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News ArticleChildren say they were "treated like animals" and left traumatised as part of a decade of “systemic abuse” by a group of mental health hospitals, an investigation by The Independent and Sky News has found. The Department of Health and Social Care has now launched a probe into the allegations of 22 young women who were patients in units run by The Huntercombe Group, which has run at least six children’s mental health hospitals, between 2012 and this year. They say they suffered treatment including the use of “painful” restraints and being held down for hours by male nurses, being stopped from going outside for months and living in wards with blood-stained walls. They also allege they were given so much medication they had become “zombies” and were force-fed. But despite reports to police and regulators dating back seven years, and findings by the Care Quality Commission (CQC) that the units were inadequate, the NHS has still handed Huntercombe nearly £190m since 2015-16 to admit children to its mental health beds. Through witness testimony, documents obtained by Freedom of Information request and leaked reports, the investigation has uncovered: The CQC has received more than 700 whistleblowing and safeguarding reports, including “incidents of concern” and several “sexual safety” concerns. NHS England was notified of 195 safeguarding reports between 2020 and 2021. A 2018 internal report at Meadow Lodge hospital in Newton Abbot (now closed) found staff members using sexually inappropriate language in front of patients. 160 reports investigated by Staffordshire police about Huntercombe Staffordshire between 2015 and 2022. Between March 2021 and 2022, the CQC gave permission for 29 patients to be admitted to Maidenhead hospital after it was placed in special measures. Read full story Source: The Independent, 27 October 2022
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News ArticleAbout 4,000 UK victims of the infected blood scandal are to receive interim compensation payments of £100,000 by the end of this month. It is being paid to those whose health is failing after developing blood borne viruses like hepatitis and HIV. It is also being paid to partners of people who have died. Conan McIlwrath, from Larne in County Antrim, who is among the 100 or so victims affected in Northern Ireland said it was "very much welcomed". "This is the first compensation that's ever been paid - anything prior has been support," he told BBC News NI. All victims have campaigned for actual 'compensation' as they have said only this would acknowledge decades of physical and social injury, as well as loss of earnings and the cost of care. Read full story Source: BBC News, 22 October 2022
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News Article
CQC taking ‘enforcement action’ against every fourth service it inspects
Patient Safety Learning posted a news article in News
A quarter of services the Care Quality Commission has recently inspected required enforcement action from the regulator, its chief executive has revealed. Speaking at the launch of the regulator’s annual State of Care report, Ian Trenholm called for a “long-term, sustainable funding solution” from the government to aid a service that was ”genuinely struggling to cope”. Mr Trenholm said “about a quarter of the services” the CQC has inspected in 2022 had resulted in it having to take “enforcement action”. Examples of action taken against NHS trusts in the last year included enforcement measures placed on Nottingham University Hospitals, University Hospitals Sussex, and Princess Alexandra Hospital. In response to a question from HSJ about the robustness of the CQC’s inspection regime following further care quality and safety scandals, Mr Trenholm said observers should not focus solely on the ratings given to trusts by the CQC as there was a lot ”work going on in the background, whether that’s enforcement or otherwise”. He added the CQC had significantly increased the amount of information it was gathering in relation to concerns about services. Read full story Source: HSJ, 21 October 2022 -
News Article
East Kent NHS inquiry finds better care might have prevented 45 babies’ deaths
Patient Safety Learning posted a news article in News
The deaths of at least 45 babies could have been avoided if nationally recognised standards of care had been provided at one of England’s largest NHS trusts, a damning inquiry has found. Dr Bill Kirkup, the chair of the independent inquiry into maternity at East Kent hospitals university NHS foundation trust, said his panel had heard “harrowing” accounts from families of receiving “suboptimal” care, with mothers ignored by staff and shut out from discussions about their own care. The inquiry’s report said: “An overriding theme, raised with us time and time again, is the failure of the trust’s staff to take notice of women when they raised concerns, when they questioned their care, and when they challenged the decisions that were made about their care.” Of 202 cases reviewed by the experts, the outcome could have been different in 97 cases, the inquiry found. In 69 of these 97 cases, it