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Found 1,558 results
  1. Content Article
    The term 'Gemba Walk' is derived from the Japanese word 'Gemba' or 'Gembutsu' which means 'the real place', so it can be literally defined as the act of seeing where the actual work happens. A safety Gemba Walk, or Gemba safety walk, is a safety walk integrated with the Gemba method, emphasising the continuous improvement of safety by watching the actions required to complete daily tasks and determine ways to make work safer. While a typical site safety walk through aims to maintain compliance with safety standards, a safety Gemba Walk focuses on looking for opportunities to continuously improve workplace safety. This article describes the Gemba Walk method and includes information on: What is a Safety Gemba Walk? What is a Virtual Gemba Walk? Why are Gemba Walks important? Benefits How to do a Gemba Walk Process How often should you do a Gemba Walk? Effective ways to do a Gemba Walk Examples
  2. Content Article
    In this blog, After Action Review (AAR) specialist Judy Walker shares an account of a successful AAR that took place amongst a surgical team. The AAR was called after a near-miss where the anaesthetist was prevented from injecting spinal block medication into the wrong side of a patient's spine by an operating department practitioner (ODP). The story demonstrates the benefits of AAR, including accelerated learning, a no-blame approach, flattening staff hierarchy and a significant reduction in the time it takes to investigate an incident.
  3. Content Article
    This policy paper from the Department of Health and Social Care sets out the Government’s response to the recommendations of the investigation into the death of Elizabeth Dixon in respect of the failures of care she received from the NHS.
  4. Content Article
    Judy Walker summarises four tools that can be used for the Patient Safety Incident Response Framework (PSIRF), explaining what they are and the strengths and weaknesses of each: SWARM Huddle MDT Review After Action Review Patient Safety Incident Investigation (PSII).
  5. Content Article
    This factsheet explains more about how the new independent Health Service Safety Investigations Body (HSSIB) will function
  6. News Article
    A formal complaint accuses the British Government of facilitating ‘the largest single health and safety disaster to befall the United Kingdom workforce since the introduction of asbestos products’. An expert letter to the UK Government’s Health & Safety Executive (HSE) from one of its own advisors accuses the agency of failing to use its statutory authority to correct “seriously flawed” guidance on infection protection and control (IPC), imperilling “the health and safety of healthcare workers by failing to provide for suitable respiratory protection”. The continued failure to protect healthcare workers by ensuring they are wearing the appropriate form of PPE (personal protective equipment) to minimise the risk of infection from COVID-19 airborne transmission, the letter says, has led to thousands of avoidable deaths. The failures amount both to “gross negligence” and serious “criminal offences”, claims the letter seen by Byline Times. The letter addressed to HSE chief executive Sarah Albon is authored by 27-year chartered health and safety consultant David Osborn, who is a ‘consultee member’ of the HSE’s COSHH (Control of Substances Hazardous to Health) Essentials Working Group, where he has helped HSE to prepare guidance for employers and employees. Written in his own personal capacity, the letter is a formal complaint accusing the members of the Government’s “IPC Cell” – a group of experts behind official guidance on infection protection and control – along with other senior Government officials of committing a “criminal offence… ultimately punishable by fine and/or imprisonment” by breaching Section 36 of the Health and Safety at Work Act. The letter argues that a police investigation is needed. The guidance, Osborn writes in his letter, has failed to ensure that healthcare workers understand that they should wear and have access to respiratory protection equipment (RPE) designed to protect from COVID-19 airborne transmission. “There is sufficient prima-facie evidence to suggest that the offence has led to the potentially avoidable deaths of hundreds of healthcare workers and the debilitating disease known as Long COVID in thousands of other healthcare workers,” the letter says. “I firmly believe that the primary source of infection was the inhalation of aerosols whilst caring for infected patients at close quarter,” says Osborn in his letter. Read full story Source: Byline Times, 10 February 2022
  7. News Article
