalled) Source: The Times, 13 June 2023 -
News ArticleInquests will be held into the deaths of at least 36 patients – and potentially dozens more – treated by the jailed former breast surgeon Ian Paterson. As the fallout of one of the most horrific medical scandals in the history of the NHS continues, a pre-inquest review hearing at Birmingham and Solihull coroner’s court on Friday heard that 417 of Paterson’s cases where breast cancer was listed as the immediate cause of death had been examined. Paterson, who attended the hearing remotely from prison, was sentenced to 15 years in jail in 2017, later increased to 20 years, for carrying out needless surgery on patients who were left traumatised and scarred. Inquests have been confirmed in 36 cases, with a further 21 cases deemed likely to need an inquest after “preliminary” investigations. Another 36 cases are still to be reviewed. The judge Richard Foster said a further 130 cases had been reported to the coroner where breast cancer was listed as contributing to death. A review of a selection of those cases was being carried out and a decision on whether they should all be reviewed would be made on its completion, he said. Read full story Source: The Guardian, 9 June 3023
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News ArticlePolice are investigating about 40 hospital deaths over allegations of medical negligence made by two consultant surgeons who lost their jobs after blowing the whistle about patient safety. The allegedly botched operations took place at Royal Sussex County hospital (RSCH) in Brighton, part of University hospital Sussex NHS trust, when it was run by a management team hailed by Jeremy Hunt as the best in the NHS. Last week, detectives from Sussex police wrote to the trust’s chief executive, George Findlay, confirming they had launched a formal investigation into “a number of deaths” at the RSCH. They were investigating allegations of “criminal culpability through medical negligence” made by “two separate clinical consultants” at the trust, the letter said. It is understood about 40 deaths occurred between 2015 and 2020 after alleged errors in general surgery and neurosurgery departments. Both whistleblowers alleged the trust failed to properly investigate the deaths and learn from the mistakes made. Read full story Source: The Guardian, 9 June 2023
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News ArticleA police investigation is under way into allegations of abuse at an NHS-run home for men with severe learning disabilities and autism, it has emerged. Several staff from the home have already been “removed” from the site by Surrey and Borders Partnership Foundation Trust, although the trust would not comment on whether any disciplinary action has been taken against them. The home – Oakwood, in Caterham, Surrey – will close at the end of the summer in response to the failings, the trust said. No one has been charged in relation to the allegations, which HSJ understands focus on coercive behaviour and unnecessary deprivation of liberty, with no allegations of violent or sexual behaviour. Read full story (paywalled) Source: HSJ, 9 June 2023
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News Article
Covid inquiry: Families unhappy with Welsh government
Patient Safety Learning posted a news article in News
Bereaved families of coronavirus victims feel the Welsh government has not adequately taken part in the Covid public inquiry, their solicitor says. Craig Court, who represents bereaved families, said the Welsh government had not participated "as well as they should have". He claimed the Welsh government failed to deliver crucial paperwork with just days to go before Tuesday's inquiry. The UK-wide inquiry could go on as long as three years, and will predominantly look at the UK government's approach to the pandemic. A Wales-specific inquiry was blocked by Labour members of the Senedd, with First Minster Mark Drakeford saying it should wait until after the UK-wide investigation had been completed. Mr Court told BBC Wales "there is a great concern over the duty of candour" displayed by the Welsh government. Read full story Source: BBC News, 9 June 2023 -
News Article
Kettering General Hospital chief apologises over children's care
Patient Safety Learning posted a news article in News
A chief executive whose hospital has been accused of failing children has admitted it has not always "got it right" and apologised at a meeting. The care regulator has warned Kettering General Hospital (KGH) over its children's and young people's services and rated them inadequate. Dozens of parents with children who died or became seriously ill have contacted the BBC with concerns. Deborah Needham told a board meeting she was "here to listen" to worries. In April it was revealed inspectors from the Care Quality Commission (CQC) raised concerns over sepsis treatment, staff numbers, dirt levels and not having an "open culture" where concerns could be raised without fear, following an inspection in December. The CQC had inspected the Northamptonshire hospital's paediatric assessment unit, Skylark ward, and the neonatal unit after hearing concerns of safety. Read full story Source: BBC News, 9 June 2023 -
