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News Article
Late diagnosis of ectopic pregnancy 'putting women at risk'
Patient Safety Learning posted a news article in News
Women are at risk of serious harm and death because hospitals are not always diagnosing ectopic pregnancies quickly enough, an investigation reveals. About 12,000 women a year in the UK suffer an ectopic pregnancy – when a fertilised egg grows outside the womb – putting them at risk if a fallopian tube containing the foetus ruptures and causes potentially fatal heavy bleeding. An investigation by the Healthcare Safety Investigation Branch (HSIB) has found flaws in the treatment women receive. It has highlighted late diagnosis and consequent delay in treatment as a major concern, especially as a result of the condition being mistaken for a urinary tract infection. NHS patient safety data shows that 30 ectopic pregnancies were missed and led to “serious harm” between April 2017 and August 2018. As well as the risk to life, an ectopic pregnancy can also damage a woman’s chances of conceiving again and have serious psychological effects. Read full story Source: The Guardian, 5 March 2020 -
News Article
East Kent baby deaths: "Hospital did not learn from mistakes"
Patient Safety Learning posted a news article in News
The parents of a baby who nearly died after a series of failings during his birth said they were "heartbroken" mistakes continued to be made East Kent Hospitals told Harry Halligan's parents they would learn lessons from his delivery in 2012. But similar failings recently came to light after the death of Harry Richford in 2017 and the trust is now being probed over up to 15 baby deaths. The trust said it made "many changes to the maternity service" after 2012. Parents Dan and Alison Halligan, from New Romney, said watching news coverage of an inquest into Harry Richford's death earlier this year, which laid bare the failings, had brought back stressful memories. Mr Halligan said the trust "clearly haven't learned from [the] mistakes" made in his son's care, adding that it was "heartbreaking" to see "the same mistakes being repeated". Read full story Source: BBC News, 5 March 2020 -
News Article
"Get doctors in the room for clinical negligence mediation," lawyers told
Patient Safety Learning posted a news article in News
Mediators want more clinicians to come forward – and lawyers to enable them – to speak directly to patients bringing medical negligence claims against the NHS. Alan Jacobs, mediator at the Centre for Effective Dispute Resolution, told a conference of lawyers that they should do more to encourage discussions between injured people and those allegedly responsible. His call came as figures show record numbers of clinical claims against the NHS went to mediation in 2018/19 – with the majority of mediations resulting in damages being agreed on the day. Jacobs, speaking at the Claims Media conference in Manchester, said the challenge now is to ensure medical professionals volunteer to take part in the process. "It allows an apology to be given face to face and allows explanations to be given," he said. "It is also an opportunity for the clinician to have a discussion, sit down with the claimant and answer questions and concerns. It can be tremendously important for a claimant to vent and express their frustrations and for the trust to hear that." Both claimant and defendant lawyers agreed on the merits of bringing doctors in to the room, but stressed this was not always a realistic aim. Barrister Daniel Frieze, head of the personal injury team at St Johns Buildings, said: "Often it is too late and there is too much water under the bridge. Claimants are very stressed and it may be counter-productive for them to face the other side. I know the idea is of being collaborative but I’m not sure that’s necessarily always true." Read full story Source: 21 February 2020, The Law Society Gazette -
News ArticleThe Independent Inquiry into the issues raised by Paterson is yet another missed opportunity to tackle the systemic patient safety risks which lie at the heart of the private hospital business model, says David Rowland from the Centre for Health and the Public Interest in a recent BMJ Opinion article. Although the Inquiry provided an important opportunity for the hundreds of patients affected to bear witness to the pain and harm inflicted upon them it fundamentally failed as an exercise in root cause analysis. None of the “learning points” in the final report touch on the financial incentives which may have led Paterson to deliberately over treat patients. Nor do they cover the business reasons which might encourage a private hospital’s management not to look too closely. He suggests that the Inquiry report threw the responsibility for managing patient safety risks back to the patients themselves in two of its main recommendations but that it should be for the healthcare provider first and foremost to ensure that the professions that they employ are safe, competent and properly supervised, and for this form of assurance to be underpinned by a well-functioning system of licensing and revalidation by national regulatory bodies. Read full story Source: BMJ Opinion, 20 February 2020
