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News Article
Bullying and toxic culture at one of England's largest NHS trusts
Patient Safety Learning posted a news article in News
Repeated cases of bullying and a toxic environment at one of England's largest NHS trusts have been found in a review. The Bewick report was ordered after a BBC Newsnight investigation heard from staff at University Hospitals Birmingham (UHB) saying a climate of fear had put patients at risk. A first phase of the rapid review, headed by independent consultants IQ4U and led by Prof Mike Bewick, was published Tuesday. It is one of three major reviews into the trust, commissioned following a series of reports by Newsnight and BBC West Midlands in which current and former staff raised concerns. Summarising the findings, Prof Bewick, a former NHS England deputy medical director, said: "Our overall view is that the trust is a safe place to receive care. "But any continuance of a culture that is corrosively affecting morale and in particular threatens long-term staff recruitment and retention will put at risk the care of patients across the organisation - particularly in the current nationwide NHS staffing crisis. "Because these concerns cover such a wide range of issues, from management organisation through to leadership and confidence, we believe there is much more work to be done in the next phases of review to assist the trust on its journey to recovery." The West Midlands trust said it fully accepted the report's recommendations. Read full story Source: BBC News, 28 March 2023 -
News Article
Trust fears medics will be ‘harassed’ if it publishes surgery report
Patient Safety Learning posted a news article in News
Two external reviews have been carried out into a trust’s general surgery services amid concerns about whether it is a ‘safe interpersonal working environment’. But University Hospitals Sussex Foundation Trust has refused to make the reviews – which were both completed last year – public, partly because of what it says are concerns that they could lead to “harassment” of doctors who spoke to the authors. Both reviews were into aspects of the general surgery services at the Royal Sussex County Hospitals in Brighton. The trust has had a series of highly critical Care Quality Commission reports into some of its surgical services and a “well led” report is expected to be released in the next few weeks. The trust has refused HSJ’s Freedom of Information Act request to release the reviews, arguing that those interviewed had been promised confidentiality, and the issues involved are “emotive and sensitive matters”. “Disclosure could cause those involved in the reviews damage, distress and upset and could even lead to harassment,” it said. Read full story Source: HSJ, 27 March 2023 -
News Article
Apologies for 2013 mental health failings over mum
Patient Safety Learning posted a news article in News
A son has accepted a settlement and an apology from the north Wales health board nearly 10 years after his mother was a patient in a mental health unit. Jean Graves spent nine weeks at the Hergest unit in Ysbyty Gwynedd in Bangor in 2013 after struggling with anxiety and depression. Her son David said she was left "severely malnourished" and fell. He previously said his mother - who was 78 when she was treated at the unit - collapsed six times and, over the course of six weeks, lost 25% of her body mass. The health board also apologised for the "distress" the family experienced while seeking answers "over many years" and said it hopes to "learn and improve" from Mr Graves's experience. In a letter to him, executives said: "It is very clear to us that we have failed your mother and that she should have had a better care whilst in our services." It said her records were incomplete or were "amended without proper evidence" and she was placed on a ward with a mix of patients with both psychiatric illness and older organic mental illness, which was not "best practice". Read full story Source: BBC News, 26 March 2023 -
News ArticlePolice are investigating fresh allegations of sexual assault against a child patient by a care worker at a scandal-hit private mental health hospital group. It is the second time reports have been made about a former Huntercombe Group hospital after two care workers were quizzed over the alleged rape of a child at its Taplow Manor Hospital in Maidenhead last year. The latest allegations are from a patient at the group’s Ivetsy Bank Hospital, in Staffordshire, which was rated as inadequate last week. In a statement, Staffordshire Police confirmed it had received a report of sexual assault and said inquiries were ongoing. The news comes as the NHS’s safety watchdog has threatened to close Taplow Manor after hospital leaders failed to make improvements in care. The action comes after joint investigations by The Independent and Sky News found the private hospital had put the safety of young mental health patients at risk, with more than 50 patients and staff members alleging “systemic abuse” and poor care. Read full story Source: The Independent, 24 March 2023
