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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 -
News Article
NHS staff to receive ‘air accident’ safety training to reduce patient harm
Patient Safety Learning posted a news article in News
Frontline NHS staff will be given specialist ‘air accident investigation’ style training to help improve the way the health service learns from patient safety incidents. Cranfield University, which has been training air, maritime and rail safety investigators for more than 40 years, is to launch the first intensive course for NHS staff responsible for investigating safety incidents in hospitals. It is part of a growing effort to install a safety science approach to avoidable harm in the NHS, with the service increasingly looking to other industries to adopt new approaches based on the science of human factors and just culture. Traditionally the NHS has focused on simpler investigations that too often miss systemic causes of mistakes and instead target individual nurses and doctors for blame. The new one week intensive course, run in partnership with the charity Baby Lifeline, will start in January and will give students a basic grounding in the science of investigation and using real-life actors and a maternity based scenario, show participants how to get to the real causes of what went wrong. Read full story Source: The Independent, 20 July 2020 -
News Article
Patient safety - will there be a big step forward?
Patient Safety Learning posted a news article in News
The list is a dismal and shameful one - Mid-Staffordshire, Morecambe Bay, the rogue surgeon Ian Paterson, maternity care at the Shrewsbury and Telford. All are patient safety scandals involving tragic stories of life-changing mistreatment of patients and, in some cases, the loss of loved ones. Pledges have been made that patient safety will be put front and centre of health policy. New regulators have been put in place. But now yet another review has found the health system in England to be "disjointed, siloised and defensive" and that the culture needs a shake-up. It has called for a new patient safety champion with legal powers to be put in place. The plan is to have an individual with "real standing" outside and independent of the system, accountable to the parliamentary Health and Social Care Select Committee. The Commissioner would be expected to take up and investigate patient complaints where appropriate, and hold organisations to account - the review had stated that the failure of health authorities to respond to concerns was a recurrent theme. Read full story Source: BBC News, 8 July 2020 -
News ArticleA hospital trust at the centre of Britain’s largest ever maternity scandal has widespread failings across departments and is getting worse, the care regulator has warned as it calls for NHS bosses to take urgent action. Ted Baker, chief inspector of hospitals, urged NHS England to intervene over the “worsening picture” at Shrewsbury and Telford Hospital Trust, which is already facing a criminal investigation. There are as many as 1,500 cases being examined after mothers and babies died and were left with serious disabilities due to poor care going back decades in the trust’s maternity units. Now, in a leaked letter seen by The Independent, Prof Baker has warned national health chiefs that issues are still present today across wards at the trust – with inspectors uncovering poor care in recent visits that led to “continued and unnecessary harm” for patients. He raised the prospect that the Care Quality Commission (CQC) could recommend the trust be placed into special administration for safety reasons, which has only been done once in the history of the NHS – at the former Mid Staffordshire NHS Trust, where a public inquiry found hundreds of patients suffered avoidable harm and neglect because of widespread systemic poor care. In a rarely seen intervention, Prof Baker’s letter to NHS England’s chief operating officer, Amanda Pritchard, warned there were “ongoing and escalating concerns regarding patient safety” and that poor care was becoming “normalised” at the trust, which serves half a million people with its two hospitals – the Royal Shrewsbury and Telford’s Princess Royal. Read full story Source: The Independent, 16 July 2020