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News Article
Infected Blood Enquiry: Timetable and factsheet for expert hearings
Clive Flashman posted a news article in News
This is the independent public statutory inquiry into the use of infected blood. The timetable and factsheet to provide information for those attending the hearings in London on 24-28 February have just been published. Go to this link for more information >> https://www.infectedbloodinquiry.org.uk/news -
News Article
Senior nurse who tried to whistleblow unfairly dismissed, tribunal rules
Patient Safety Learning posted a news article in News
A trust unfairly dismissed a senior nurse after she tried to invoke its formal whistleblowing policy, an employment tribunal has ruled. North Tees and Hartlepool Foundation Trust had suspended Linda Fairhall for 18 months without a “meaningful or adequate” explanation prior to her dismissal, the judgment said. Ms Fairhall, who led a team of 50 district nurses in Hartlepool, reported on the trust’s risk register that a “change in policy” by the local authority had directly led to increased workloads for her staff. The change meant staff had to monitor patients who had been prescribed medication “so as to ensure the correct medicines were being taken at the correct time”, the judgment said. She reported numerous concerns to senior management between December 2015 and October 2016, amounting to 13 protected disclosures according to the tribunal, ranging from work-related stress, sickness, absenteeism and a need to retrain healthcare assistants. A patient’s death triggered a meeting involving her and senior managers, which she said could have been prevented had her earlier concerns “been properly addressed”. Ms Fairhall told care group director Julie Parks she wanted to initiate the formal whistleblowing policy on 21 October 2016, before going on annual leave a few days later. When she returned, she was told she had been suspended for 10 days. The judgment, handed down at Teesside Justice Hearing Centre and published last week, added: “No reasonable employer, in all the circumstances of this case, would have conducted the investigation in this manner.” The judgment said the tribunal believed the principal reason for her dismissal was because she had made protected disclosures. It upheld her claim that her dismissal was automatically unfair. Read full story (paywalled) Source: HSJ, 17 February 2020 -
News Article
Surgeon suspended over treatment concerns
Patient Safety Learning posted a news article in News
A doctor who worked at the same private healthcare firm as rogue breast surgeon Ian Paterson has been suspended, it has emerged. Spire Healthcare said Mike Walsh – a specialist in trauma and orthopaedic surgery – was suspended in April 2018 over concerns about patient treatment. Almost 50 of his patients from its Leeds hospital had been recalled. The details emerged following an independent inquiry into Paterson, who is serving a 20-year jail sentence. Earlier this month, an inquiry into the breast surgeon found that a culture of "avoidance and denial" had allowed him to perform botched and unnecessary operations on hundreds of women. Spire said in a statement that it acted after concerns were raised about Mr Walsh's work at its hospital in Leeds in 2018. The company, which contacted the Royal College of Surgeons to assist with its investigation, said it had reviewed the notes of fewer than 200 patients, of which "fewer than 50" had been invited back for a follow-up appointment. "Where we have identified concerns about the care a patient received, we have invited the patient to an appointment with an independent surgeon to review their treatment," a spokesman for Spire Healthcare said. "This is a complex case and the review is ongoing." It said that Mr Walsh, who was immediately suspended after the concerns were raised, was no longer working with Spire Healthcare. The company said any patients at its Spire Leeds Hospital who had concerns about their treatment under Mr Walsh should contact the hospital. It said its findings had also been shared with the Care Quality Commission and the General Medical Council (GMC). Read full story Source: BBC News, 17 February 2020 -
News Article
Review launched into East Kent NHS trust after baby deaths
Patient Safety Learning posted a news article in News
