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News Article
Coroner criticises NHS trust’s treatment of family of woman who killed herself
Patient Safety Learning posted a news article in News
An NHS trust has “not covered itself in glory” in its dealings with the family of a vulnerable young woman who killed herself after being refused admission to hospital, a coroner has found. The three-day hearing looked at evidence withheld from the original inquest into the death of Sally Mays, who killed herself in 2014 after being turned away from a mental health unit. Mays was failed by staff “neglect” at Miranda House in Hull, a 2015 inquest ruled, after a 14-minute assessment led to her being refused a place, despite being a suicide risk. Her parents, Angela and Andy Mays, won a high court battle in December to hear details of an informal chat outside the building between Laura Elliot, a community mental health nurse who was supporting Mays, and the consultant psychiatrist Dr Kwame Fofie, which only later came to light. This was ruled to be “neither a clinical conversation nor an attempt to escalate her care” by senior coroner Prof Paul Marks on Wednesday. He said: “It was a conversation between colleagues in which the frustrations of the working day were vented.” But, he said: “The trust has not covered itself in glory with regard to its dealings with the family and the disclosing of documents.” The Mays have spent the last seven years fighting to hear details of the car park conversation, which could have changed their understanding of what happened before their daughter died. Angela Mays added: “I never considered myself to be a campaigner. I have only considered myself to be a mother who actually wants the truth about the facts relating to her daughter’s death.” Read full story Source: The Guardian, 28 September 2022 -
News Article
Dying patient should have been seen in person
Patient Safety Learning posted a news article in News
NHS officials ruled a man who died after his ear infection was not picked up in GP telephone consultations should have been seen face to face, a BBC Newsnight investigation has found. David Nash, 26, had four remote consultations over three weeks during Covid restrictions but was never offered an in-person appointment. His infection led to a fatal abscess on his brainstem. David first spoke to the practice on 14 October 2020, after finding lumps on his neck. He sent a photograph but was never examined. With David worried the lumps might be cancerous, the GP asked a series of questions about his health and reassured him that while she could not rule it out completely, she was not worried about cancer. She suggested he booked a blood test for two to three weeks' time. In those three weeks, David would go on to speak to another GP and two advanced nurse practitioners but never face to face or via video call. He was actually due to be seen in person at the GP surgery that day, for the blood tests booked some 19 days earlier, when he had presented with neck lumps. But - fearing he could have coronavirus, despite a negative PCR test - the nurse cancelled the bloods and asked David to retest for Covid. In its investigation, NHS England found "the overarching benefit [of this decision] was less than the risk with going ahead with blood tests". After five calls to NHS 111, David was taken to hospital in an ambulance that day but died two days later. NHS England, in a finding seen by Newsnight, said: "A face-to-face assessment should have been offered or organised to confirm the diagnosis and initiate definitive management." Read full story Source: BBC News, 29 September 2022 -
News Article
CQC triggers two reviews into whistleblowing concerns
Patient Safety Learning posted a news article in News
The Care Quality Commission (CQC) has commissioned an independent review into handling of a high-profile whistleblower case, and a wider internal review of how it responds when it is given “information of concern”. The independent review will be led by Zoë Leventhal KC of Matrix Chambers and will consider how the regulator handled “protected disclosures” from University Hospitals of Morecambe Bay Foundation Trust surgeon Shyam Kumar, alongside “a sample of other information of concern shared with us”. Mr Kumar won a tribunal against the CQC earlier this month, which found he was unfairly dismissed as a special advisor on hospital inspections after raising serious patient safety concerns. Between 2015 and his dismissal in 2019 Mr Kumar wrote to senior colleagues at the CQC with a number of concerns within his trust around bullying, patient harm and the quality of CQC hospital inspections. The tribunal drew particular attention to the two whistleblowing disclosures made by Mr Kumar about the CQC itself, which it found “clearly had a material influence on the decision to dismiss”. The CQC said in an announcement today that the independent review would aim to determine whether it took “appropriate action” in response to the information disclosed in Mr Kumar’s case and others. It will include consideration of whether the ethnicity of the people raising concerns impacted on decision making or outcome and is expected to conclude by the end of the year. Read full story (paywalled) Source: HSJ, 28 September 2022 -