    A crisis in cancer care at NHS Tayside could have been averted if the health board had publicly supported doctors who were criticised by an official report, according to a top oncologist. The last remaining breast radiotherapy specialist left at the end of January, with the board unable to replace him. Patients must now travel to Aberdeen, Glasgow or Edinburgh for radiotherapy. The situation has emerged three years after an investigation into chemotherapy treatment at Ninewells Hospital. NHS Tayside apologised to patients in 2019 after an investigation found doctors deviated from national standards on chemotherapy dosages given to breast cancer patients after surgery. A subsequent review found that the lower dosages were highly unlikely to have led to the deaths of any patients. Last year the doctors involved were cleared of any wrongdoing by the General Medical Council (GMC), who also found no fault with the treatment patients received. Some clinicians close to those involved told BBC Scotland the cancer doctors felt they had no choice but to leave because they did not have the backing of the board. Colleagues who support the oncologists say none of this needed to happen. Prof Alastair Munro, emeritus professor of radiation oncology at Dundee University, who previously worked as a cancer doctor in the department, said: "It's a totally avoidable tragedy, this should not have happened. "The first thing the health board need to do is to come clean, and say we got it wrong, we put our hands up, we want to start again with a clean slate and we want to attract good people to come to Tayside to deliver breast cancer services to the patients whose needs we serve." Read full story Source: BBC News, 9 February 2022
  8. News Article
    An inquiry into allegations of abuse at Muckamore Abbey Hospital officially begins on Monday. The Co Antrim facility treats patients with severe learning difficulties and mental health problems. Allegations of abuse at Muckamore Abbey Hospital - which is run by the Belfast Trust and located on the outskirts of Antrim - first came to light in 2017. Police said they reviewed thousands of hours of CCTV footage as part of a major investigation. At present seven people are to be prosecuted and more than 20 have been arrested for a range of offences, including alleged ill-treatment and wilful neglect. The core objectives of the inquiry are "to examine the issue of abuse of patients at Muckamore Abbey Hospital (MAH), to determine why the abuse happened and the range of circumstances that allowed it to happen and ensure that such abuse does not occur again at MAH or any other institution providing similar services in Northern Ireland". Read full story Source: Belfast Telegraph, 11 October 2021
  9. News Article
    A hospital trust has apologised to a mental health patient who reported being sexually assaulted in its A&E department – after it emerged in a safety review that staff wrote ‘this has not happened’ and dismissed her claims of the attack. The victim was admitted to West Suffolk Hospital’s emergency department following an overdose in January last year. While waiting in A&E for a mental health assessment from a specialist team employed by Norfolk and Suffolk Foundation Trust, she reported being sexually assaulted by a male patient who had also been admitted to A&E. Yet a review into the incident, published several months later and shared with HSJ, reveals that after the victim reported the attack to a nurse, the staff member recorded “this has not happened”. They stated that the male suspect in the cubicle next to her had not left his bed and was under constant observation. However, the patient safety review, drawn up after a serious incident probe was launched, adds that this statement was “incorrect, as the [male] patient was not under constant observation”. “There were witnesses to this incident, and CCTV, and yet it was not escalated until I contacted the trust myself to complain,” the victim said. She added that she pursued the complaint, which resulted in a serious incident probe that took several months to conclude, “to prevent others from being failed” in the same way. She said she was left “shocked, confused and furious” to discover staff had dismissed her assault and claimed the male suspect had not been admitted for an assessment on the day of the attack. Read full story (paywalled) Source: HSJ, 7 February 2022
  10. News Article
    An amputee's wife having to "carry him to the toilet" after her husband was sent home from hospital without a care plan was just one of many findings in a report into vascular services at Betsi Cadwaladr University Health Board in north Wales. The critical report by the Royal College of Surgeons England makes five urgent recommendations "to address patient safety risks". Part one of the report, published last summer, made nine urgent recommendations and raised issues including too many patient transfers to the centralised hub, a lack of vascular beds and frequent delays in transfers. The final part of the report, published on 3 February, focussed on the clinical records of 44 patients dating from 2014 - five years before centralisation - to July 2021, two years after the Ysbyty Glan Clwyd hub opened. Assessors were "extremely concerned" about the case of a man where a decision was made to "amputate the foot rather than proceed to a below-the-knee amputation as the primary procedure". The report adds: "The review team also noted that the patient had been discharged without a care plan and that the patient's wife was having to 'carry him to the toilet'." It also highlights an "inappropriate" decision to offer a patient an "unnecessary and futile" amputation when "palliation and conservative therapy should have been considered instead". Referring to that case, the report added that the risk from "major amputation was extremely high". Read full story Source: BBC News, 3 February 2022
  11. News Article