is predicted the outcome should reasonably have been different and it could have been different in a further 28 cases. Of the 65 babies’ deaths examined, 45 could have had a different outcome if nationally recognised standards of care had been provided. In nearly half of all cases examined by the panel, good care could have led to a different outcome for the families. Some of the bereaved parents accused the trust of “victim blaming” mothers for their children’s deaths. Kelli Rudolph and Dunstan Lowe, whose daughter Celandine died at five days old, said: “Doctors sought to blame Kelli for Celandine’s death. This victim blaming was the first in a long line of interactions with those in the trust who sought to delay, deflect and deny our search for the truth about what happened to our baby. “In isolation, these tactics traumatised us after the tragedy of our daughter’s death. But when seen in the light of 10 years of failures, they signal a concerted effort to cover up the trust’s responsibility for what happened to Celandine and the many others who lost their lives due to failures in clinical judgment.” Read full story Source: The Guardian. 19 October 2022 -
News Article
'No-one joined the dots' - grandad who exposed an NHS scandal
Patient Safety Learning posted a news article in News
More than 200 families in south-east England will learn today the results of a major inquiry into the maternity care they received from a hospital trust. The investigation into East Kent Hospitals NHS Trust follows dogged campaigning by one determined bereaved grandfather. Derek Richford's grandson Harry died at East Kent Hospitals after his life support system was withdrawn. Sixty one-year-old Derek had never campaigned for anything in his life. His initial approach was to wait for East Kent Hospitals Trust to investigate the death, as it had promised. However, one nagging issue that was to become central to Derek's view of the trust, was the hospital's continual refusal to inform the coroner of Harry's death. The family repeatedly requested it, but the trust said it was unnecessary as it knew the cause, namely the removal of the life support system. The hospital also recorded Harry's death as "expected" - again because his life support system had been withdrawn. On both points, the family were left confused and increasingly angry. In early March 2018, some four months after Harry's death, the family finally received the outcome of the trust's internal investigation - known as the Root Cause Analysis (RCA). The RCA indicated multiple errors had been made in Harry and Sarah's care and treatment, and his death was "potentially avoidable". Prior to the meeting, Derek wrote to the Kent coroner's office outlining in general the circumstances of Harry's case, asking if that was the type they would expect to be notified of. The email response from the coroner's office was clear. It said: "Based on the facts you have presented, this death should have been reported to the coroner." Despite this, at the meeting with the trust, the lead investigator into Harry's death told the family: "If we have a clear cause of death by and large we do not involve the coroner." The family's insistence eventually paid off - five weeks after that meeting, the trust informed the coroner of Harry's death. While his son and daughter-in-law started trying to recover from the trauma of losing Harry, Derek turned his attention to investigating East Kent, one of the largest hospital trusts in England. "When I started investigating what was going on with Harry, it was very much like peeling back an onion. 'Hang on a minute, that can't be right, that doesn't add up.' Ever since I was a small kid, justice has been so important to me. "What I found was that, up to that point, no-one had ever joined the dots. And that's so important. I think this had to happen, someone had to do it. There will be families before us that wish they did it. We will be saving a level of families after us." Read full story Source: BBC News, 19 October 2022 -
News ArticleThe former lead governor of East Kent Hospitals University Foundation Trust has resigned this morning, claiming there is “a cancer at the top of the organisation” and that its services won’t be safe until the government provides funding for critical estates work. His resignation as a governor came hours before the publication of what is expected to be a “harrowing” report into maternity services at the trust from an independent review led by Sir Bill Kirkup. He is also expected to raise concerns about national progress on maternity services safety in recent years. Alex Lister, who is chair of the council of governors’ membership engagement and communications committee, said in the letter: “I believe officials on six-figure salaries continue to mislead, obfuscate, bully and conceal vital information. I consider the way the trust communicates internally and externally to be completely unacceptable and utterly untrustworthy. “Without the valiant efforts of the brave families caught up in a tragedy of the trust’s making, the world may never have found out about the disastrous health failings at our trust.” In the letter to chair Niall Dickson, Mr Lister says he has seen a continuation “of the same apparent policy of manipulation and discrediting dissenting voices that existed prior to the scandal”. Read full story (paywalled) Source: HSJ, 19 October 2022