News ArticleFamilies have blasted a NHS Trust after it said it did not intend to publish an independent review into their loved ones deaths. Three young people died in nine months at the same mental health unit. A Coroner was told last week that the review will be "ready" this month. Rowan Thompson, 18, died while a patient at the unit, based in the former Prestwich Hospital, Bury, in October 2020, followed by Charlie Millers, 17, in December that year, and Ania Sohail, 21, in June last year. Earlier this year, Greater Manchester Mental Health NHS Foundation Trust (GMMH), which runs the hospital, commissioned an 'external report' into the deaths. A pre-inquest hearing into the death of Rowan - who used the pronoun 'they' - heard that the full report would be available for the coroner to read 'on or around September 30'. Asked by the Manchester Evening News if the review would be published a spokesperson for the Trust said the Trust "always act on the wishes of the family regarding publication of reports," adding "and so in line with this we have no immediate plans to make the report public." But the parents of both Rowan Thompson and Charlie Mllers said they wanted the report publishing. Charlie's mother, Sam, said: "We want it published. It needs to be put out there, otherwise there is no point in having it. We are hoping they (The Trust) will learn lessons. We want answers but it should also be published for the benefit of the wider public - and the parents of other young people who are being treated in that unit." Read full story Source: The Manchester News, 13 September 2022
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News Article
Sickle cell: NHS to investigate racial inequalities for first time
Patient Safety Learning posted a news article in News
Sickle cell patients’ experiences of barriers to treatment and racial inequalities will be investigated by an NHS body next month, The Independent has learned. The NHS Race and Health Observatory has collaborated with Public Digital, a consultancy group, to lead original research into the experiences of people with sickle cell, including listening to NHS patients’ and carers’ first-hand accounts of acute emergency hospital admissions and managing the condition at home. Research will focus on a series of interviews and ‘experience mapping’ workshops, the findings of which are anticipated to inform recommendations that will help improve emergency care and treatment pathways. “As a priority, we need to discover new measures and treatment plans that can help eradicate the often unacceptable, substandard care people with sickle cell have historically received whilst being unwell and in acute pain,” Dr Habib Naqvi, Director of the NHS Race and Health Observatory, said. This move comes after a parliamentary inquiry into avoidable sickle cell deaths called upon the Observatory to undertake work into sickle cell care in relation to race and ethnicity. The inquiry published a report, ‘No one’s listening’, in November 2021, which uncovered the bleak reality of patients grappling with racism in the NHS while attempting to access healthcare. Only half of healthcare professionals feel they have sufficient tools to manage the long-term damage that sickle cell disease brings, new research from Global Blood Therapeutics found, following extensive studies carried out across 10 countries including the UK, US and Canada. Read full story Source: The Independent, 22 September 2022 -
News Article
Lawyers warned trust that staff could ‘pick and choose’ documents for coroners
Patient Safety Learning posted a news article in News
An ambulance trust accused of withholding key evidence from coroners was previously warned its staff needed training to ‘understand the real risk of committing criminal offences’ in relation to inquests into patient deaths. North East Ambulance Service, which has been accused by whistleblowers of withholding details from coroners in more than 90 deaths, was told by its lawyers in 2019 about serious shortcomings in its processes for disclosing information, according to internal documents obtained by a campaigner. According to the documents, the lawyers said trust staff could “pick and choose” documents to release to coroners “regardless of relevance.” The following year, an audit report said the issues had not been addressed. Whistleblowers’ concerns about the trust were first reported by The Sunday Times in the spring, with a review highlighting several cases between 2018 and 2019 where key facts were omitted in disclosures to coroners. But campaigner Minh Alexander has since obtained new details of warnings that were being made to internally, from lawyers and auditors who were advising the trust. Read full story Source: HSJ, 20 September 2022 -
News Article
Nurse struck off for failing to dispense morphine
Patient Safety Learning posted a news article in News