    An NHS England review into the behaviour of high-profile senior leaders who took over a Midlands trust has concluded that the interim CEO “behaved poorly and inappropriately” while its chair was “complicit with” and failed to address problems. NHS England had commissioned an independent probe into allegations about the behaviour of new executives, who had recently been appointed to the board of Walsall Healthcare Trust. David Loughton and Professor Steve Field, who hold the same roles at the Royal Wolverhampton Trust, were brought in as interim chief executive and chair respectively in spring 2021. Walsall has faced care quality concerns for some years and it was hoped the pair from neighbouring Wolverhampton would bring improvements. Dr McLean wrote in her review: “Leadership changes can, understandably, represent a period of anxiety for those affected but this can be minimised if changes are made in line with appropriate values and processes. “Whilst I conclude that the joint chair and interim CEO were motivated to act in the best interests of patients, I was saddened by much of what I heard. ”In the narratives I heard, there was a consistent lack of compassion or respect for people.” She concluded: “The interim CEO, while motivated by the safety and care of patients, has behaved poorly and inappropriately … the joint chair has been complicit with and failed to address this behaviour.” Read full story (paywalled) Source: HSJ, 2 February 2022
  12. News Article
    The inquiry into sex offences carried out in a hospital mortuary will consider whether the trust board ‘received sufficient assurance’ about the issues raised by the assaults, documents shared with HSJ show. The draft terms of reference for the independent inquiry have been shared with the families of women and girls abused by maintenance supervisor David Fuller for comment. The inquiry will take place in two phases. The first phase – which will concentrate on Mr Fuller’s actions in Maidstone and Tunbridge Wells Trust – will look at his initial employment and access to the mortuary and other areas, and whether processes were appropriate. It will also in this phase “consider whether the trust’s board received sufficient assurance on the issues raised by the case”. But it will also seek to identify any evidence of “other inappropriate or unlawful activities” by Mr Fuller elsewhere on trust premises. It will review any evidence of concerns around his behaviour, and how the trust and the private contractors who later employed him addressed them. In a letter to the families, inquiry chair Sir Jonathan Michael says it is intended that the evidence sessions will be held in private “primarily to protect and safeguard the dignity and anonymity of those people that Fuller abused” but also to encourage people to be “candid”. It is unclear whether families or their legal representatives will be able to attend these private sessions – other than when they are giving evidence – and to raise questions. Read full story (paywalled) Source: HSJ, 28 January 2022
  13. News Article
    The Healthcare Safety Investigation Branch (HSIB) has launched an investigation into community mental health care following the death of a 56-year-old woman. HSIB has begun examining how patients in crisis with severe mental health needs are assessed by NHS services. The investigation came after warnings from multiple coroners over the poor assessment of suicide risk in people in mental health crisis in the last year and followed the death of Frances Wellburn, who took her own life in August 2020 while under the care of Tees, Esk and Wear Valleys Foundation NHS Trust (TEWV). Wellburn had long-term mental health problems but suffered a crisis and was admitted to hospital in September 2019. Following discharge, she was not referred to a specialist NHS service for people experiencing psychosis because clinicians incorrectly believed she was too old for the service, according to a TEWV investigation report seen by The Independent. Despite being assessed as a “medium risk”, Wellburn was not contacted by mental health teams for three months. In June 2020, she was admitted to an inpatient unit for three weeks, but her health deteriorated, and she later took her own life. Separately, coroner warnings in three prevention of future deaths reports published last year found mental health staff failing to risk assess people who later took their own lives. HSIB’s investigation will look into how patients’ risk is assessed when receiving care in the community and how services interact with families and other health services. It will also examine how mental health services consider menopause when assessing women’s mental health and referrals to early intervention psychosis services. Read full story Source: The Independent, 27 January 2022
  14. News Article
    A string of failings may have contributed to the death of a “deeply vulnerable” law student who killed herself while being treated in a psychiatric hospital in Bristol, an inquest jury has said. Zoë Wilson, 22, had informed staff she was hearing voices in her head telling her to kill herself and 30 minutes before she died was seen by a nurse through an observation hatch looking frightened and behaving oddly but nobody went into her room to check her. Speaking after the jury’s conclusions, Wilson’s family said that Avon and Wiltshire mental health partnership NHS trust (AWP) should face criminal charges over the case. AWP said it accepted it had fallen short in its care of Wilson. Zoë on the 17 June 2019 she told staff she was hearing voices telling her to kill herself and handed over an item that she could have used to harm herself