News ArticleOne of the NHS’ largest hospital trusts is being investigated over “possible gross negligence manslaughter” after a baby died 24 hours after her birth. Polly Lindop died at St Mary’s Hospital on 13 March and Greater Manchester Police have now launched a probe into her death. Police said its major incident team launched the investigation into “possible Gross Negligence manslaughter” after concerns were raised to the force and local coroner. DCI Mark Davis of GMP’s major incident team said: “First, I want to express my condolences to the parents of Polly at what is an extremely difficult time for them. Our thoughts will remain with them as we carry out our investigation. “A number of hospital staff have been spoken to as witnesses by officers and no arrests have been made at this time. “The hospital trust has been fully cooperative with the police and all relevant authorities have been kept informed. The investigation into Polly’s death is on-going and her family will continue to be kept updated in relation to any significant developments.” Read full story Source: The Independent, 5 June 2023
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News Article
Doctor told cancer patient she had anorexia despite three ‘red flag’ signs
Patient Safety Learning posted a news article in News
A woman was “fobbed off” by her doctors who failed to diagnose her colon cancer for a year, an investigation revealed. In May 2019, Charlie Puplett, 45, expressed concern at her GP surgery in Yeovil, Somerset, about unexplained weight loss, lack of appetite and a change in bowel habits. But the surgery did not test her for colon cancer – with one doctor suggesting she had anorexia and was “in denial”, she said. She was not diagnosed until almost a year later when she was rushed to hospital after vomiting blood. Ms Puplett’s experience was detailed in an investigation by the Parliamentary and Health Service Ombudsman (PHSO), which found that her symptoms should have been “red flags” leading to urgent testing within two weeks, and said she had been “failed” by her doctors. Read full story Source: The Independent, 4 June 2023 -
News ArticleWomen are waiting too long for abortions, according to a major review into a leading UK provider. The Care Quality Commission (CQC) review of the leadership at the abortion provider the British Pregnancy Advisory Service found there were “delays” in “investigating incidents”. The remains of some pregnancies were sometimes not stored properly and there were issues were record keeping, patient monitoring and safe care, the review found. The watchdog also noted “women did not always receive care in a timely way to meet their needs”. The health watchdog said: “In August 2021 we found significant concerns in we found that safe care was not being provided; ineffective safeguarding processes; incomplete risk assessments were not fully completed; observations were not monitored or recorded; records were not fully completed, clear or up to date.” Read full story Source: The Independent, 2 June 2023
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News Article
East Kent: A decade of failure in maternity care
Patient Safety Learning posted a news article in News
After health inspectors considered closing a maternity unit over safety fears, the BBC's Michael Buchanan looks at a near-decade of poor care at East Kent Hospitals NHS Trust. "I've been telling you for months. The place is getting worse." The message in February, which Michael received from a member of the maternity team, was stark but unsurprising. In a series of texts over the previous few months, the person had been getting increasingly concerned about what was happening at the East Kent trust. The leadership is "totally ineffective" read one message. "How long do we have to keep hearing this narrative - we accept bad things happened, we have learned and are putting it right. Nothing changes." Friday's report from the Care Quality Commission (CQC) is unfortunately just the latest marker in a near-decade of failure to improve maternity care at the trust. The revelation that inspectors considered closing the unit at the William Harvey Hospital in Ashford comes nine years after the trust's head of midwifery made a similar recommendation for the same reasons - that it was a danger to women and babies. The failure to act decisively then allowed many poor practices to continue. Read full story Source: BBC News, 28 May 2023 -
News Article
Child died at mental health hospital ‘while staff were meant to be watching her’
Patient Safety Learning posted a news article in News
A 14-year-old girl who should have been under constant supervision at a mental health hospital died after a member of staff on his first shift left her unattended, an inquest has heard. Ruth Szymankiewicz died at Taplow Manor Hospital in Maidenhead on 12 February 2022 after a care worker responsible for her one-to-one supervision “sporadically” left his post, the hearing was told. It also emerged at the hearing that the care worker, who is now abroad, was allegedly using a fake name. Detectives are investigating him as part of a fraud investigation although he has not yet been interviewed by police. After Ruth’s death, the Care Quality Commission launched a criminal investigation. In an update to the coroner, it said that the investigation was looking at whether the provider had “brought about avoidable harm or exposure to risk” in relation to the young girl’s death. Read full story Source: The Independent, 26 May 2023 -