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News ArticleThe link between menopause and poor mental health should be reviewed, the health watchdog has said, after an inquiry into a woman’s suicide found staff lack training to spot the risks. Frances Wellburn, 56, took her own life in 2020 after she was incorrectly assessed as being a “medium risk” of suicide by Tees, Esk and Wear NHS Trust (TEWV). A national study by the Health and Safety Investigation Branch (HSIB), prompted by her death, warned that this was a national problem, with funding and capacity problems driving staff to use ineffective “checklist” tools when assessing suicidal patients. HSIB also found staff were not trained to spot mental health risks associated with menopause, and menopause is not routinely considered a contributing factor among women with low mood who need help. It said that women are often prescribed antidepressants when hormone replacement therapy (HRT) would be more appropriate. In Ms Wellburn’s case, HSIB found TEWV staff had failed to take into account that she was going through menopause when they assessed her as being at medium risk of self-harm. This went against national guidance, which states scales should not be used to predict future suicide or self-harm. Read full story Source: The Independent, 23 March 2023
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News Article
‘Insufficiently curious’ leaders ‘tolerated’ safety failures
Patient Safety Learning posted a news article in News
Leaders at a mental health trust tolerated high levels of safety incidents and accepted verbal assurance with ‘insufficient professional curiosity’, a critical report has found. An NHS England-commissioned review into governance at Tees, Esk and Wear Valleys Foundation Trust has been published, reviewing the organisation’s response to serious safety concerns flagged at the former West Lane Hospital in Middlesbrough. It follows separate reports identifying “systemic failures” over the deaths of inpatients Christie Harnett, Nadia Sharif and Emily Moore. The new report, conducted by Niche Consulting, criticises board and service leaders’ handling of concerns about the regular occurrence of restraint and self-harm. More than a dozen incidents of inappropriate restraint, some seeing patients dragged along the floor, were identified in November 2018, resulting in multiple staff suspensions and some dismissals. Niche found there was a “lack of accountable leadership at all levels” and lack of evidence for decisions in response to the November 2018 incidents. Read full story (paywalled) Source: HSJ, 21 March 2023 -
News ArticleA scandal-hit hospital group has been sanctioned by inspectors after The Independent revealed “systemic abuse” at a string of children’s mental health units. England’s safety watchdog issued an official warning to Ivetsey Bank Hospital in Staffordshire, run by The Huntercombe Group, after an extensive investigation by this newspaper found the private hospital had put the safety of young mental health patients at risk. The Care Quality Commission also downgraded the hospital’s rating to “inadequate”. If improvements are not made in line with the warning notice, the hospital could be forced to close. An inspection was carried out two weeks after The Independent revealed widespread allegations of abuse and excessive restraint across The Huntercombe Group’s hospitals. The investigation revealed the provider, which also runs Taplow Manor children’s hospital in Maidenhead, was facing allegations from more than 50 former patients as well as claims of poor care from staff whistleblowers and dozens of negligence claims. Read full Source: The Independent, 15 March 2023
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Content ArticleTwenty-six doctors were referred to the General Medical Council by a single hospital trust - no further action taken. BBC Newsnight investigated.
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Content ArticleThe only NHS service in England to offer gender identity services to children announced it would be closing down last year - after years of whistleblowers who worked there trying to raise the alarm about a scandal in their midst: a failure to safeguard some of the country's most vulnerable young adults. What went wrong? And how much did the toxic political climate at the time over trans issues contribute to a work practice that was not fit for purpose. Investigative reporter Hannah Barnes reflects her years spent talking to those involved - the staff, the families and most importantly, the children themselves.
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Content ArticleThis summary of how a National Patient Safety Board (NPSB) will benefit patients and families was coproduced by the NPSB Advocacy Board with Patients for Patient Safety US. It outlines how the NPSB would ensure more comprehensive learning from patient safety incidents, ensure patients and families have a core role in governance and priority setting and that data is used to better understand patient safety in the US.