with. She was not moved to an acute ward and other items that she could have used were not removed. At 1am on 19 June she was observed standing beside her bathroom door looking frightened but staff did not go to her. Thirty minutes later she was checked again and had harmed herself. Emergency services were called but she was pronounced dead. Giving evidence to Avon coroner’s court, the nurse who saw Wilson at 1am said he had only worked in the unit a handful of times and had not met Wilson before that night. The jury concluded that steps taken to keep her safe that night had been inadequate and also criticised communication and information sharing. In a statement, her family, said: “Zoë was a wonderful, bright, and deeply vulnerable young woman. She was on a low-risk ward even when she told staff that voices in her head were telling her to kill herself.” They called for AWP to face a criminal prosecution by the Care Quality Commission (CQC). “We will continue to fight for justice in her name,” they said. “She will never be forgotten.” Read full story Source: The Guardian, 27 January 2022
  15. News Article
    A vulnerable woman judged to be at medium risk of self harm was on a mental-health ward that catered for low-risk patients, an inquest heard. Zoe Wilson, 22, died on the Larch Ward at Bristol's Callington Road Hospital in June 2019 after being found unconscious in her room at 01.30 BST. She had previously told staff that voices were telling her to kill herself, her inquest heard. Healthcare assistant Sarah Sharma found her and immediately called for help. Addressing a jury inquest at Avon Coroners' Court, she said that "patients admitted to Larch should have all been low risk". This meant they would "preferably" have hourly observations by staff and be able to take their medication without any issues. Many were ready to be discharged and they were there because something was holding them up, normally housing, she said. The experienced healthcare assistant said if the patient's risk increased they should be placed under "one to one" monitoring with a member of staff until they were moved to a more suitable unit. The inquest heard earlier that Ms Wilson had been judged to be medium risk and was placed on 30-minute observations on 18 June. Her risk level was re-assessed when she handed a belt to staff and informed them voices were telling her to kill herself. Ms Sharma told the court that she was on her first overnight shift in two and a half weeks that night, and was informed in a handover that Ms Wilson was at risk of self-harming. Having never met Ms Wilson - who had schizophrenia - she queried what kind of self-harm the patient was at risk of but said the nurse performing the handover told her he "didn't know". Ms Sharma told the inquest she was unaware of the belt incident or that Ms Wilson had not been sleeping well and had requested medication to calm her down. Read full story Source: BBC News, 24 January 2022
  16. News Article
    A group of survivors and relatives of people who died in the infected blood scandal are suing a school where they contracted hepatitis and HIV after being given experimental treatment without informed consent. A proposed group action lodged by Collins Solicitors in the high court on Friday alleges that Treloar College, a boarding school in Hampshire that specialised in teaching haemophiliacs, failed in its duty of care to these pupils in the 1970s and 80s. The claim could result in a payout running into millions of pounds, and is based on new testimony given by former staff at the school to the ongoing infected blood inquiry. Gary Webster, 56, a former pupil who was infected with hepatitis C and HIV after being treated with contaminated blood at the school in the early 80s and gave evidence to the inquiry last year, is the lead claimant of the 22 survivors in the group. Speaking to the Guardian, he said: “We were lab rats or guinea pigs. We always thought that we may have been experimented on for research purposes, but we had no proof until the evidence given in the inquiry.” Last year in testimony to the inquiry, the former headteacher of Treloars, Alec Macpherson, confirmed that doctors at the school were “experimenting with the use of factor VIII”, an imported pooled plasma that was later discovered to be contaminated with HIV and hepatitis. He said he and other teaching staff did not question doctors about the trials. He told the inquiry: “We didn’t have any authority or reason to interfere. You can’t – doctors are god, aren’t they?” Macpherson said he consented to the treatment because he trusted the doctors, and he could not recall if parents were informed and consulted. Read full story Source: The Guardian, 23 January 2022
  17. News Article