The government has announced an independent review into maternity services at an NHS trust where a number of babies have died. “Immediate actions” have also been promised and an independent clinical team has been placed “at the heart” of East Kent Hospitals University NHS Foundation Trust. It comes amid reports that at least seven preventable baby deaths may have occurred at the trust since 2016, including that of Harry Richford. Harry died seven days after his emergency delivery in a “wholly avoidable” tragedy, contributed to by neglect, in November 2017, an inquest found. Speaking in the House of Commons, the health minister Nadine Dorries confirmed the independent review would be carried out by Dr Bill Kirkup, who led the investigation into serious maternity failings at Morecambe Bay. It will look at preventable and avoidable deaths of newborns to ensure the trust learns lessons from each case and will put in place appropriate processes to safeguard families. The review is expected to begin shortly and work in partnership with affected families. Read full story Source: 13 February 2020 -
News Article
Hospital's 'gross failings' led to pressure sores death
Patient Safety Learning posted a news article in News
A double amputee suffered fatal pressure sores caused by "gross and obvious failings" in her hospital treatment. Janet Prince, from Nottingham, developed the sores after being admitted to Queen's Medical Centre (QMC) in July 2017. The 80-year-old died in January 2019. Assistant Coroner Gordon Clow issued a prevention of future deaths report to Nottingham University Hospitals NHS Trust (NUH). Nottingham Coroner's Court had heard Ms Prince was taken to QMC in Nottingham with internal bleeding on 15 July 2017. The patient was left on a trolley in the emergency department for nine hours and even though she and daughter Emma Thirlwall said she needed to be given a specialist mattress, she was not given one. "No specific measures of any kind were implemented during that period of more than nine hours to reduce the risk of pressure damage, even though it should have been easily apparent to those treating her that [she] needed such measures to be in place," Mr Clow said. Ms Prince was later transferred to different wards, but a specialist mattress was only provided for her a few days before she was discharged on 9 August, by which time Mr Clow said her wounds "had progressed to the most serious form of pressure ulcer (stage four) including a wound with exposed bone". Mr Clow said there were "serious failings" over finding an appropriate mattress and other aspects of her care while at the QMC, including "a gross failure" to prevent Ms Prince's open wounds coming into contact with faeces. Mr Clow said the immediate cause of her death was "severe pressure ulcers", with bronchopneumonia a contributory factor. Recording a death by "natural causes, contributed to by neglect", he said he was "troubled by the lack of evidence" of any changes to wound management at NUH. NUH medical director Keith Girling apologised for the failings in Ms Prince's care, claiming the trust had "learnt a number of significant lessons from this very tragic case". Read full story Source: BBC News, 14 February 2020 -
News Article
East Kent baby deaths: Scale of deaths at trust 'not clear-cut'
Patient Safety Learning posted a news article in News
The boss of an NHS trust at the centre of concerns about preventable baby deaths has claimed the scale of the failings is not clearly defined. Susan Acott, Chief Executive of East Kent Hospitals Trust, said there had only been "six or seven" avoidable deaths at the trust since 2011. However, the BBC revealed on Monday that the trust previously accepted responsibility for at least 10. Ms Acott said some of the baby deaths were "not as clear-cut". A series of failings came to light during the inquest of Harry Richford who died seven days after his birth at the Queen Elizabeth the Queen Mother Hospital in Margate in November 2017. A coroner ruled Harry's death was "wholly avoidable" and was contributed to by hospital neglect. Ms Acott added she had not read a key report from 2015 drawing attention to maternity problems at the trust until December 2019. Ms Acott claims that from 2011 to 2020 there were "about six or seven" baby deaths that were viewed as preventable. She says the other deaths were being investigated adding "these things aren't always black and white". Read full story Source: BBC News, 12 February 2020 -
News Article
East Kent baby deaths: Four more families come forward
Patient Safety Learning posted a news article in News
A BBC News investigation has uncovered more preventable baby deaths at an NHS trust that has already been criticised for its maternity services. Four families said their babies would have survived had East Kent Hospitals NHS Trust provided better care. The NHS's Healthcare Safety Branch is investigating 25 maternity cases at the hospitals in Margate and Ashford. The trust has apologised for the care provided in two of the cases and said they were investigating a third. It has denied any wrongdoing in the fourth case. The government is due to receive the Healthcare Safety Branch's report into the 25 cases later, as well as a Care Quality Commission report from an inspection carried out in January. Last month, the BBC discovered at least seven preventable deaths may have occurred at the trust since 2016. Four further families have now spoken out, saying their babies would not have died if medics had provided better care. In two of the cases, the mothers said the actions of the trust left them feeling they were to blame for their babies' deaths. In a statement, East Kent Hospitals Trust it had set up a board sub-committee "to ensure we are complying with national safety standards and ensure we are implementing the coroner's recommendations fully and swiftly". "We are deeply saddened by the stories of families who have suffered the death of a much-loved baby, and we are extremely sorry for their loss," it added. Read full story Source: BBC News, 10 February 2020 -