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News Article
NHS faces £90bn bill for ‘staggering’ maternity blunders
Patient Safety Learning posted a news article in News
The NHS faces a record £90 billion maternity bill, The Telegraph can reveal ahead of a “harrowing” report into failings at East Kent Hospitals Trust. Official figures show the number of claims have risen by almost one quarter in just two years following a series of scandals. The data show 1,243 maternity negligence claims in 2021/22 - up from 1,015 in 2019/20. Safety campaigners said the figures were “staggering” - with £90 billion now set aside to cover the costs of claims. It means that in total, 70% of total liability provision for NHS negligence is associated with failings in pregnancy and childbirth, amid rising claims. The figure - equivalent to two-thirds of the NHS annual budget - represents an estimate for the total costs if all claims it expects to settle were paid out, at today’s prices. An NHS spokesperson said: “Despite improvements to maternity services over the last decade – with significantly fewer stillbirths and neonatal deaths – we know that further action is needed to ensure safe care for all women, babies and their families. “The NHS is ensuring that work is already underway to make these improvements, including a £127 million investment this year to boost the maternity workforce, strengthen leadership and increase neonatal cot capacity – which is on top of an annual boost of £95 million for staff recruitment and training announced last year.” Read full story (paywalled) Source: The Telegraph, 18 October 2022 -
News Article
Former trust CEO and medical director cleared over surgery scandal
Patient Safety Learning posted a news article in News
A major trust’s former chief executive and medical director have been cleared, after being accused of failing to protect breast patients from a rogue surgeon. The Medical Practitioners Tribunal Service has ruled neither Mark Goldman nor Ian Cunliffe’s fitness to practise was impaired, in a case brought by the General Medical Council. Mr Goldman was chief executive of the Heart of England Foundation Trust from 2001 until 2010, while Dr Cunliffe served as HEFT medical director between 2006 and 2010. Both held roles at HEFT while Ian Paterson was there. Mr Paterson was jailed for 20 years in 2017 after being convicted of 17 offences of wounding with intent while being employed at HEFT, while a later inquiry concluded he may have conducted up to 1,000 botched and unnecessary operations over a 14-year period. Mr Goldman and Dr Cunliffe are now pursuing the GMC for the costs of the case, which is expected to be heard over five days in January 2023. Read full story (paywalled) Source: HSJ, 18 October 2022 -
News ArticleA key national policy change recommended by the inquest which led to the East Kent maternity inquiry will not be implemented until next February – more than three years after it was called for by a coroner. The recommendation – that obstetric locum doctors be required to demonstrate more experience before working – was made in a prevention of future deaths report following the inquest into the death of seven-day-old Harry Richford at East Kent Hospitals University Foundation Trust. The remaining 18 recommendations from the PFD report were requiring specific actions by the trust, rather than national policy makers. The trust says they have been implemented. However, NHS England and the Royal College of Obstetricians and Gynaecologists have only in recent months produced guidance on using short-term locums in these services, and it will not come into effect until February. When it does, it will require them to complete a certification of eligibility, demonstrating they have had recent experience in a number of clinical situations, including complex Caesarean sections. Middle-grade locums have until next February to gain the certificate. The independent inquiry into maternity at the trust – prompted by Harry’s death – will report tomorrrow, Wednesday 19 October, and is expected to be highly critical of the trust, and of national efforts to make services safe over recent years. Read full story (paywalled) Source: 18 October 2022
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News Article
Family hit a 'brick wall' seeking justice for baby
Patient Safety Learning posted a news article in News
