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News Article
Young mother reveals sepsis warning signs after losing both feet and 10 fingers
Patient Safety Learning posted a news article in News
A young mother lost both her feet and all 10 fingers to sepsis after a significant delay in treatment, an investigation has found. Sadie Kemp has been left permanently disabled from the “dangerous condition”, whilst an NHS hospital probe found a 3.5 hour delay in starting her care. Sadie is now calling for lessons to be learned after the internal report found numerous concerns in her treatment that ultimately led to her needing multiple amputations. The 35-year-old mother-of-two first attended A&E with agonising back pain caused by a kidney stone on Christmas night 2021. She was given pain relief at Hinchingbrooke Hospital, Cambridgeshire, and sent home to return the following morning for a kidney scan. She returned the same night at 4am as her pain endured. An assessment at 5.40am found she may have also been suffering from sepsis, but the step-by-step guide to chart and treat the illness was not found in her notes as being done at the time. The investigation found not only should the sepsis have been discovered and treated sooner, but the “lack of effective treatment” of the sepsis prior to the surgery meant she needed prolonged critical care. Read full story Source: The Independent, 22 November 2022 -
News ArticleWhen David Morganti’s case notes landed on Andrew Cox’s desk this autumn they told a devastating story — but one which was depressingly familiar to the senior coroner for Cornwall. The 87-year-old RAF veteran had fallen and hit his head in the bathroom of the house he shared with his wife, Valerie, in April. It took nine hours for paramedics to reach their home near St Austell, Cornwall. As they waited, the bleeding on his brain became gradually worse until he lost consciousness. By the time he reached hospital it was too late. An expert neurosurgeon told Cox that had he reached hospital faster, Morganti might have survived. The coroner said the effects of the injuries he suffered were likely to have been exacerbated “by a delay in the arrival of an ambulance and his subsequent admission into hospital.” It was the latest in a series of similar deaths the coroner had encountered. After Morganti’s inquest, Cox resolved to carry out a wider investigation into what appeared to be a broken system. He has now sent his findings to Steve Barclay, the health secretary, and demanded he act to prevent more deaths. Read full story (paywalled) Source: The Times, 19 November 2022
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News Article
Harrowing ‘systemic abuse’ at children’s hospitals revealed
Patient Safety Learning posted a news article in News
Children 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. 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, 17 November 2022 -
News Article
US Senate investigates ‘catastrophic failure’ to protect female migrant detainees
Patient Safety Learning posted a news article in News
A US Senate investigation into allegations that unwanted medical procedures were performed on detained female immigrants in Georgia has uncovered “a catastrophic failure by the federal government” to protect the detainees. A Senate hearing on Tuesday by the bipartisan permanent subcommittee on investigations (PSI), chaired by the Georgia senator Jon Ossoff, announced its findings on conditions and practices at the Irwin county detention center (ICDC). The ICDC, located in Ocilla, Georgia, housed detainees who shared accounts of poor treatment including gynaecological procedures that were “excessive, invasive and often unnecessary”. An account of what was occurring at the ICDC first came to light when Dawn Wooten, a nurse at the facility, acted as a whistleblower. Ossoff called the alleged unnecessary and sometimes non-consensual medical treatment and procedures disclosed in the 18-month investigation “nightmarish and disgraceful”. Ossoff said: “This is an extraordinarily disturbing finding, and in my view represents a catastrophic failure by the federal government to respect basic human rights.” The report detailed the harrowing account of an unnamed woman who was detained in the ICDC in 2020. The detainee describes how Dr Mahendra Amin allegedly removed a portion of her fallopian tube, a result of a dilation and curettage procedure she was not made aware of, and how Amin told her “she would never be able to have children naturally again”. Read full story Source: The Guardian, 15 November 2022 -
News Article
Orthodontist advised treatment with risk of harm to children, tribunal told
Patient Safety Learning posted a news article in News