News Article
Woman with anorexia 'faced delays' before death
Patient Safety Learning posted a news article in News
A woman described as a "high risk" anorexia patient faced delays in treatment after moving to university, an inquest has heard. Madeline Wallace, 18, from Cambridgeshire, was told there could be a six-week delay in her seeing a specialist after moving to Edinburgh. The student "struggled" while at university and a coroner said there appeared to be a "gap" in her care. Ms Wallace died on 9 January 2018 due to complications from sepsis. A parliamentary health service ombudsman report into her death was being written at the time of Ms Wallace's treatment in 2017 and issues raised included moving from one provider to another and higher education. Coroner Sean Horstead said Ms Wallace only had one dietician meeting in three months, despite meal preparation and planning being an area of anxiety she had raised. Dr Hazel said she had tried to make arrangements with the Cullen Centre in Edinburgh in April 2017 but had been told to call back in August. The Cullen Centre said it could only accept her as a patient after she registered with a GP and that an appointment could take up to six weeks from that point. Read full story Source: BBC News, 10 February 2020 -
News ArticleThe toxicity of a commonly prescribed beta blocker needs better recognition across the NHS to prevent deaths from overdose, a new report warns today. The Healthcare and Safety Investigation Branch (HSIB) report focuses on propranolol, a cardiac drug that is now predominately used to treat migraine and anxiety symptoms. It is highly toxic when taken in large quantities and patients deteriorate quickly, making it difficult to treat. The investigation highlighted that these risks aren’t known widely enough by medical staff across the health service, whether issuing prescriptions to at risk patients, responding to overdose calls or carrying out emergency treatment. Dr Stephen Drage, ICU consultant and HSIB’s Director of Investigations, said: “Propranolol is a powerful and safe drug, benefitting patients across the country. However, what our investigation has highlighted is just how potent it can be in overdose. This safety risk spans every area of healthcare – from the GPs that initially prescribe the drug, to ambulance staff who respond to those urgent calls and the clinicians that administer emergency treatment." The report also emphasises that there is a link between anxiety, depression and migraine, and that more research is needed to understand the interactions between antidepressants and propranolol in overdose. Read full story Source: HSIB, 6 February 2020
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News Article
Paterson scandal: Is the NHS learning from mistakes?
Patient Safety Learning posted a news article in News
Shipman, Mid Staffordshire, Morecambe Bay, and now Ian Paterson, the breast surgeon that performed botched and unnecessary operations on hundreds of women. The list of NHS-related scandals has got longer. It's tempting to say the health service has not learned lessons even after a string of revelations and reviews. But is that fair? asks BBC Health Editor Hugh Pym. The inquiry, chaired by Bishop Graham James, makes clear there were failings at every level of a dysfunctional health system when it came to patient safety. The public and private health systems did not compare notes about suspicious behaviour by a consultant. Staff working with Paterson thought that his surgical methods were unusual but, perhaps cowed by being ignored after raising concerns, kept their heads down. Add to that the power and status of a surgeon in the medical world and, in the words of the report, Paterson was "hiding in plain sight". So could it happen again? James says it's clearly impossible to eliminate the activities of determined criminals in any profession. He acknowledges that some improvements have been made on policing. But he says that a decade on from the Paterson scandal, he is not convinced that medical regulators, with a combined budget of half a billion pounds a year, are doing enough collectively or collaboratively to make the system safe for patients. The review chair notes tellingly that while regulators spoke of major improvements which should identify another Paterson, some doctors and nurses had told the inquiry that it was "entirely possible that something similar could happen now". Read full story Source: BBC News, 4 February 2020 -
News Article