The grandfather of a baby who died at a hospital that was fined over failings in the delivery has spoken of his five-year fight for justice. Derek Richford was speaking as an independent report into baby deaths at the East Kent Hospitals Trust will be released this week. He said he "came up against a brick wall" while searching for answers over the death of grandson Harry Richford. An inquest into Harry's death at Margate's Queen Elizabeth the Queen Mother Hospital in 2017 found it was wholly avoidable and contributed to by neglect. Coroner Christopher Sutton-Mattocks said the inquest, which was finally held in 2020, was only ordered due to the family's persistence. The following year the trust was fined £733,000 after admitting failing to provide safe care and treatment for mother Sarah Richford and her son following a prosecution by the Care Quality Commission (CQC). Mr Richford said: "To start with we felt fairly alone and we felt like we were coming up against a brick wall. "The trust were refusing at that time to call the coroner. They were reporting Harry's death as 'expected'. "We didn't contact anyone other than the CQC just to say 'look there's been a problem here'." He said at a meeting with the trust, more than five months later, "we suddenly realised that there were a huge [number] of errors". Mr Richford told the BBC: "It took me about a year to come up with all the detail I needed and to speak to all the right people." He said the family then spoke to the Health Safety Investigation Branch who found there were issues. Mr Richford also tracked down a "damming" report by the Royal College of Obstetricians and Gynaecologists (RCOG). "In the end it was like peeling back the layers of an onion, and the more you took off, the more you found," he said. Read full story Source: BBC News, 18 October 2022 -
News ArticlePeter Duffy warned that there is a growing risk of electronic patient records and NHS staff communications being exposed to tampering efforts in disputes with managers and executives. The surgeon, who now practices on the Isle of Man, made the comments during talks given in September – to the Association for Perioperative Practice (AfPP) and at the Royal College of Surgeons Ireland (RCSI) in Dublin. He told audiences that “there is increasing potential for electronic tampering” of NHS IT records, holding serious implications for patient safety reporting and disputes with government and health service bodies. The consultant medic, who says he was driven out of UHMBT in 2016 after blowing the whistle on dangerous practices and uninvestigated cases of harm within the trust’s urology services, won a constructive dismissal claim against his ex-employer in 2018. Duffy now alleges that emails concerning the care of a patient at the centre of his whistleblowing were forged and backdated by senior UHMBT staff, several years after his employment claim against the trust had ended. The emails were not disclosed during the tribunal – despite a court order having been issued to release all communications concerning the care of the patient in question, the late Peter Read, who died in early 2015 – and are understood to have surfaced during the course of an external review into UHMBT’s urology services carried out between late 2019 and 2021. Niche Consult, a private firm commissioned by NHS England/Improvement (NHSE/I) to investigate Duffy’s patient safety disclosures alongside broader concerns regarding the trust’s urology department, determined that the emails in question were not fakes. Duffy told the AfPP and RCSI audiences that, during the Niche review of UHMBT’s urology services in 2020, he was “abruptly told that two entirely new, never-seen-before emails had suddenly, unexpectedly appeared”. The emails appear to partly implicate him in the series of clinical errors and missed care opportunities that contributed to Read’s death. Duffy described the allegedly falsified emails as being part of “an executive vendetta” waged against him in retaliation for his whistleblowing activity and negative publicity surrounding it, as UHMBT was seeking to cultivate the image of a “turnaround” trust in the years following a major maternity scandal between 2004 and 2013. Read full story Source: Computer Weekly, 28 September 2022
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News Article
Staff at Kent NHS trust warned of 'harrowing report' into preventable baby deaths
Patient Safety Learning posted a news article in News
The chief executive of an NHS trust at the centre of a maternity scandal where there were at least seven preventable baby deaths has warned staff to prepare for a "harrowing report" into what happened. In an email seen by Sky News, East Kent Hospitals University NHS Foundation Trust chief executive Tracey Fletcher told her staff to expect a "harrowing report which will have a profound and significant impact on families and colleagues, particularly those working in maternity services". An independent investigation into the trust, stretching back over a decade, will be published this week and is expected to expose a catalogue of serious failings. It is also expected to say the avoidable baby deaths happened because recommendations that were made following reports into other NHS maternity scandals were not implemented. The East Kent review is led by obstetrician Dr Bill Kirkup, who also chaired the investigation into mother and baby deaths in Morecambe in 2015. Dawn Powell's newborn son Archie died in February 2019 aged four days. In an emotional interview, Mrs Powell told Sky News she will never get over the loss of her son, who would be alive today if she or Archie had been given a routine antibiotic. "For families like us, where your child has been taken away, you have forever got that hole in your life that you will never heal," Mrs Powell said. Read full story Source: Sky News, 16 October 2022 -