A nurse in Somerset has been struck off after she failed to give morphine to a patient before they underwent surgery. Amanda-Jane Price had been suspended from front-line duties since the incident in March 2019. The Nursing and Midwifery Council ruled that Miss Price had been "dishonest" with her colleagues and her ability to practice medicine safely was "impaired". Miss Price had been a nurse at Musgrove Park Hospital in Taunton since 2018. On 31 March 2019, Miss Price did not administer morphine to an individual in her care, falsely recording in her notes that morphine had been given. An investigation by the hospital's emergency medicine consultant found that the morphine dose of 6mg had been noted on the patient's chart, but that the drug had not actually been administered. Miss Price subsequently admitted to falsifying the prescription chart, and to "being consciously aware of her decision". As a result of Miss Price's actions, the patient underwent an invasive procedure without analgesia, and subsequently complained of being in pain. The panel concluded that Miss Price was guilty of misconduct and would initially be suspended. "This was deliberate dishonesty which concealed her failure in clinical issues and caused actual patient harm to a vulnerable victim," the panel concluded. Read full story Source: BBC News, 20 September 2022 -
News Article
Infected blood transfusions killed 1,820 in UK, study estimates
Patient Safety Learning posted a news article in News
An estimated 1,820 people died in the UK after being given contaminated blood transfusions between 1970 and 1991, a report has found. The findings were published by the public inquiry into the scandal. The long period between infection and symptoms appearing makes it difficult to know how many people were infected through a transfusion in the 1970s and 1980s, before it became possible to screen blood donations for the virus. New modelling for the public inquiry estimated that between 21,300 and 38,800 people were infected after being given a transfusion between 1970 and 1991, with a central estimate of 26,800. The study, by a group of 10 academics commissioned by the public inquiry, calculated that 1,820 of those died as a result, although the number could be as high as 3,320. Its findings were based on the rate of hepatitis C infection in the population, the number of blood donations made over that time, the survival rate of the disease and other factors. It found at least 79 and possibly up to 100 people also contracted HIV through donated blood, based on data provided by the UK Health Security Agency (UKHSA), with most infections between 1985 and 1987. It said 67 people in that group had now died, although there was no data confirming the causes of death. The public inquiry into the infected blood scandal began taking evidence in 2019 and is expected to publish its final report in 2023. Read full story Source: BBC News, 17 September 2022 -
News Article
Muckamore Abbey Hospital: Bid to suspend public inquiry dismissed
Patient Safety Learning posted a news article in News
A legal bid to suspend the public inquiry into alleged abuse at Muckamore Abbey hospital has been dismissed by a High court judge. The applicant in the case has been granted anonymity. They challenged Health Minister Robin Swann's refusal to suspend the public inquiry until criminal proceedings against them had concluded. Lawyers argued that the applicant's article six right to a fair trail had been jeopardised. The applicant's lawyers cited "adverse and prejudicial" commentary already in the media. Rejecting the application the judge, Mr Justice Colton, said that the applicant's article six rights were fully protected within the criminal trial process. The judge referred to submissions from the applicant's legal team who had argued that if the inquiry recommences as planned this month, it would consider evidence reported by the media which could affect the ability of a jury to act impartially. The judge told the court there was nothing to suggest that there had been a "virulent media campaign" about the applicant. Read full story Source: BBC News, 15 September 2022 -
News ArticlePolice are preparing to investigate alleged mistreatment of patients at a mental health unit. The Edenfield Centre based in the grounds of the former Prestwich Hospital in Bury is at the centre of the claims. The unit cares for adult patients. The Manchester Evening News understands that action was taken after the BBC Panorama programme embedded a reporter undercover in the unit and then presented the NHS Trust which runs it with their evidence. A spokesperson for Greater Manchester Police said: "We are aware of the allegations and are liaising with partner agencies to safeguard vulnerable individuals and obtain all information required to open an investigation." A spokesperson for Greater Manchester Mental Health NHS Foundation Trust said: "We can confirm that BBC Panorama has contacted the Trust, following research it conducted into the Edenfield Centre. We would like to reassure patients, carers, staff, and the public that we are taking the matters raised by the BBC very seriously". "Immediate action has been taken to address the issues raised and to ensure patient safety, which is our utmost priority. We are liaising with partner agencies and stakeholders, including Greater Manchester Police. We are not able to comment any further on these matters at this stage." Read full story Source: Manchester Evening News, 14 September 2022
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News Article
Staff warned of ‘harrowing’ care standards review
Patient Safety Learning posted a news article in News