Ian Paterson: Surgeon wounded hundreds amid 'culture of denial'
Patient Safety Learning posted a news article in News
A culture of "avoidance and denial" allowed a breast surgeon to perform botched and unnecessary operations on hundreds of women, an independent inquiry has found. The independent inquiry into Ian Paterson's malpractice has recommended the recall of his 11,000 patients for their surgery to be assessed. Paterson is serving a 20-year jail term for 17 counts of wounding with intent. One of Paterson's colleagues has been referred to police and five more to health watchdogs by the inquiry. The disgraced breast surgeon worked with cancer patients at NHS and private hospitals in the West Midlands over 14 years. His unregulated "cleavage-sparing" mastectomies, in which breast tissue was left behind, meant the disease returned in many of his patients. Others had surgery they did not need - some even finding out years later they did not have cancer. Patients were let down by the healthcare system "at every level" said the inquiry chair, Bishop of Norwich the Rt Revd Graham James, who identified "multiple individual and organisational failures". One of the key recommendations from the report is that the Government should make patient safety a the top priority, given the ineffectiveness of the system identified in this Inquiry. Read full story Source: BBC News, 4 February 2020 -
News Article
Inquiry into rogue breast surgeon to call for changes to private hospital safety
Patient Safety Learning posted a news article in News
An independent inquiry is expected to call for major changes in the way private hospitals supervise doctors after hundreds of women were put through unnecessary operations by a rogue breast surgeon. Ian Paterson was jailed for 20 years in 2017 after being convicted of 13 counts of wounding with intent and three counts of unlawful wounding. But his surgical malpractice may have harmed more than 750 women over more than a decade. He carried out unnecessary surgery for breast cancer on women who did not have the disease, and put other women who did at risk by using his own unofficial technique, which left behind partial breast tissue. On Tuesday an inquiry chaired by the Bishop of Norwich, the Right Reverend Graham James, will be published and is expected to make recommendations about how doctors are allowed to work across both the NHS and private sector with minimal supervision and oversight. One key area of focus is expected to be a process known as “practising privileges”, where private hospitals allow clinicians to carry out their own activities within the hospital, similar to self-employed contractors. They effectively rent the hospital space for their work. Read full story Source: The Independent, 2 February 2020 -
News Article
Urgent inquiry ordered into 'witch-hunt' at West Suffolk hospital
Patient Safety Learning posted a news article in News
The government has ordered an urgent inquiry into the local hospital of the health secretary, Matt Hancock, after the Guardian revealed its unprecedented “witch-hunt” for a whistleblower. The Department of Health and Social Care (DHSC) has told NHS England to commission a “rapid review” of the actions of bosses at West Suffolk hospital. They are under fire for demanding that staff give fingerprints and samples of their handwriting to help identify who wrote to a family alerting them to failings in care that contributed to a patient’s death. Unusually, the investigation has been instigated by Edward Argar, a junior minister at the DHSC, because Hancock and another health minister, Jo Churchill, are both local MPs who have close ties to the hospital. Argar has made clear to NHS England that the inquiry must be undertaken by independent experts, given those existing relationships. Announcing the review, Argar made clear that he wanted hospital personnel to speak openly. “I want all staff to feel that they can speak up and have the confidence that anything they raise will be taken seriously,” he said. Read full story Source: The Guardian, 28 January 2020 -
News Article
Hundreds recalled as consultant accused of ‘unnecessary’ surgery
Patient Safety Learning posted a news article in News
A surgeon has been accused of carrying out “unnecessary” shoulder operations on several NHS patients at a private hospital linked to the Ian Paterson scandal, with 217 patients recalled. HSJ has been told at least five patients, all commissioned by the NHS, have instructed solicitors to take legal action against Habib Rahman, a consultant orthopaedic surgeon at Spire Parkway Hospital in Solihull. Mr Rahman is accused of undertaking “unnecessary or inappropriate surgical procedures at Spire Healthcare hospitals” . Spire has confirmed it has recalled 217 patients over the concerns. The allegations come weeks before the findings are due from an independent inquiry into disgraced surgeon Ian Paterson – who was found guilty of wounding with intent after giving hundreds of patients unnecessary breast surgeries in Spire hospitals across the Midlands. Read full story (paywalled) Source: HSJ, 24 January 2020 -