An orthodontist whose methods around shaping the jawline have gone viral advised treatment to young children that “carried a risk of harm”, a tribunal has heard. Dr Mike Mew, whose “mewing” techniques have racked up nearly 2 biillion views on TikTok, faces a misconduct hearing at the General Dental Council (GDC). Opening the hearing in central London on Monday, Lydia Barnfather, representing the GDC, said comments made by Mew, who claims to help “alter the cranial facial structure” on his YouTube channel, were “pejorative” about orthodontists. Barnfather told the professional conduct committee that Mew seeks to treat children with “head and neck gear” and “lower and upper arch expansion appliances” to help align teeth and shape the jawline. “The GDC alleges this is not only very protracted, expensive, uncomfortable and highly demanding of the child, but it carries the risk of harm", Barnfather said. It was heard that between September 2013 and May 2019, advice and treatment were provided to two children, referred to as Patient A and Patient B. Mew was accused of failing to “carry out appropriate monitoring” of their treatment and “ought to have known” this was liable to cause harm. Barnfather said: “The GDC allege you are not to have treated patients the way you did.” She argued that both children had “perfectly normal cranial facial development for their age” before treatment took place. She added that the treatment was “not clinically indicated” and that Mew “had no adequate objective evidence” it would achieve its aims. Read full story Source: The Guardian, 14 November 2022 -
News Article
Dr Heather Steen to be removed from medical register
Patient Safety Learning posted a news article in News
A senior doctor is to be removed from the medical register after she was found to have attempted to cover-up the circumstances of a young girl's death. Paediatrics consultant Dr Heather Steen was found to be unfit to practise after an investigation into the death of nine-year-old Claire Roberts in 1996. A medical tribunal examining the doctor's case ruled that the majority of allegations against her were true. Claire's mother said it was "just the start of getting full justice". "I am angry at Dr Steen for putting us through 26 years of mental torment," said Jennifer Roberts. At the time of Claire's death, her parents were told she had a viral infection that had spread from her stomach to her brain. But in 2018 a public inquiry determined that she had died from an overdose of fluids and medication caused by negligent care at the Royal Belfast Hospital for Sick Children. The inquiry also concluded there had been "cover up" and the girl's death had not been referred to the coroner immediately to "avoid scrutiny". The case was then put to the Medical Practitioners Tribunal Service (MPTS), which rules on doctors' fitness to practise. When the case reached the tribunal stage Dr Steen twice applied to be voluntarily removed from the medical register and was twice refused. Had that been successful the tribunal would have been halted as she would no longer have been a doctor. However the tribunal continued and examined allegations that between October 1996 and May 2006 Dr Steen "knowingly and dishonestly carried out several actions to conceal the true circumstances" of Claire. Read full story Source: BBC News, 11 November 2022 -
News Article
Swab 'left inside patient for months after surgery'
Patient Safety Learning posted a news article in News
A consultant urologist left a 6.5cm swab in a patient after surgery and failed to identify it in a scan three months later, an inquiry has heard. The public inquiry concerns the work of Aidan O'Brien at the Southern Trust between January 2019 and June 2020. It heard Mr O'Brien endangered or potentially endangered lives by failing to review medical scans. He previously claimed the trust provided an "unsafe" service and was trying to shift blame on to its medics. On Tuesday, the inquiry into Mr O'Brien's clinical practice heard almost 600 patients received "suboptimal care". Counsel for the inquiry Martin Wolfe KC said the 6.5cm swab was left inside a patient by Mr O'Brien during a bladder tumour operation in July 2009. The error was described as a "never event'. At a CT scan appointment three months later in October 2009, a mass inside the patient's body was discovered by the reporting consultant radiologist. While he did not say it was a swab, he did "highlight the abnormality", said Mr Wolfe. A report was sent to Mr O'Brien but, the Inquiry heard, he did not read it and no one took steps to check out the abnormality. Read full story Source: BBC News, 9 November 2022 -
News Article
1 in 3 infected with HIV in blood scandal was a child
Patient Safety Learning posted a news article in News
Almost one out of every three people infected with HIV through contaminated NHS blood products in the 1970s and 80s was a child, research has found. About 380 children with haemophilia and other blood disorders are now thought to have contracted the virus. The new estimate was produced by the public inquiry into the disaster, after a BBC News report into the scandal. In August, the government agreed to pay survivors and the partners of those who died compensation. The first interim payments of £100,000 per person were made last month. The initial agreement does not cover bereaved parents or the children of those who have died. A wider announcement on compensation is expected when the inquiry concludes, next year. Read full story Source: BBC News, 9 November 2022 -