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Content ArticleThe MHRA is aware of cases of increased intraocular pressure in patients recently implanted with EyeCee One preloaded and EyeCee One Crystal preloaded intraocular lenses (IOLs), which are manufactured by NIDEK and distributed by Bausch + Lomb. The root cause has not been identified and further investigations are ongoing with the manufacturer. Due to the potential risks for patient safety, you should stop using these IOLs and quarantine remaining stock immediately pending the results of further investigations. Additional communications will be issued shortly advising clinicians and affected patients on the next steps.
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Content ArticleTen years ago today, a public inquiry concluded that patients were subject to shocking levels of neglect at Stafford Hospital - putting it among the worst care scandals in NHS history. A young local reporter, Shaun Lintern – now The Sunday Times' health editor – helped expose the scandal. With the NHS again under huge pressure, can we be sure the same failings won't happen again? In this podcast, part of the Stories of our Times podcast series, Shaun speaks to the barrister who chaired the inquiry.
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Content ArticleThis investigation by the Healthcare Safety Investigation Branch (HSIB) aims to improve patient safety by supporting staff to access critical information about patients at their bedsides in emergency situations. It defines critical information as ‘information about patients that needs to be accessed rapidly and accurately to ensure correct care is delivered when it is required’. In this investigation, critical information was considered through a focus on patient identifiers (such as name and date of birth) and decisions relating to whether someone is recommended to receive cardiopulmonary resuscitation (CPR) if their heart stops (cardiac arrest). The reference event for this investigation was the care of a patient in a hospital who was found unresponsive in bed. A short time later, he stopped breathing and his heart stopped. Help was immediately sought from the ward staff and a team gathered around the patient’s bed, where they confirmed the patient’s identity and noted that a decision had been made that he was not recommended to receive CPR if his heart stopped. As a result, CPR was not started. Around 10 minutes later, a nurse who had previously been caring for the patient returned from their break and recognised that the patient had been misidentified as the patient in the next bed. The patient whose heart had stopped was recommended to receive CPR. CPR was immediately started, but despite this, the patient died.
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Content ArticleThis is a brief summary of a Westminster Hall debate in the House of Commons on the 31 January 2023 concerning the Essex Mental Health Independent Inquiry.
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Content ArticleThis poster produced by researchers at Warwick Medical School summarises a qualitative research project that examined attitudes and behaviours related to patient safety culture at a single West Midlands Trust. The study's objective was to gain an understanding of staff’s views regarding the culture within the Trust and of their attitudes and behaviours when reviewing clinical incidents and mortality and morbidity. The poster was a winner at the HSJ Patient Safety Congress 2022 in the category 'A just culture for learning and change'. Read the full research paper.
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Content ArticleThis article in BMJ Open Quality aimed to improve patient safety by examining the organisational and individual factors that contribute to adverse events, enabling corrective action so that errors are not repeated. Using interviews and observations of Trust meetings at a single Hospital Trust in the Midlands, England, this qualitative study: analysed whether the attitudes and behaviours of clinicians and managers are aligned with a Just Culture. identified barriers and enablers to an organisation adopting a Just Culture. The study found evidence of a fair incident management process within the Trust; however, there was no agreed vision of a Just Culture and the majority of the staff were unfamiliar with the term. Negative perspectives relating to clinical incidents and their management persist among staff with many having concerns about being the subject of an investigation and doubts about whether they drive improvement.