News Article
Closing baby unit considered over safety concerns
Patient Safety Learning posted a news article in News
Health inspectors considered shutting down a maternity unit earlier this year over safety concerns. The Care Quality Commission (CQC) instead called for "immediate improvements" following a visit to the William Harvey hospital in Ashford, Kent. Helen Gittos, whose newborn daughter died in the care of the East Kent Hospitals Trust, said there were "fundamental" problems at the trust. The inspection of East Kent's William Harvey hospital laid bare multiple instances of inadequate practices at the unit, including staff failing to wash their hands after each patient, and life-saving equipment not being in the right place. Days after the visit, the watchdog raised safety concerns and threatened the trust with enforcement action to ensure patients are protected. Ms Gittos, whose baby Harriet was born at the East Kent trust's Queen Elizabeth the Queen Mother Hospital (QEQM) in 2014 and died eight days later, said: "When my daughter Harriet was born, the then head of midwifery was so concerned about safety that she thought that the William Harvey in particular should be closed down." She told BBC Radio 4's Today programme: "Here we are, almost nine years later, in a similar kind of situation. What has been happening has not worked. "I keep being surprised at how possible it is to keep being shocked about all of this, but I am shocked, that under so much scrutiny, and with so much external help, it's still the case that so much is not right. "The problems that are revealed are so fundamental that we have to do things differently." Read full story Source: BBC News, 26 May 2023 -
News Article
Top doctor questions need for change at gender clinic
Patient Safety Learning posted a news article in News
A doctor with a key role in reforming a controversial gender identity clinic for children has been recorded questioning the need for change. Prof Gary Butler, clinical lead for the children's gender clinic in England and Wales, also appeared to accuse the author of a report, which will underpin the new service, of "nepotism". He was recorded making the comments in a keynote speech at a major conference. The Gender Identity Development Service (Gids), based at London's Tavistock and Portman NHS Foundation Trust, was rated as "inadequate" by inspectors, who visited in late 2020. It was earmarked for closure in July 2022. An independent review, led by Dr Hilary Cass, also called for a "fundamentally different" model of care for children with gender dysphoria. Prof Butler has been awarded a key role in shaping the new service, as one of several people tasked with implementing a new training programme, underpinned by Dr Cass's recommendations. However, BBC Newsnight has learned Prof Butler has publicly questioned the need for change and described Dr Cass's recommendations as "slightly unusual". In the 14-minute speech at the conference, he talked about current services across the UK, the legal challenges to the situation in England, and how he felt Gids has been the subject of "lies" in the media. Read full story Source: BBC News, 24 May 2023 -
News Article
Trust execs accused of creating a ‘cult of the individual’
Patient Safety Learning posted a news article in News
Regulators are probing a series of whistleblowing claims about the leadership culture of a trust which is rated ‘outstanding’ for its management, HSJ has learned. It is understood multiple current and former staff members at Bolton Foundation Trust, including people in senior positions, have been in contact with NHS England and the Care Quality Commission in recent months. The claims include a dramatic worsening in leadership culture at the trust, particularly around the FTSU process and people who speak up being bullied, side-lined and silenced. And investigations and meetings are stage-managed and tightly controlled by executives, with constant “sugar-coating” and positive spin on board reports, and intolerance of people who disagree. Read full story (paywalled) Source: HSJ, 22 May 2023 -
News Article
Warning as baby dies and seven more fall critically ill with ‘usually mild virus’
Patient Safety Learning posted a news article in News
A baby has died and seven others were left requiring intensive care after a “usually mild” virus appeared to trigger a serious heart condition, health officials have said. The World Health Organization (WHO) said it had been notified of an “unusual” increase in myocarditis –inflammation of the heart – among newborns in south Wales infected with an enterovirus over the past year. While enteroviruses are common and often asymptomatic, they are known to cause “occasional outbreaks in which an unusually high proportion of patients develop clinical disease, sometimes with serious and fatal consequences – in this instance myocarditis”, the UN health agency said. While prior to the recent cluster of cases, south Wales had experienced only two similar cases in six years, the 10 months to April saw 10 cases of myocarditis in babies under the age of 28 days who tested positive for enterovirus, according to WHO. Read full story Source: The Independent, 19 May 2023 -