News Article
Death of three-day-old baby ‘avoidable’, coroner rules
Patient Safety Learning posted a news article in News
The death of a three-day-old baby could have been avoided if medical professionals had acted differently, a coroner concluded. Rosanna Matthews died three days after being delivered at Tunbridge Wells Hospital in Kent in November 2020. The hospital trust apologised, saying the level of care for Ms Sala and her daughter “fell short of standards”. Ms Sala told the inquest midwives were "bickering" and appeared confused during her labour. She claimed that if she had been allowed to start pushing when she wanted to, instead of waiting as midwives advised, Rosanna would have lived. Rachel Thomas, then deputy head of gynaecology and midwifery, said there had been "errors in communication". Following the conclusion of the inquest, the coroner ruled Rosanna died following a “prolonged period of avoidable hypoxia”, which led to brain damage. The coroner, sitting in Maidstone, also found midwives at the hospital failed to recognise that Rosanna was already unwell with congenital pneumonia. Ms Sala said her daughter could have lived had medical professionals acted differently on the day of her birth. Read full story Source: BBC News, 8 November 2022 -
News Article
Landlord was warned of mould that killed toddler in Rochdale flat
Patient Safety Learning posted a news article in News
A health visitor wrote to housing officials expressing concern about conditions in a rented flat months before a two-year-old died after his exposure to mould. An inquest in Rochdale is investigating the death of toddler Awaab Ishak who lived with his mother and father in a one-bedroom housing estate flat managed by Rochdale Boroughwide Housing (RBH). Awaab’s father, Faisal Abdullah, first reported the damp and mould in autumn 2017, a year before the birth of his son. He made numerous complaints – phoning and emailing – and requested re-housing. In December 2020 Awaab developed flu-like symptoms and had difficulty breathing. He was given hospital treatment and then discharged. Two days later his condition at home worsened and he was seen at Rochdale urgent care centre where he was found to be in respiratory failure. He was transferred to Royal Oldham hospital where, upon arrival, he was in cardiac arrest and died. It was just a week after his second birthday. A pathologist told the inquest that the child’s throat was swollen to an extent it would compromise breathing. Exposure to fungi was the most plausible explanation for the inflammation. Lawyers for the family say the inquest will consider a number of matters including concerns about mould and damp and how they were dealt with. It will also look at the sharing of information between agencies and how the family’s cultural and language requirements were taken into account. Officials from RBH have yet to give evidence at the inquest but a statement was provided to the coroner on Tuesday in which RBH admits it “should have taken responsibility for the mould issues and undertaken a more proactive response”. Read full story Source: The Guardian, 8 November 2022 -
News Article
‘Squashed’ breathing tube may have caused teenager’s death, inquest hears
Patient Safety Learning posted a news article in News
A teenager died after a breathing tube was possibly squashed by a wheel of her hospital trolley during emergency surgery, an inquest has heard. Jasmine Hill, 19, had a cardiac arrest shortly after undergoing a procedure on her neck at Gloucestershire royal hospital in Gloucester. The inquest heard that a report commissioned by lawyers acting for Hill’s family referred to the tube being “squashed by the wheel of a trolley”. Hill, from Cirencester, had been readmitted to the hospital after her neck became swollen five days after a thyroidectomy – the removal of all or part of the thyroid gland – in September 2020. Doctors thought the site of the surgery in Hill’s neck, which was red and swollen, may have become infected and it was decided the wound should be cleaned under general anaesthetic. The procedure took less than an hour and the teenager went into cardiac arrest shortly after she was moved by staff from the operating table to a bed. Gloucestershire coroner’s court heard an endotracheal tube, which supports breathing, was positioned behind Hill’s head and away from her neck, fixed to a holder and connected to the ventilator. The assistant Gloucestershire coroner Roland Wooderson asked Dr Hiro Ishii, who carried out the procedure, whether he was aware that the anaesthetist had checked the position of the endotracheal tube. Ishii replied: “I didn’t make a formal inquiry at that stage.” Read full story Source: The Guardian, 7 November 2022 -
News Article
NHSE investigates concerns over-65s have received ineffective flu jab
Patient Safety Learning posted a news article in News