News Article
NHS logging baby deaths as stillbirths ‘to avoid scrutiny’
Patient Safety Learning posted a news article in News
NHS hospitals have claimed that babies born alive were stillborn, a Telegraph investigation has found, prompting accusations they were trying to avoid scrutiny. Six children who died before they left hospital were wrongly described as stillborn. Several of the children lived for minutes and one lived for five days. Coroners are not able to carry out inquests into stillbirths, leaving some families unable to get answers until the error was corrected. In one case, an obstetrician told a coroner in Stockport that he had been pressured by an NHS manager to say a baby he had delivered had definitely been stillborn, in order to be “loyal” to the trust. His comments are likely to raise fears that some NHS trusts in England have used the stillbirth label to avoid having coroners examine any errors that may have been made by staff. The revelations raise questions over transparency at some NHS trusts. The babies identified by The Telegraph should have been recorded as neonatal deaths, but staff claimed they were stillbirths – babies that never had any signs of life outside the mother’s body, even for a single moment. All the NHS trusts that wrongly classified neonatal deaths as stillbirths have apologised to the babies’ parents, and say they have changed their practices. Read full story (paywalled) Source: The Telegraph, 16 October 2022 -
News Article
‘Obfuscations and failures’ in trust’s handling of death, damning review finds
Patient Safety Learning posted a news article in News
There were ’obfuscations, difficulties and failures’ in a scandal-hit trust’s handling of a baby’s death, a damning review has found, although it cleared the organisation’s former chair of ’serious mismanagement’. A fit and proper person review into the conduct of former Shrewsbury and Telford Hospital Trust chair Ben Reid, who left in August 2020, has been published by the board. The report follows complaints about Mr Reid’s conduct from the family of baby Kate Stanton-Davies, who died in the trust’s care and whose case – alongside that of Pippa Griffiths – sparked the original Ockenden inquiry. In March 2022, the final Ockenden report into maternity services at Shrewsbury found poor maternity care had resulted in almost 300 avoidable baby deaths or brain damage cases in the most damning review of maternity services in the NHS’s history. Report author Fiona Scolding KC said she does not believe Mr Reid “lied” or acted unethically in his handling of complaints from the family and therefore this does not disqualify him from holding office within the terms of such a review. However, the report is highly critical of the trust, with Ms Scolding concluding it is “undoubtedly true” the provider had not dealt with Kate’s father Richard Stanton and her mother Rhiannon Davies in an “open and honest” way in respect of their daughter’s death. Read full story (paywalled) Source: HSJ, 13 October 2022 -
News ArticleThe mother of a bullied 12-year-old girl has said her daughter struggled to get mental health support on the NHS in the months before she killed herself, and accused her school of failing to deal with inappropriate messages circulating among pupils. The mother of Charley-Ann Patterson, Jamie, told a hearing that despite being seen by three medical professionals, Charley-Ann had been unable to get mental health support in the months before her death. In a statement read at an inquest at Northumberland coroner’s court on 12 October, Jamie said her daughter had changed halfway through her first year of secondary school, when she was sent “inappropriate” and “shocking” messages by other pupils. The inquest heard that Jamie first took her daughter to a GP over self-harm concerns in June 2019, but she said she “did not believe that the GP took Charley-Ann’s self-harm seriously, potentially due to her age”. She took Charley-Ann to A&E in May 2020 after a second episode of self-harm, where she was referred to a psychiatric team and given a telephone appointment in which she was told Charley-Ann would be referred to child and adolescent mental health services (CAMHS), but that “it was likely that she would not be seen for three years”. In an appointment with a nurse she was told that she would be referred to the Northumberland mental health hub for low mood and anxiety, but later learned “that this referral was never made”. Read full story Source: The Guardian, 12 October 2022
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News Article
Deaths inquiry will exclude dozens of concerning cases, says whistleblower
Patient Safety Learning posted a news article in News