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News ArticleAcross the country there have been reports of “do not resuscitate” (DNR) orders being imposed on patients with no consultation, as is their legal right, or after a few minutes on the phone as part of a blanket process. Laurence Carr, a former detective chief superintendent for Merseyside Police, is still angry over the actions of doctors at Warrington Hospital who imposed an unlawful “do not resuscitate” order on his sister, Maria, aged 64. She has mental health problems and lacks the capacity to be consulted or make decisions and has been living in a care home for 20 years. As her main relative, Mr Carr found out about the notice on her records only when she was discharged to a different hospital a week later. Maria had been admitted for a urinary tract infection at the end of March. Although she has diabetes and an infection on her leg her condition was not life threatening. Mr Carr said: “My sister has no capacity to effectively be consulted due to her mental illness and would not understand if they did try to explain, so I was furious that I had not been consulted." He later learnt that the reason given by the hospital for imposing the DNR was "multiple comorbitidies". In a statement, Warrington and Halton Teaching Hospitals Foundation Trust said it was fully aware of the law, which was reflected in its policies and regular training. It said: “We did not follow our own policy in this case and have the requisite discussions with the family. The template form which was completed in this case indicates that discussion with the family was ‘awaiting’. Regretfully due to human error this did not occur." Mr Carr and his sister are not alone. National charity Turning Point said it had learnt of 19 inappropriate DNARs from families, while Learning Disability England said almost one-fifth of its members had reported DNARs placed in people’s medical records without consultation during March and April. Read full story Source: The Independent, 14 July 2020
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News Article
Trust failed to complete 21 instructions from safety review
Patient Safety Learning posted a news article in News
Only two out of 23 recommendations from a royal college review into a trust’s troubled maternity services can be shown to be fully implemented, a new investigation has revealed. A learning and review committee, set up by East Kent Hospitals University Foundation Trust, found that 11 more of the recommendations from a 2016 review by the Royal College of Obstetricians and Gynaecologists (RCOG) were “partially” implemented. But it said there was either no evidence the remaining 10 had been delivered, or there was evidence they were not implemented. The original RCOG review looked at a number of cases where babies had died as well as broader issues within the maternity service at the trust. The committee was set up after an inquest into the death of Harry Richford, who died a week after his birth in 2017 at the trust’s Queen Elizabeth, the Queen Mother, Hospital in Thanet. Many of the issues which came to light at his inquest echoed those from the RCOG report. Committee chair Des Holden, medical director of Kent Surrey Sussex Academic Health Science Network, highlighted the difficulties in tracking evidence and action plans during a time when the trust had significant changes in leadership. But he said the committee felt cases where evidence could not be found or the standard of evidence gave concern, the recommendations could not be said to be met. Derek Richford, Harry’s grandfather, said on behalf of the family: “We are saddened and shocked to find that over four years after the RCOG found fundamental systemic failings and made 23 recommendations, only two have been completed. It is not good enough for them to now say ‘leadership has changed’. The main board must take responsibility and be held to account.” Read full story (paywalled) Source: HSJ, 13 July 2020 -
News ArticleDaniel Mason was born half a century ago without hands, with missing toes, a malformed mouth and impaired vision. From an early age, he and his family had to deal with people asking about his disabilities. The impact on his life has been considerable. Daniel’s mother Daphne long suspected the cause of his problems was a powerful hormone tablet called Primodos that was given to women to determine whether they were pregnant. But when she raised her concerns with doctors, they were dismissed. Now, at last, Daphne has been vindicated with official confirmation this week that her fears were right, in the landmark review by Baroness Cumberlege into three separate health scandals that has exposed a litany of shameful failings by the NHS, regulatory authorities and private hospitals. This damning report shows again the danger of placing a public service on a pedestal, with politicians happy to spout platitudes but scared to tackle systemic problems or confront the medical establishment. But how many more of these inquiries must be held? How many more disturbing reports and reviews must be written? How many more times must we listen to ministerial apologies to betrayed patients? How much more must we hear of ‘lessons being learned’ when clearly they are largely ignored? Read full story Source: Mail Online, 9 July 2020
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News Article
MHRA's response to the Cumberlege report
Patient Safety Learning posted a news article in News