NHS England is investigating a “potential serious incident” in its flu programme following concerns that people aged 65 and over are being given a vaccination jab known to be ineffective for this age group. Details of the investigation were set out in a letter by NHS England’s South East regional team. The letter, seen by HSJ, said: “The NHS regional direct commissioning team are investigating reported administration of QIVe flu vaccine to patients aged 65 years or older by a number of primary care providers (primary care and pharmacy) across the region. QIVe is not recommended for use in this age group due to its poor effectiveness.” It said officials were contacting practices and pharmacists directly where there was a record of QIVe vaccine having been given to the older age cohort to identify whether this is a recording coding error, or a genuine administration of QIVe. Initial investigations “suggest a mixture of both”, it said. The letter added: “If any patient 65 or over has received QIVe, we will be asking the practice or pharmacist to treat this as an incident. Patients will need to be contacted, informed of the error, its potential implications and offered the opportunity to receive a vaccine which is appropriate for their age group." It is unclear how many patients have been given the wrong jab. Read full story Source: HSJ, 8 November 2022 -
News Article
West Lane Hospital: Staff concerns 'ignored' at Middlesbrough site
Patient Safety Learning posted a news article in News
A whistleblower at a mental health trust criticised over the deaths of three teenagers has said bosses ignored workers when they raised concerns. Christie Harnett and Nadia Sharif, both 17, and Emily Moore, 18, who were friends, all took their own lives within eight months of each other. The whistleblower said agency workers fell asleep on duty at Middlesbrough's West Lane Hospital and staff struggled "to keep children alive". The trust has apologised for failings. Reports into the women's care found 120 failings at Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV), which ran the hospital, and other agencies. Speaking after the reports were published, the health trust worker, who did not wish to be identified, told the BBC staff were "ignored" when they tried to warn bosses about conditions in the hospital. "Staff repeatedly raised concerns with managers, some of the time we just didn't have enough staff to keep the children safe," the worker said. "We warned them something serious was going to happen, but they just ignored us. "Senior managers looked at numbers, rather than the skillset that staff actually had. "The agency staff would sometimes fall asleep on duty or watch the telly rather than engage with patients." Read full story Source: BBC News, 4 November 2022 -
News Article
Trusts should seek extra funding to be ready for major incidents, says inquiry
Patient Safety Learning posted a news article in News
Ambulance trusts should review their ability to respond to mass casualty incidents and press commissioners for any additional resources they need, the report into the Manchester Arena bombing has said. Only 7 of the 319 North West Ambulance Service Trust vehicles available on the night of the attack, in 2017, were able to deploy immediately, the report said. It said experts believed that “such a situation would almost inevitably be replicated if a similar incident were to occur again anywhere in the country”, given current resources and demand. Ambulance trusts are now hugely more stretched than in 2017, with response times having significantly lengthened due to lack of resources. The second volume of the report from the inquiry, chaired by Sir John Saunders, published today, is critical of the emergency services’ response to the bombing which killed 22 people. NWAS “failed to send sufficient paramedics into the City Room [an area adjoining the Arena]” and did not use available stretchers to remove casualties in a safe way, it says. A key role for managing the incident – that of ambulance intervention team commander – was not allocated for half an hour. But it also raised issues of ambulance capacity and availability for major incidents involving mass casualties. “Around the UK, ambulance services are always ’playing catch up,’” it said, with no spare frontline capacity. With demand doubling over the last 10 years, the inability to respond to such incidents is only going to get worse – and lives will be lost if they do not attend the scene quickly and in sufficient numbers, the report said. Read full story (paywalled) Source: HSJ, 3 November 2022 -
News Article
Ministers may order inquiry or review over English mental health care failings
Patient Safety Learning posted a news article in News