An inquiry into alleged efforts to cover up care failings at an ambulance trust has been criticised by a key whistleblower for being too limited in scope. NHS England recently commissioned the inquiry into North East Ambulance Service, which has been accused of withholding key details from coroners in a number of deaths. Whistleblowers have raised concerns about disclosure in more than 90 cases. Draft terms of reference for the review, seen by HSJ, say it will examine cases which occurred over a 12-month period up until December 2019. Paul Calvert, a coroners’ officer at NEAS who raised concerns about the issues, said this effectively means only five cases will be scrutinised. He added: “The terms of reference are clearly designed to not include the ongoing malpractice, only focusing on a limited time period and limited cases." “The fact that the [inquiry] has chosen such a narrow time window and a handful of cases, is designed to perpetuate that after 2018 and 2019, the mistakes of the past were remedied. This is simply incorrect, misleading and dishonest to suggest.” He said concerns about information being withheld continued “well into 2021” and the terms of reference risked “continuing the cover up of univestigated deaths”. Read full story (paywalled) Source: HSJ, 13 October 2022 -
News Article
Lucy Letby was ‘constant malevolent’ presence on neonatal ward, court hears
Patient Safety Learning posted a news article in News
A nurse murdered seven babies and attempted to kill 10 others by poisoning them on a hospital neonatal unit where she was a “constant malevolent presence”, a court has heard. Lucy Letby, 32, fatally injected newborns with insulin, air or milk during night shifts when she knew their parents would not be present, a jury was told. One of the babies was just 24 hours old when Letby allegedly injected him with air, killing him just 90 minutes after she came on shift. The nurse tried to kill his twin sister the next day, it is alleged. The court was told that Letby, who was trained to care for the most seriously ill babies, developed an “unusual interest” in the parents of some of her 17 alleged victims and in some cases tracked them on Facebook. Jurors were told that she was the only “common denominator” that connected the deaths of seven infants and the “catastrophic” collapses of 10 others at the Countess of Chester hospital between June 2015 and June 2016. She allegedly tried to kill some babies more than once – in one case, three times – using various methods. Nick Johnson KC, prosecuting, told the jury: “We say the collapses and deaths of the 17 children named on the indictment were not normally occurring tragedies. They were all the work, we say, of the woman in the dock who we say was a constant malevolent presence when things took a turn for the worse for these children.” Read full story Source: The Guardian, 10 October 2022 -
News Article
Bullying, misogyny and sexual culture at Royal College of Nursing, inquiry finds
Patient Safety Learning posted a news article in News
A damning inquiry into the Royal College of Nursing, the world’s biggest nurses’ union, has exposed bullying, misogyny and a sexual culture where women are at risk of “alcohol and power-related exploitation”. A 77-page internal report by Bruce Carr KC, leaked to the Guardian, lays bare how the RCN’s senior leadership has been “riddled with division, dysfunction and distrust” and condemns the male-dominated governing body, known as council, as “not fit for purpose”. Grave concerns are also raised about the RCN’s annual conference, known as congress, where Carr says an “inappropriate sexual culture” warrants further urgent investigation “to identify the extent to which [it] has actually resulted in exploitation of the vulnerable”. The eminent barrister reports that there is evidence to support the “impression” that senior individuals have been seeking to take sexual advantage of subordinates and “engaging in unwanted sexual behaviours”. He calls on those whose conduct is cited in the report, whom he does not name, to consider their positions in the light of testimony of groping, humiliation of female staff members and a refusal of those in positions of responsibility to reflect on the letters of resignation from women on the council, who have complained of “gaslighting and microaggressions”. Read full story Source: The Guardian, 10 October 2022- Posted
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News Article
How 175 British children were infected with HIV
Patient Safety Learning posted a news article in News
At least 175 children with the blood disorder haemophilia were infected with HIV in the 1980s, according to documents from the national archives seen by BBC News. Some of the families affected are giving evidence at a public inquiry into what has been called the worst treatment disaster in the history of the NHS. It was almost 36 years ago - in late October 1986 - but Linda will never forget the day she was told her son had been infected. She had been called into a consulting room in Birmingham Children's Hospital, with 16-year-old Michael. As a toddler, he had been diagnosed with haemophilia, a genetic disorder that stopped his blood clotting properly. Linda assumed the meeting was to discuss moving his care to the main Queen Elizabeth Hospital in the city. "It was so routine that my husband stayed in the car outside," she says. "Then, all of a sudden, the doctor said, 'Of course, Michael is HIV positive,' and he came out with it like he was talking about the weather outside. My stomach just fell." Between 1970 