Trust staff have been warned that an independent investigation into maternity services will be ‘a harrowing read’ with a ‘profound and significant impact’. The report into services at East Kent Hospitals University Foundation Trust between 2009 and 2020 had been expected to be published on Wednesday 21 September. However, this morning families involved in the investigation received an email saying publication would be postponed to an unknown date in October.. Next Wednesday, when the report was expected to be released and a statement made to Parliament, has been set aside for all MPs to take an oath of allegiance to King Charles III. An email sent to staff at East Kent last week and seen by HSJ said publication would place “significant focus on the trust and all of our services”, and that the trust would make support available to staff as well as former, current and potential patients. The trust will not see the report before publication. The investigation – led by Dr Bill Kirkup, who also led the Morecambe Bay maternity investigation – was prompted by the death of week-old Harry Richford after a traumatic birth at the trust’s Queen Elizabeth, the Queen Mother, Hospital in Thanet in 2017. Around 200 families are thought to have contacted the investigation team with concerns around maternity care. Read full story (paywalled) Source: HSJ, 15 September 2022 -
Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation focuses on the systems used by healthcare providers to book patient appointments for clinical investigations, such as diagnostic tests and scans. ‘Clinical investigation booking systems’ are used throughout the NHS to support the delivery of patient care. Healthcare services use paper-based or fully electronic systems, or a combination of the two (hybrid systems), to communicate to patients the time, date and location of their appointment. These systems also produce information for patients about actions they need to take to prepare for their appointment. Written patient communication is a key output of clinical investigation booking systems. This investigation examines the safety implications of patient communications, produced by booking systems, that do not account for the needs of the patient. In addition, it looks at why patients are ‘lost to follow-up’ after an appointment is cancelled, rescheduled or not attended. Lost to follow-up is the term used to describe a patient who does not return for planned appointments (whether for continued care or evaluations) or is no longer being tracked in the healthcare system when they should be.
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Content ArticleA research paper was published in October 2021 highlighting results of Freedom of Information (FOI) Requests sent to NHS Trusts in England. The FOI Requests asked for the number of incidents of sexual assault reported by hospitals where the victim was aged over 60, and the alleged perpetrator was a member of staff. The resulting findings were that there were at least 75 reports of sexual assault on patients over 60 by hospital staff in the past five years. The findings also show that whilst the majority of victims were female, 30% were male and that a disappointing number were reported to police – only 16. Of these, 14 were closed as “No Further Action” by the police. In this viewpoint paper published in the Journal of Adult Protection, Amanda Warburton-Wynn highlights the findings of this research.
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Content ArticleHindsight bias (colloquially known as ‘the retrospectoscope’) is the tendency to perceive past events as more predictable than they actually were. It has been shown to play a significant role in the evaluation of an past event, and has been demonstrated in both medical and judicial settings. This study in Clinical Medicine aimed to determine whether hindsight bias impacts on retrospective case note review, through an internet survey completed by doctors of different grades. The authors found that in some cases, doctors are markedly more critical of identical healthcare when a patient dies compared to when a patient survives. Hindsight bias while reviewing care when a patient survives might prevent identification of learning arising from errors. They also suggest that hindsight bias combined with a legal duty of candour will cause families to be informed that patients died because of healthcare error when this is not a fact.
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Content ArticleOn 22 May 2021, 17-year-old Alexandra Briess underwent a tonsillectomy and subsequently experienced post-operative bleeding, requiring second operation carried out at Royal Berkshire Hospital on the 30 May. During anaesthesia, she experienced a sudden deterioration and cardiac arrest. Despite extensive resuscitation efforts, Alexandra died on the 31 May. Subsequent investigations have revealed that the most likely cause of her sudden deterioration was an anaphylactic reaction to Rocuronium. In this report, the Coroner highlights connections between this case and three other Prevention of Future Deaths Report’s and suggests there needs to be greater funding and a role within the NHS to coordinate a national approach to prevent/reduce future deaths.