Ministers may order a public inquiry into mental health care and patient deaths across England because of the number of scandals that are emerging involving poor treatment. Maria Caulfield, the minister for mental health, told MPs on Thursday that she and the health secretary, Steve Barclay, were considering whether to launch an inquiry because the same failings were occurring so often in so many different parts of the country. They would make a final decision “in the coming days”, she said in the House of Commons, responding to an urgent question tabled by her Labour shadow, Dr Rosena Allin-Khan. An independent investigation found this week that that three teenage girls – Christie Harnett, 17, Nadia Sharif, 17, and Emily Moore, 18 – took their own lives within the space of eight months after receiving inadequate care from the Tees, Esk and Wear Valleys (TEWV) NHS mental health trust in north-east England. They died after “multifaceted and systemic failings” by the trust, especially at its West Lane hospital in Middlesbrough, the inquiry found. Allin-Khan pointed to a series of scandals that have come to light, often through media investigations, about dangerously substandard mental health care being provided by NHS services and also private firms in England, including in Essex and in Greater Manchester. “Patients are dying, being bullied, dehumanised, abused and their medical records are being falsified, a scandalous breach of patient safety,” Allin-Khan said. “The government has failed to learn from past failings.” Read full story Source: The Guardian, 3 November 2022 -
News Article
Damning report on surgeon's botched operations
Patient Safety Learning posted a news article in News
A damning report has highlighted failures in how NHS Tayside oversaw a surgeon who harmed patients for years. Prof Eljamel, the former head of neurosurgery at NHS Tayside in Dundee, harmed dozens of patients before he was suspended in 2013. The internal Scottish government report into Prof Sam Eljamel, which has been leaked to the BBC, said the health board repeatedly let patients down. It outlined failures in the way Prof Eljamel was supervised and the board's communication with patients. The report was commissioned last year over unanswered questions and concerns from patients Jules Rose and Pat Kelly. Mr Kelly has been left housebound and Ms Rose has PTSD after the neurosurgeon removed the wrong part of her body. After her operation in 2013, Ms Rose discovered that Prof Eljamel had taken out the wrong part of her body. He removed her tear gland instead of a tumour on her brain. She still has not been told exactly when health bosses knew he was a risk to patients. The latest Scottish government report said she should receive an apology. The written apology she received from the board last month said it was sorry she "feels" there has been a breakdown in trust. "I actually rejected the apology," she said. Ms Rose said she wanted the chairwoman of the health board to explain why it will not offer a "whole-hearted apology" for its failures. Scottish Conservative MSP Liz Smith called for a public inquiry, saying there had been a lack of accountability and the investigation had still not got to the truth. Read full story Source: BBC News, 3 November 2022 -
News Article
Three girls died after major failings in NHS mental health care, inquiry finds
Patient Safety Learning posted a news article in News
Three teenage girls died after major failings in the care they received from NHS mental health services in the north-east of England, an independent investigation has found. “Multifaceted and systemic” failures by the Tees, Esk and Wear Valleys (TEWV) NHS trust contributed to the young women’s self-inflicted deaths within eight months of each other, it concluded. Christie Harnett died aged 17 on 27 June 2019 at the trust’s West Lane hospital in Middlesbrough. Nadia Sharif, also 17, died there six weeks later, on 5 August. Emily Moore, who had been treated there, died on 15 February 2020 at a different hospital in Durham. All three had complex mental health problems and had been receiving NHS care for several years. The investigation into their deaths, commissioned by the NHS, found that 119 “care and service delivery problems” by NHS services, especially TEWV, had occurred. Charlotte and Michael Harnett, Christie’s parents, said their daughter had “lost her life whilst in a hospital run by TEWV trust where there was little or no care or compassion”. Emily’s parents, David and Susan Moore, said she received “horrific care” while at West Lane. Services at the hospital were understaffed, “unstable and overstretched”, the investigation’s final report found. Both families, and also Nadia’s parents, Hakeel and Arshad Sharif, said the dangerous inadequacy of the care provided by TEWV, and the likelihood that other patients with fragile mental health had died as a result, showed that ministers should order a full public inquiry. “This mental health trust is a danger to the public,” the Moores said. The report said TEWV failed to properly monitor the girls, given their known risk of self-harm; to take seriously concerns about their care and suicide risk raised by their families; and to remove all potential ligature points. Read full story Source: The Guardian, 2 November 2022 -