The Medicines and Healthcare products Regulatory Agency (MHRA) has published its response to the Independent Medicines and Medical Devices Safety Review. In its response, the MHRA said: “Today’s publication of the Independent Medicines and Medical Devices Safety Review is of profound importance for the MHRA, since the safety of the public is our first priority." "We therefore take this report and its findings extremely seriously. Throughout the Review’s work we have listened intently to the many distressing experiences of women and their families. We will now carefully study the findings and recommendations of the Report. We recognise that patient safety must be continually protected and that many of the major changes recommended by the Review cannot wait. We are therefore making changes without delay to ensure that we listen to patients and involve them in every aspect of our work. We are already taking steps to strengthen our collaboration with all bodies in the healthcare system and will strive to ensure that, working with these other bodies, the safety changes we advise are embedded without delay in clinical practice. We wholeheartedly commit to demonstrating to those patients and families who have shared their experiences during the Review, and anyone else who has suffered, that we have learned from them and are changing and improving because of what they have told us. We are determined to put patients and the public at the heart of everything we do." Read full statement Source: GOV.UK, 8 July 2020 -
News ArticleFormer health secretary Jeremy Hunt has warned ministers not to let the Cumberlege review “gather dust on a shelf”. The chair of the Commons Health and Social Care Committee told The Independent it was vital action was taken to implement the recommendations. Mr Hunt, who made patient safety a key focus of his tenure as health secretary, backed the idea of an independent patient safety commissioner that would be outside the NHS and have powers to advocate for patient issues. Mr Hunt said: “This report should be a powerful wake-up call that our healthcare system is still too closed, defensive and focused on blame rather than learning lessons. It’s truly harrowing to hear of all the women and families who live with permanent anguish because of these medicines and devices, and it has clearly taken too long for their voices to be heard.” “The NHS is one of the safest health systems in the world, and we’re all rightly in awe of our frontline heroes. But in healthcare getting it right ‘most’ times isn’t good enough because the exceptions wreak lifelong devastation on families. So we must not allow this seminal report to gather dust on a shelf: lessons must be learnt once and for all.” Read full story Source: The Independent, 8 July 2020
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News Article
Lives ruined as damage viewed as 'women's problems'
Patient Safety Learning posted a news article in News
Many lives have been ruined because officials failed to hear the concerns of women given drugs and procedures that caused them or their babies considerable harm, says a review. More than 700 women and their families shared "harrowing" details about vaginal mesh, Primodos and an epilepsy drug called sodium valproate. Too often worries and complaints were dismissed as "women's problems". It says arrogant attitudes left women traumatised, intimidated and confused. June Wray, 73 and from Newcastle, experienced chronic pain after having a vaginal mesh procedure in 2009. "Sometimes the pain is so severe, I feel like I will pass out. But when I told GPs and surgeons, they didn't believe me. They just looked at me like I was mad." The chairwoman of the highly critical review, Baroness Julia Cumberlege, said the families affected deserved a fulsome apology from the government. She said: "I have conducted many reviews and inquiries over the years, but I have never encountered anything like this; the intensity of suffering experienced by so many families, and the fact that they have endured it for decades. Much of this suffering was entirely avoidable, caused and compounded by failings in the health system itself." Read full story Source: BBC News, 8 July 2020 -
News Article
GMC to restart fitness-to-practise investigations this month
Patient Safety Learning posted a news article in News
The GMC has set out its plans to restart fitness to practise (FTP) investigations this month. Existing FTP cases will resume, where this is possible, with flexibility on timescales and on the basis of direct discussion with those involved and ‘careful consideration and agreement’ with responsible officers, the regulator said. Acknowledging that investigations are ‘difficult’ for all involved’, the GMC said it is of the view that delaying decisions any further could ‘cause additional stress’. It also said investigations would resume with the ‘understanding that many individuals and organisations remain under pressure and any potential impact needs to be proportionate’. During this period, it will continue to review concerns that are raised to protect patient safety. Read full story Source: Pulse, 3 July 2020 -