News ArticleAn inquiry into maternity care failings at an NHS trust that left dozens of babies dead or brain-damaged is “wholly insufficient” because only a fraction of Black and Asian women have come forward, its chair has warned. Donna Ockenden, who is leading a review into Nottingham University Hospitals NHS Trust, suggested the health service must do more to increase the number of responses from ethnic minorities if the trust is to learn from the scandal. Less than 20 families from Black and Asian communities are currently involved in the inquiry, compared to more than 250 white families, The Independent understands. It is understood letters have only been sent out in English, while Ms Ockenden pointed to examples of women being unable to access translation services and expectant Muslim mothers being turned away if they objected to male sonographers. She said the communities’ “mistrust” towards the trust had “deepened”, leaving the review team “climbing a mountain” to engage with them. Read full story Source: The Independent, 18 May 2023
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News Article
Gosport hospital drug deaths: Police identify 19 suspects
Patient Safety Learning posted a news article in News
Nineteen suspects have been identified by police as part of a new inquiry into hundreds of deaths at a hospital. An independent panel found 456 patients died after being given opiates inappropriately at Gosport War Memorial Hospital between 1987 and 2001. The new criminal investigation is being led by Kent Police after three previous ones by Hampshire Constabulary resulted in no prosecutions. Police said interviews with the suspects under caution were ongoing. Detectives are examining more than 750 patient records as part of Operation Magenta after families, who have also campaigned for judge-led "Hillsborough-style" inquests, repeatedly called for justice. Read full story Source: BBC, 17 May 2023 -
News Article
Allegations of bullying within maternity programme of HSIB
Patient Safety Learning posted a news article in News
It was created with the very best of intentions – to help hospitals learn lessons when a baby or mother is harmed or dies. But a Channel 4 News investigation has been hearing that the maternity programme of the Healthcare Safety Investigation Branch – or HSIB – was riddled with flaws. One former senior staff member spoke to Channel 4 about bullying within the organisation and failings which could have led to harm. In a previous report, Channel 4 heard from the mothers of Beatrice and Marnie, who were stillborn and other parents have come forward with their experience. Watch the story Source: Channel 4 News, 16 May 2023 -
News Article
GMC to investigate ‘stalker’ doctor who shared patient’s records
Patient Safety Learning posted a news article in News
The UK medical regulator has launched an investigation into a “stalker” doctor who accessed intimate details of the health history of a woman who had begun dating the doctor’s ex-boyfriend. The General Medical Council (GMC) is investigating whether the doctor – a consultant at Addenbrooke’s hospital in Cambridge – breached their professional, ethical and legal duties to protect the woman’s personal information. The victim has given the watchdog a statement detailing the consultant’s repeated violations of her medical records and documentation that shows what she did. The GMC declined to comment because it has not yet decided to open a formal disciplinary case against the consultant, who could face serious sanctions including a ban on working as a doctor. One of the GMC’s investigative officers is examining the victim’s claims and collecting evidence. The Guardian revealed how the doctor had looked at the victim’s hospital and GP records seven times last August and September, in the early stages of the woman’s relationship with a man the consultant had been involved with for several years. Read full story Source: The Guardian, 15 May 2023 -
News Article
Baby heart death parents left waiting 14 months for answers
Patient Safety Learning posted a news article in News
Grieving parents have been left waiting more than 14 months for answers about why their 12-day-old son died. Elijah was born at Merthyr Tydfil's Prince Charles Hospital on 25 February 2022 and died after being diagnosed with enterovirus and myocarditis. Joann and Christian Edwards said they were told they would have a report by the end of 2022, but are still waiting. Joann and Christian, from Mountain Ash, Rhondda Cynon Taf, said they were told Elijah's myocarditis was a "one off" but subsequently read about 10 babies, including one who died, getting severe enterovirus with myocarditis across south Wales. Public Health Wales (PHW) said Elijah's death was not being looked into as part of an investigation into this cluster of cases, as the dates were set at June 2022 to April 2023 to coincide with the enterovirus season. But it said it would look to include Elijah's death as part of a "wider clinical investigation" of the cases. Read full story Source: BBC News, 15 May 2023