News ArticleTheresa May has urged the government to consider “redress” for the victims of a hormone pregnancy test blamed for causing serious birth defects. The former prime minister said that while Primodos victims had received an apology, “lives have suffered as a result” of the drug’s use. In an interview for a Sky News documentary, she praised campaigners who had been “beating their head against a brick wall of the state” which tried to “stop them in their tracks”. A review in 2017 found that scientific evidence did “not support a causal association” between the use of hormone pregnancy tests such as Primodos and birth defects or miscarriage. But Ms May ordered a second review in 2018, because, she said, she felt that it “wasn’t the slam-dunk answer that people said it was”. “At one point it says that they could not find a causal association between Primodos and congenital anomalies, but neither could they categorically say that there was no causal link,” she said. The second review concluded last month that there had been “avoidable harm” caused by Primodos and two other products – sodium valproate and vaginal mesh. An interview for Bitter Pill: Primodos, which will air on Sky Documentaries, Ms May said: “I think it’s important that the government looks at the whole question of redress and about how that redress can be brought up for people. Read full story Source: The Independent, 28 August 2020
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News ArticleA nurse in the US sued Louisville, Ky.-based Kindred Healthcare this week, alleging the organisation fired him in retaliation for raising patient safety concerns. Sean Kinnie worked as an intensive care unit nurse at Kindred Hospital-San Antonio. Mr Kinnie claims he was suspended twice and then fired after leaders at the 59-bed transitional care hospital learned he anonymously reported patient safety concerns to The Joint Commission in November 2019 and January. Mr Kinnie said issues related to inadequate staffing and unsanitary care environments put patients in "grave danger," according to the lawsuit. He also said the hospital created a culture in which employees were afraid to stand up for patients for fear of retaliation from management. In January, Mr Kinnie told the hospital's chief clinical officer Sharon Danieliewicz that he was the staff member who reported the patient safety concerns to The Joint Commission. Mr. Kinnie claims he faced increased scrutiny after this disclosure and was ultimately fired Feb. 24 for violating facility policy. Read full story Source: Becker's Hospital Review, 24 August 2020
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News Article
Unclear UK advice on PPE cited in home care COVID-19 death inquiry
Patient Safety Learning posted a news article in News
A home care worker who did not wear protective equipment may have infected a client with a fatal case of coronavirus during weeks of contradictory government guidance on whether the kit was needed or not, an official investigation has found. The government’s confusion about how much protection care workers visiting homes needed is detailed in a report into the death of an unnamed person by the Healthcare Safety Investigation Branch (HSIB), which conducts independent investigations of patient safety concerns in NHS-funded care in England. It was responding to a complaint raised by a member of the public in April. The report shows that Public Health England published two contradictory documents that month. One advised care workers making home visits to wear PPE and the other did not mention the need. The contradiction was not cleared up for six weeks. The government’s guidance had been a shambles that had placed workers and their vulnerable clients at risk, the policy director at the United Kingdom Homecare Association, Colin Angel, said on Wednesday. The association also accused the government of sidelining its expertise and publishing new guidance with little notice, sometimes late on Friday nights, meaning that it was not always noticed by the people it was intended for. -
News Article
Trust warned after CQC’s ‘serious concerns’ for patients
Patient Safety Learning posted a news article in News
Safety inspectors have ordered a mental health trust to make immediate improvements after visiting two inpatient wards where three patients died inside six months. The Care Quality Commission this week warned Devon Partnership Trust it would take “urgent action” over “serious concerns about patients” unless the trust made the required improvements swiftly. The watchdog inspected the trust’s Delderfield and Moorland wards in June following concerns about three patient deaths in September, October and March, along with “a number of” patient safety incidents - including ligature incidents. The CQC also highlighted poor patient observation routines and a lack of learning from previous incidents, amid delays in completing investigations into safety incidents. Read full story Source: HSJ, 21 August 2020 -