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Content ArticleThis investigation by the Healthcare Safety Investigation Branch (HSIB) explored the detection and diagnosis of jaundice in newborn babies, in particular babies born prematurely (before 37 weeks of pregnancy). Specifically, it explored delayed diagnosis due to there being no obvious visual signs of jaundice apparent to clinical staff. Jaundice is a condition caused by too much bilirubin in a person’s blood. Bilirubin is a yellow substance produced when red blood cells are broken down. If left undiagnosed and untreated, high bilirubin levels in newborn babies can lead to significant harm. Newborn babies have a higher number of red blood cells in their blood which increases their risk of jaundice. Jaundice can cause yellowing of the skin and whites of the eyes; however, sometimes the visual signs of jaundice are not obvious, particularly for premature or newborn babies with brown or black skin. The reference event for this investigation was the case of baby Elliana, who was born at 32 weeks and 1 day via a forceps delivery and then transferred to the Trust’s special care baby unit (SCBU). Elliana was assessed on admission to the SCBU by staff as a clinically stable premature baby and a routine blood sample was taken from around two hours after her birth to establish a baseline. Analysis of the blood sample indicated bilirubin was present and so the level was measured. This result was uploaded onto the Trust’s computer system alongside the results of the blood tests that had been requested by the clinical team. The bilirubin result was seen by a SCBU member of staff who recognised that the level was high, indicating the possible need for treatment. However, this member of staff was then required to attend an emergency and the bilirubin result was not acted upon. Another blood sample was taken when Elliana was two days old and was uploaded to the Trust’s computer system. It is unclear if this bilirubin result was seen by staff; it was not documented in clinical records and was not acted upon. Over the next two days, Elliana continued to show no visible signs of jaundice that were detected by staff and she was documented to be developing well. When Elliana was five days old, a change in her skin colour was observed and visible signs of jaundice were detected. A further blood sample was taken which showed she had a high level of bilirubin in her blood and treatment was started accordingly. Elliana’s bilirubin levels returned to within acceptable levels over the next three days and she was subsequently discharged home.
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Content ArticleThis article in The Times explains why the Times Health Commission was set up, what it aims to achieve and how it will do this. The year-long commission aims to address the most urgent challenges facing health and social care including the growing pressure on budgets, the A&E crisis, rising waiting lists, health inequalities, obesity and the ageing population. Commissioners will draw up recommendations in ten areas to identify problems and find solutions. The Commission will publish its final report in January 2024.
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Content ArticleThis video published by the Irish Health Service Executive (HSE) tells the story of Pat, whose bowel cancer diagnosis was missed, resulting in his premature death. His daughter Patricia talks about the two investigations that took place into her father's death and how the hospital's internal investigation failed to acknowledge that a staff member had raised concerns about Pat's initial colonoscopy on five occasions, but this had not been followed up. She describes the impact of these events on her father and the rest of the family and calls on medical professionals to "trust us (families) more and fear solicitors less."
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Content Article
In a blog for National Voices, the leading coalition of health and social care charities in England, Patient Safety Learning’s Chief Executive Helen Hughes discusses an independent report written by risk expert Tim Edwards that highlights serious and widespread safety concerns around the misdiagnosis of pulmonary embolism. -
Content Article
Dr Freya Smith, a Specialty Trainee in General Practice, reflects on the sinister and toxic side of medicine, using the recent Paterson and vaginal mesh scandals to demonstrate how patients have been let down by the system. In an honest and personal account, she shares with us the horror and sadness she felt at learning of these scandals and how she aspires to keep her future patients safe. -
Content ArticleIn this blog, Matthew Wain highlights how NHS organisations can support staff with patient safety investigations, and more generally, in the face of increased pressure. He looks at missed learning opportunities, psychological impact, and the support tools and programmes available for staff. Further reading: Patient Safety Learning's Staff Support Guide: a good practice resource following serious patient harm
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Content ArticleRecording of the Health and Social Care Committee meeting held on Tuesday 13 December 2022. Meeting started at 10.03am, ended 11.45am.
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Content Article
HSIB: Safety investigation jargon buster
Patient Safety Learning posted an article in HSSIB investigations
A guide to the terms commonly used in safety investigations and their definitions. -
Content ArticleElizabeth Holmes, the 38 year old founder of failed diagnostic start-up Theranos, was sentenced to more than 11 years in prison this November. The sentence was handed down nearly a year after she was found guilty of defrauding investors about her finger prick blood testing devices, and seven years after the Wall Street Journal published its first investigation exposing the company’s struggles. Theranos’ customers received false laboratory test results indicating life threatening conditions such as cancer and HIV. Patients were left to wait anxiously while traditional laboratories repeated the tests, and at least one customer stopped taking his medication on the basis of erroneous results. Holmes was ultimately not convicted of charges relating to patient harm, instead she will be locked up for misleading wealthy investors.