and 1991, 1,250 people with blood disorders were infected with HIV in the UK after taking Factor VIII - a new treatment that replaced the clotting protein missing from their blood. About half of those infected with HIV died of an Aids-related illness before life-saving antiretroviral drugs became available. Almost three decades later, Linda is giving evidence to the long-running public inquiry into the treatment disaster. She will appear alongside other parents, in a special session about the experiences of families whose children were infected in the 1970s and 80s. "I felt as though I needed to do it because I want to help get to the bottom of it," she says. "We all want to know why it was allowed to happen and to keep on happening as well." Read full story Source: BBC News, 6 October 2022 -
News Article
Covid inquiry ‘marginalising’ bereaved on first day of hearing
Patient Safety Learning posted a news article in News
Bereaved families fear their experiences will be “diluted” in the UK Covid-19 Inquiry after it was confirmed their evidence would be submitted to a third-party company. Instead of the usual “pen portraits” heard in the inquiry, families will submit their evidence to a private research company as part of a parallel listening exercise that will analyse the responses and feed back the findings to the inquiry chaired by Baroness Heather Hallett. Matt Fowler, co-founder of the Covid-19 Bereaved Families for Justice campaign, said while families believe the start of the inquiry is a step in the right direction after campaigning for two years, they fear being excluded from the inquiry because of the listening exercise. “All bereaved families want from the inquiry is the same outcome that anyone should, for lessons to be learnt from our loss that can stop the monumental scale of death that took place from happening again,” Matt said following the preliminary hearing. “As Baroness Hallett herself has acknowledged, for that to happen the experiences of the bereaved must be learnt from, so why is she leaving us out in the cold instead of working with us?” A&E doctor Saleyah Ahsan, from east London, worked in intensive care units during the pandemic. She said she remembers holding hands with people and telling them they needed to be incubated as they desperately called their families – some died in intensive care. “It is very important that stories jump off the page and are real because they are real,” She added: “If we really want to make sure we get this right there is only this inquiry, it has to be right. I am a medic, I see the numbers are rising, it’s autumn. Thankfully we’ve got a booster but hospitals are getting busy – I’m worried.” Read full story Source: The Independent, 4 October 2022 -
News ArticleTina Hughes, 59, died from sepsis after doctors allegedly delayed treating the condition for 12 hours while they argued over which ward to treat her on. Ms Hughes was rushed to A&E after developing symptoms of the life-threatening illness on September 8 last year. Despite paramedics flagging to staff they suspected sepsis, it was not mentioned on her initial assessment at Sandwell General Hospital, in West Bromwich. A second assessment six hours later also failed to mention sepsis while medics disagreed over whether to treat her on a surgical ward or a high dependency unit. The grandmother-of-five was eventually transferred to the acute medical unit at 3am the next morning where sepsis was finally diagnosed, but she continued to deteriorate and was admitted to intensive care four hours later and put on a ventilator. She died the following morning. A serious incident investigation report by Sandwell and West Birmingham Hospitals NHS Trust has since found there was "a delay in explicit recognition of sepsis". Read full story (paywalled) Source: The Telegraph, 4 October 2022
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News Article
Tribunal told of 'failure' over girl's blood tests
Patient Safety Learning posted a news article in News
If doctors had tested a nine-year-old girl's blood sooner they may have changed the treatment she received before her death, an expert witness has confirmed to a medical tribunal. The hearing was told this was a "significant failure" in the care of Claire Roberts. Claire died at the Royal Belfast Hospital for Sick Children in 1996. In 2018 a public inquiry concluded she died from an overdose of fluids and medication caused by negligent care. At the time, her parents were told a viral infection had spread from her stomach to her brain. The General Medical Council (GMC) said one of the doctors involved in Claire's care, Dr Heather Steen, acted dishonestly in trying to conceal the circumstances of her death. Dr Steen denied allegations that she acted dishonestly and engaged in a cover-up. The Medical Practitioners Tribunal Service (MPTS) heard from a defence expert witness on Monday who said doctors not checking the sodium levels in Claire's blood earlier was a "significant failure" in her care. Dr Nicholas Mann told the tribunal he would have ordered more blood tests on Claire on the morning after she was admitted to hospital but he said he did not know if this would have prevented her