News ArticleA healthcare professional is facing a fitness to practise investigation for delaying attending to a COVID-19 positive patient because of inadequate personal protective equipment (PPE), in what may be the first case of its kind. The revelation came from a healthcare regulatory solicitor, Andrea James, who tweeted, “Was expecting it, but still disgusted to have received first #FitnessToPractise case arising from NHS trust disciplining healthcare professional who expressed concern about/delayed attending to a Covid+ patient without PPE (NHS Trust having failed to provide said PPE). For shame.” Doctors and nurses reacted with outrage to the tweet, and the Medical Protection Society issued a strong statement condemning the move. But James said that her client wanted to remain anonymous and declined to identify the profession or the regulator involved. She said that the treatment in question was expected to be an aerosol generating procedure. Rob Hendry, medical director at the Medical Protection Society (MPS), said, “It is appalling enough that healthcare professionals are placed in the position of having to choose between treating patients and keeping themselves and their other patients safe. The stress should not be compounded by the prospect of being brought before a regulatory or disciplinary tribunal. “MPS members who are faced with regulatory or employment action arising from a decision to not see a patient due to lack of PPE can come to us for advice and representation. However, it should not come to this: healthcare workers should not be held personally accountable for decisions or adverse outcomes that are ultimately the result of poor PPE provision.” Read full story Source: BMJ, 12 August 2020
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News Article
Regulator launches independent review into care of vulnerable man
Patient Safety Learning posted a news article in News
NHS England and Improvement have launched an independent review into the care and death of a man with learning disabilities, following concerns raised by HSJ. The regulator has appointed Beverley Dawkins to carry out an independent review of the case of Clive Treacy, as part of the learning disability mortality review programme. Clive, who died in 2017, had previously been denied a review under LeDer and, according to emails seen by HSJ, his death was never officially recorded by the programme, which is meant to record all deaths of people with a learning disability. NHS England and Improvement overturned the decision earlier this year after HSJ presented evidence of a series of failures in his care between 2012 and 2017. Today, it was confirmed to us that Ms Dawkins has been commissioned to carry out the review, and that it would review his care throughout his life, as well as his death. Read full story Source: HSJ, 23 July 2020 -
News Article
Shrewsbury maternity scandal: Hospital bosses ‘softened’ damning safety report
Patient Safety Learning posted a news article in News
Hospital bosses at scandal-hit Shrewsbury and Telford Hospital Trust were more concerned with reputation management than addressing patient safety concerns in its maternity department, according to a new NHS investigation. Families harmed by poor care at the trust have called for chairman Ben Reid to resign after the report by NHS England revealed how senior figures in the trust, including the former chief executive, tried to soften a report into maternity services that raised serious concerns over safety. The Royal College of Obstetricians and Gynaecologists (RCOG) report was not published until after the college had agreed to an “unprecedented” addendum report 12 months after its inspection in 2017, that presented the trust in a more positive light. When the final report was made public in July 2018 the addendum was placed at the front of the report. The original RCOG report warned: “Neonatal and perinatal mortality rates will not improve until areas of poor / substandard care are addressed.” Read full story Source: The Independent, 22 July 2020 -
News Article
Hundreds more potentially avoidable baby deaths found at Shropshire NHS trust
Patient Safety Learning posted a news article in News
Hundreds more cases of potentially avoidable baby deaths, stillbirths and brain damage have emerged at an NHS trust, raising concerns about a possible cover-up of the true extent of one the biggest scandals in the health service’s history. The additional 496 cases raise further serious concerns about maternity care at Shrewsbury and Telford hospital NHS trust since 2000. The cases involving stillbirths, neonatal deaths or baby brain damage, as well as a small number of maternal deaths, have been passed to an independent maternity review, led by the midwifery expert Donna Ockenden. They bring the total number of cases being examined to 1,862. They will also be passed to West Mercia police, which last month launched a criminal investigation into the trust’s maternity services. Detectives are trying to establish whether there is enough evidence to bring charges of corporate manslaughter against the trust or individual manslaughter charges against staff involved. The extra 496 cases had not emerged until now because an “open book” initiative led by the NHS in 2018 asked only for digital records of cases identified as a cause for serious concerns. The vast majority of the 496 further cases were recorded only in paper documents. Read full story Source: The Guardian, 21 July 2020