News ArticleFormer patients of rogue breast surgeon Ian Paterson may have died of “unnatural deaths” two senior coroners have said. Senior coroner for Birmingham and Solihull, Louise Hunt, and area coroner Emma Brown have said they believe there is evidence to suspect victims of Ian Paterson, who was jailed for 17 counts of wounding with intent in 2017, died unnaturally as a result of his actions. They now plan to open four inquests into the deaths of patients who died from breast cancer after being treated by Paterson. “Following preliminary investigations, the senior and area Coroner believe there is evidence to have reason to suspect that some of those deaths may be unnatural. In accordance with the Coroners and Justice Act 2009, inquests will now be opened in relation to four former patients of Mr Paterson.” Deborah Douglas, a victim of Paterson who leads a support group in Solihull, told The Independent: "I have spoken to so many women over the years who have since died. This is what I have always known and fought for. "Paterson lied about pathology reports and people did develop secondary cancers." Read full story Source: The Independent, 4 July 2020
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News Article
Royal colleges should be more open on care reviews
Patient Safety Learning posted a news article in News
The leader of the Morecambe Bay inquiry has spoken of his disappointment that some of the recommendations have not led to changes, and said royal colleges could inform regulators when they are commissioned to carry out care quality reviews. Bill Kirkup was speaking after HSJ revealed only a small proportion of royal college “invited reviews” were made public, and in some cases even the Care Quality Commission (CQC) had not been made aware of the reviews, or seen final reports. Trusts had commissioned dozens of them into care failings over three years. The inquiry which he chaired into maternity services at the University Hospitals of Morecambe Bay Foundation Trust recommended that all external reviews of suspected service failings should be registered with the CQC and that NHS boards should have a duty to report their findings “openly”. The recommendations of the inquiry were accepted by both the government and the CQC. HSJ used freedom of information law to get copies of reports from recent years, but in many cases trusts refused to share them. Dr Kirkup, who stressd his comments did not refer to any individidual trust, said the findings highlighted a weakness in implementation of “an important recommendation”. Read full story (paywalled) Source: HSJ, 3 July 2020 -
News Article
Investigation of maternity deaths "too late"
Patient Safety Learning posted a news article in News
Parents of babies who died at a hospital trust at the centre of a maternity inquiry say a police investigation has come "too late". West Mercia Police said it was looking at whether there was "evidence to support a criminal case" at Shrewsbury and Telford NHS Hospital Trust. An independent review, contacted by more than 1,000 families, said it was working with police to identify relevant cases. "It's bittersweet," one mother said. "It's come too late for my daughter, she should still be here," said Tasha Turner, whose baby, Esmai, died four days after she was born at Royal Shrewsbury Hospital in 2013. Ms Turner's case is part of the Ockenden Review, an independent investigation into avoidable baby deaths at the trust, which runs Royal Shrewsbury Hospital and Telford's Princess Royal. LaKamaljit Uppal, 50, from Telford, who is also part of the review following the death of her son Manpreet in April 2003 at Royal Shrewsbury Hospital, said she hoped the police inquiry would bring some closure. "The trust put me through hell, someone should be held accountable," she said. Read full story Source: BBC News, 1 July 2020 -
News Article
Shrewsbury hospital: ‘New and ongoing’ safety concerns revealed by NHS watchdog
Patient Safety Learning posted a news article in News
Inspectors have raised “new and ongoing” patient safety concerns at Shrewsbury and Telford Hospitals Trust, it has emerged. The Care Quality Commission has issued a new warning notice to the Midlands trust after an inspection of the hospital earlier this month sparked concerns for the welfare of patients on its medical wards. These concerns are separate from the trust’s maternity service, which, it was revealed on Tuesday, is now facing a police investigation alongside an NHS inquiry into more than 1,200 allegations of poor maternity care dating back to the 1970s. In October, a patient at the hospital bled to death after a device used to access his bloodstream became inexplicably disconnected while he was receiving care on the renal unit. The Health Service Journal reported the latest concerns related to the inappropriate use of bed rails and risks of patients falling from beds after several incidents. The CQC is also concerned about the trust’s use of powers to detain elderly or vulnerable patients on wards. The concerns also include patients being at risk of abuse and learning from past incidents not being shared with staff. Read full story Source: The Independent, 1 July 2020