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Content Article
In this blog, Olivia Lounsbury, Committee Lead for Patients for Patient Safety US's National Patient Safety Oversight committee, looks at a new Bill calling for the creation of a US National Patient Safety Board (NPSB). She outlines why the NPSB is needed and demonstrates the importance of engaging patients and families in its design and processes. Olivia also look at existing healthcare safety organisations in other countries, highlighting the opportunity that the NSPB has to benefit from their approaches. -
Content ArticleSamuel Howes was 17 when he died by suicide in September 2020. Samuel had ongoing mental health issues including anxiety and depression. This led to his use of drugs and dependency on alcohol, which in turn further worsened his mental health. This blog by his mother Suzanne details her experience of the final day of the inquest into her son's death, which found multiple failings on the part of Child and Adolescent Mental Health Services (CAMHS), social services and the police.
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Content ArticleClinicians in emergency departments (EDs) will see babies and young children with injuries that may be non-accidental. If the cause of such injuries is missed, there is a risk of further harm to the child. However, making a judgement about whether an injury might be accidental or not is complex and difficult. This Healthcare Safety Investigation Branch (HSIB) investigation explores the issues that influence the diagnosis of non-accidental injuries in infants (children under 1 year of age) who visit an ED. Specifically, it explores the information and support available to ED clinicians to help them to make such a diagnosis. Due to the nature of the subject matter no specific incident was used to explore this area of care. Instead, the investigation analysed 10 serious incident reports (reports written by NHS trusts when a serious patient safety incident occurs) to identify the factors that contribute to non-accidental injuries not being diagnosed. These factors were grouped into themes, which informed the terms of reference for the investigation.
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Content ArticleNine care home workers are facing trial for neglecting, verbally abusing and deliberately antagonising extremely vulnerable patients at Whorlton Hall. The six men and three women, aged 25-54, are being prosecuted after a reporter went undercover and filmed the behaviour for a BBC Panorama documentary. George Julian repots on the case at Teesside crown court in Middlesbrough.
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Content ArticleSometimes after an incident, a system-wide change is implemented that makes work more difficult and creates new problems. This story from aviation is one such example, which contains useful lessons for responding to rare events. Steven Shorrock recounts the tale.
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Content Article
In this blog, Steve Turner reflects on why genuine patient safety whistleblowers are so frequently ignored, side-lined or victimised. Why staff don't speak out, why measures to change this have not worked and, in some cases, have exacerbated the problems. Steve concludes with optimism that new legislation going through Parliament offers a way forward from which everyone will benefit.- Posted
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) will transition into new arms-length body The Healthcare Services Safety Investigation Body (HSSIB) in October 2023. In this article, HSSIB's Chair Designate, Ted Baker, reflects on: how the Francis Inquiry was instrumental in changing the view of patient safety in the NHS. the role of HSIB over the last five years in identifying systemic causes of patient harm. what the future holds for HSSIB.
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Content ArticleThis blog by Dr Georgia Richards looks at the system of learning from preventable deaths in the UK. She highlights that following the publication of a Prevention of Future Deaths report (PFD), there is no system in place to ensure responses are received and actions are taken. She then describes how the Preventable Deaths Tracker collects information from PFDs to screen and analyse preventable deaths, so that lessons can be learnt
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Content ArticleNHS Wales has published a new report detailing the good progress being made to investigate and learn from hospital-acquired COVID-19 in Wales. Established in April 2022, the National Nosocomial COVID-19 Programme is supporting NHS Wales organisations to carry out a review of nosocomial (hospital acquired) COVID-19 patient safety incidents that occurred between March 2020 and April 2022. The programme has prioritised the investigation of the most complex cases, with an aim to provide as many answers as possible for service users, families, carers and staff impacted by nosocomial COVID-19. The programme also aims to maximise learning opportunities across NHS Wales, to drive quality and safety improvements.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation aims to improve patient safety by supporting healthcare staff in the safe use of central venous catheters to access a patient’s blood supply. Specifically, it looks into the use of tunnelled haemodialysis central venous catheters, which are a type of central line. The reference event involved Joan, who had a cardiac arrest caused by an air embolus after her haemodialysis catheter was uncapped, unclamped, and left open to air. This took place during a procedure to take blood culture samples to test for a possible line infection (where bacteria or viruses enter the bloodstream). This investigation’s findings, safety recommendations and safety observations aim to prevent the future occurrence of an air embolus following uncapped and unclamped haemodialysis catheters, and to improve care for patients across the NHS.