death. "There should have been more attention to her fluids and electrolytes on the day after admission. Whether that would have altered the final outcome I don't know but certainly it would have been sensible to do that," he said. The tribunal also heard that Claire's death was not referred to a coroner, despite this being something all of the doctors caring for her would have had a duty to do. It was also told that a letter sent to Claire's parents from the hospital in 2005 contained inaccuracies. During questioning of Dr Mann, a barrister for the GMC highlighted the involvement of Dr Steen in compiling the letter which was signed by another doctor. Tom Forster KC said it was the GMC's case that Claire's family were given incorrect information about potential causes of her death despite these not being definitively diagnosed. Read full story Source: BBC News, 3 October 2022 -
News Article
Covid inquiry first preliminary hearing to begin
Patient Safety Learning posted a news article in News
The first preliminary hearing of the UK Covid public inquiry will begin today. The session, in London, will focus on the UK's pandemic preparedness before 2020. It will be largely procedural, involving lawyers and an announcement about who will be giving evidence. Public hearings where witnesses are called will not start until the spring. The inquiry formally started in the summer, with a listening exercise. But this first preliminary hearing is still being seen as an important milestone for the families who lost loved ones. Lindsay Jackson's mother, Sylvia, 87, died from Covid during the first lockdown, after contracting it at a care home. Ms Jackson, of the Covid-19 Bereaved Families for Justice campaign group, said it was essential lessons were learned. She was "really pleased" the inquiry was finally starting but it had taken too long to reach this stage. "It's two-and-a-half years since the pandemic started," she said. "We lost so many people. If people have done things wrong, they need to be held accountable. "For me, my family and the others who lost loved ones, it's important that answers are found to the questions that we have." Read full story Source: BBC News, 4 October 2022 -
News ArticleHospital authorities in Wales have been accused of attempting to cover up failings in the delivery of a baby born with significant brain damage. Gethin Channon, who was born on 25 March 2019 at Singleton Hospital, in Swansea, suffers from quadriplegic cerebral palsy, a severe disability that requires 24/7 care. There were complications during his birth, due to him being in an abnormal position that prevented normal delivery, and he was eventually born via caesarean section. An independent review commissioned by Swansea Bay University Health Board (SBUHB), which manages Singleton Hospital, found “several adverse features” surrounding Gethin’s delivery that were omitted from or “inaccurately specified” in the hospital’s internal report. The investigation, carried out by obstetrician Dr Bill Kirkup, said SBUHB had “significantly” downplayed the “suboptimal” care received by Gethin and his mother, Sian, and had erroneously attributed his condition to a blocked windpipe. It also suggests that amendments were retrospectively made to examination notes taken by staff during the course of Ms Channon’s labour. The family said that SBUHB, which was flagged by national inspectors in the months after Gethin’s birth due to “concerns” over its ability to deliver “safe and effective” maternity care, had “covered up” the failings in their case. SBUHB said it had been “working tirelessly” with the family to investigate and address their concerns, and that it would be inappropriate to comment on specific allegations as the process was ongoing. Read full story Source: The Independent, 2 September 2022
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Scottish Government orders review as neonatal deaths higher than expected
Patient Safety Learning posted a news article in News
Healthcare Improvement Scotland have been commissioned to lead a review into the neonatal death rates. It follows the higher than expected deaths in both March 2022 and September last year, as published by Public Health Scotland. At least 18 babies under four weeks old died in March – a rate of 4.6 per 1,000 births. The wider inquiry is understood to have been triggered because the mortality rate passed an "upper control" threshold of 4.4 per 1,000 births. The average mortality rate among newborns is just over 2 per 1,000 births. The Scottish Government said the investigation is expected to take no longer than six to nine months once the review team is formed. Public health minister Maree Todd said: “Every death is a tragedy for the families involved. That is why earlier this year I committed to this review to find out if there is a reason for the increase. “I appreciate how difficult this time is for anyone affected and I would encourage them to access support if they wish to do so. There is information about organisations and help available on the National Bereavement Care Pathways Scotland as well as the Scottish Government website.” Read full story Source: The Scotsman, 30 September 2022