News Article
Morecambe Bay inquiry chief voices criticisms over East Kent hospital scandal
Patient Safety Learning posted a news article in News
The failure to pass a damning report about a scandal-hit hospital trust to the care watchdog has been criticised by the man who led the inquiry into baby deaths at Morecambe Bay. On Friday, a coroner ruled that the death of baby Harry Richford in 2017 resulted from neglect in the maternity unit of East Kent Hospitals NHS Trust. A report by the Royal College of Obstetrics and Gynaecologists (RCOG) completed a year earlier had warned of issues that contributed to Harry’s death, including senior doctors not showing up for their shifts. However, the report was never passed on to the Care Quality Commission (CQC), despite the recommendation of the Morecambe Bay inquiry in 2015 that relevant external reviews should be passed on to the watchdog. Bill Kirkup, who chaired the inquiry into deaths of mothers and babies at Furness General Hospital in Barrow-in-Furness, told The Independent: “When there is sufficient concern about a service to prompt an external review, the report must be available immediately to those responsible for assuring the quality of the service. That was the reason for the recommendation of the Morecambe Bay investigation, and it is disappointing that the Care Quality Commission apparently had no sight of this report until now.” Read full story Source: 26 January 2020 -
News Article
Justice is being denied to too many families
Patient Safety Learning posted a news article in News
Harry Richford's death underlines the need for the health secretary to bring back the national maternity safety training fund – and there are other issues that require urgent attention – The Independent reports. Harry Richford had not even been born before the NHS failed him. An inquest has concluded he was neglected by East Kent University Hospitals Trust in yet another maternity scandal to rock the NHS. His parents and grandparents have fought a tireless campaign against a wall of obfuscation and indifference from the NHS. In their pursuit of the truth they have exposed a maternity service that did not just fail Harry, but may have failed dozens of other families. As with the family of baby Kate Stanton-Davies at Shrewsbury and Telford Hospitals Trust, or Joshua Titcombe at the University Hospitals of Morecambe Bay Trust, it has taken a family rather than the system to expose what was going wrong. It is known that there are about 1,000 cases a year of safety incidents in the NHS across England, including baby deaths, stillbirths and children left brain damaged by mistakes. Last week, the charity Baby Lifeline, joined The Independent to call on the Department of Health and Social Care (DHSC) to reinstate the axed maternity safety training fund. This small fund was used to train maternity staff across the country. Despite being shown to be effective, it was inexplicably scrapped after just one year. There are other issues that also need urgent attention. The inquest into Harry’s death, which concluded on Friday, lasted for almost three weeks. Without pro bono lawyers from Advocate, Brick Court Chambers and Arnold & Porter law firm, the family would have faced an uphill struggle. At present, families are not automatically entitled to legal aid at an inquest, yet the NHS employs its own army of lawyers who attend many inquests and can overwhelm bereaved families in a legal battle they are ill-equipped to fight. Even the chief coroner, Mark Lucraft QC, has called for this inequality of legal backing to end, but the government has yet to take action. Read full story Source: The Independent, 26 January 2020 -
News Article
East Kent hospitals: Care watchdog inspects trust after baby death apology
Patient Safety Learning posted a news article in News
England's care watchdog has carried out a no-notice inspection of an NHS trust at the centre of concerns over the possible preventable deaths of babies. The Care Quality Commission (CQC) is investigating East Kent Hospitals NHS Trust but has not yet decided whether to prosecute. It comes as the trust is likely to be heavily criticised at an inquest into the death of baby Harry Richford. On Thursday, the BBC revealed significant concerns have been raised about maternity services at the trust, and a series of preventable baby deaths may have occurred there. On Wednesday and Thursday this week, the trust's maternity services were subject to an unannounced inspection from the CQC. On Thursday night, East Kent Hospitals University NHS Foundation Trust said in a statement: "We are truly sorry for the death of baby Harry and our thoughts and deepest sympathies go out to Harry's family. We accept that Harry's care fell short of the standard that we expect to offer every mother giving birth in our hospital and we are fully cooperating with the CQC's investigation into Harry Richford's death." Read full story Source: BBC News, 24 January 2020 -
News ArticleThe Care Quality Commission (CQC) missed multiple opportunities to identify abuse of patients at a privately run hospital and did not act on the concerns of its own members, an independent review has found. Bosses at the CQC have been criticised in an independent report by David Noble into why the regulator buried a critical report into Whorlton Hall hospital, in County Durham, in 2015. His report published today said the CQC was wrong not to make public concerns from one of its inspection teams in 2015. “The decision not to publish was wrong,” his report said, adding: “This was a missed opportunity to record a poorly performing independent mental health institution which CQC as the regulator, with the information available to it, should have identified at that time.” Read full story Source: The Independent, 22 January 2020
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News Article
East Kent hospitals: Baby deaths 'could have been prevented'
Patient Safety Learning posted a news article in News
At least seven preventable baby deaths may have occurred at one of the largest groups of hospitals in England since 2016, a BBC investigation has found. Significant concerns have been raised about maternity services at the trust. East Kent NHS Foundation Trust has apologised, saying it has "not always provided the right standard of care". The trust has struggled to improve maternity care for years, despite repeatedly being made aware of the problems. In 2015, the medical director asked experts from the Royal College of Obstetricians and Gynaecologists to review maternity care, amid "concerns over the working culture". Their review, seen by the BBC, found poor team working in the unit, a number of consultants operating as they saw fit, a lack of performance management of the consultant body and out of date clinical guidelines. It highlights consultants who: failed to carry out labour ward rounds, review women, make plans of care or attend out of hours when requested rarely attended CTG training were reported "as doing their own thing rather than follow guidelines". Read full story Source: BBC News, 23 January 2020 -
News Article
Earlier recognition of aortic dissection needed to prevent deaths
Patient Safety Learning posted a news article in News
Up to half of all patients who suffer an acute aortic dissection may die before reaching crucial specialist care, according to a new Healthcare Safety Investigation Branch (HSIB) report. The report highlights the difficulty which can face hospital staff in recognising acute aortic dissection. The investigation was triggered by the case of Richard, a fit and healthy 54-year old man, who arrived at his local emergency department by ambulance after experiencing chest pain and nausea during exercise. It took four hours before the diagnosis of an acute aortic dissection was made, and he spent a further hour waiting for the results of a CT scan. Although Richard was then transferred urgently by ambulance to the nearest specialist care centre, he sadly died during the journey. The report has identified a number of risks in the diagnostic process which might result in the condition being missed. These include aortic dissection not being suspected because patients can initially appear quite well or because symptoms might be attributed to a heart or lung condition. It also highlighted that, once the diagnosis is suspected, an urgent CT scan is required to confirm that an acute aortic dissection is present. Gareth Owens, Chair of the national patient association Aortic Dissection Awareness UK & Ireland, welcomed the publication of HSIB’s report, saying: “HSIB’s investigation and report have highlighted that timely, accurate recognition of acute Aortic Dissection is a national patient safety issue. This is exactly what patients and bereaved relatives having been telling the NHS, Government and the Royal College of Emergency Medicine for several years." Read full story Source: HSIB, 23 January 2020 -
News Article
Hundreds of serious incidents recorded at struggling small trust
Patient Safety Learning posted a news article in News
One of the country’s smallest trusts recorded 277 serious incidents over a two-year period, HSJ can reveal. Delays in treatment, missed diagnoses, adverse media coverage and “suboptimal” care were among the hundreds of serious incidents reported at the struggling Isle of Wight Trust from the start of 2018 and up to November 2019. There were also two never events in 2019 — a “wrong site” surgery and an incident in which a patient was mistakenly connected to an air flow meter, rather than an oxygen supply. The trust said the level of incidents did not neccessarily reflect poor care, and did not mean patients had come to harm. The trust was placed in special measures in April 2017 after it was rated “inadequate” by the Care Quality Commission due to “significant” concerns over patient safety. It was upgraded to “requires improvement” in September 2019, but remains in special measures. Read full story (paywalled) Source: HSJ, 22 January 2020