    Hundreds of nurses, paramedics, health and care workers have been disciplined over allegations of sexual assault, including incidents involving child sexual abuse, The Independent can reveal. It comes as the government begins a year-long inquiry into the sexual abuse of dead patients by “morgue monster” David Fuller. Charities claim the true scale of the issue is likely to be hidden by “vast underreporting” while safeguarding experts say there is no “uniformity” in how NHS trusts handle such cases. The Health and Care Professions Council (HCPC), which regulates just under 300,000 workers including paramedics, occupational therapists, psychologists and physiotherapists, has taken action on 154 occasions following 293 investigations carried out into allegations of sexual assault or abuse since 2012, according to figures obtained by The Independent. Fifty-three clinicians were struck off, 20 were cautioned and a further 29 were either suspended, had restrictions placed on their practice or agreed to be removed from registration. More than half of the actions followed allegations of sexual abuse of a child patient. Separate data from Nursing and Midwifery Council (NMC), which has more than 700,000 registered nurses and midwives. shows action was taken 113 times in the past four years against nurses and midwives who did not maintain professional boundaries; in more than 80 per cent of those cases, the clinician was struck off. Read full story Source: The Independent, 21 January 2022
  18. News Article
    Barts Health NHS Trust has been told to take action to prevent future deaths after an elderly woman was unlawfully killed at one of its hospitals. East London acting senior coroner Graeme Irvine sent a report to the trust in which he raised concerns over the death of 78-year-old Surekha Shivalkar in 2018. The report follows an inquest into Mrs Shivalkar's death, which reached a narrative conclusion incorporating a finding of unlawful killing. A Barts spokesperson said the trust had made a number of changes after carrying out an investigation. Mrs Shivalkar underwent hip replacement revision surgery at Newham Hospital on September 28, 2018 in a procedure estimated to last between four and five hours, the coroner wrote. She had a number of serious conditions, including ischaemic heart disease, osteoporosis and chronic obstructive pulmonary disorder. But Mr Irvine said an inaccurate risk of death of less than 5% was given, as no formal risk assessment tool was used. The surgery took longer than seven and a half hours, during which time Mr Irvine said Mrs Shivalkar sustained a "prolonged and dangerous" period of hypotension, or low blood pressure. He said the anaesthetist failed to communicate this to the surgical team and agreed to prolong surgery at the six hour point. Mr Irvine said: "Poor communication between the orthopaedic surgical team and the anaesthetist during surgery led to a collective failure to identify a critically ill patient." Read full story Source: Newham Recorder, 17 January 2022
  19. News Article
    “Unacceptable” failures by a mental health hospital to manage the physical healthcare of a woman detained under the mental health act contributed to her starving to death, The Independent has learned. A second inquest into the death of a 45-year-old woman, Jennifer Lewis, has found that the mental health hospital to which she was admitted “failed to manage her declining physical health” as she suffered from the effects of malnutrition. Ms Lewis had a long-term diagnosis of schizophrenia. Her family described how she had lived a full life, completed a degree, and given lectures about living with mental illness. However, after undergoing bariatric surgery, against the wishes of her family, her mental state declined and she was admitted to the Bracton Centre, run by Oxleas, in 2014. In an interview with The independent, her sister, Angela, described how, in the year before her death, Ms Lewis lost her hair, suffered from diarrhoea, and developed sores on her legs as she effectively “starved to death” from malnutrition. Ms Lewis’s sister told The Independent that in the year leading up to her death, when the family warned doctors she was “starving to death”, their concerns were dismissed and they were told that the hospital “will not let it come to that”. Mental health charity Rethink has called for improvements to physical healthcare for patients with severe mental illness, whose physical needs they say are “all too often ignored”, while experts at think tank the Centre for Mental Health have warned that patients with mental illness are dying too young as the system “still separates mental and physical health”. Read full story Source: The Independent, January 2022
  20. News Article
    A six-year-old girl thought to have died from sepsis was in fact suffering from a blood condition triggered by E coli infection, an inquest has found. Coco Rose Bradford was taken to the Royal Cornwall hospital in the summer of 2017 suffering from stomach problems and later transferred to the Bristol Royal hospital for children, where she died. The following year an independent review flagged up failings in her care in Cornwall and the Royal Cornwall hospitals trust apologised for how it had treated her. Her family were left with the belief she had died of sepsis and could have been saved if she had been given antibiotics. But on Friday, coroner Andrew Cox, sitting in Truro, found that Coco died from multiple organ failure caused by haemolytic uraemic syndrome (HUS). The inquest heard there is no proven treatment for HUS. Cox said Coco’s family had been misled over the sepsis diagnosis, which he said was deeply regrettable, adding: “As a matter of fact, I find Coco had overwhelming HUS, not overwhelming sepsis.” During the inquest, the court heard Coco’s family felt staff at the Cornish hospital were “dismissive, rude and arrogant” and did not take her condition seriously. Cox found that although staff had recognised the risk of HUS from the moment Coco was admitted, this was not clearly set out in a robust management plan. The coroner also said a lack of communication had made Coco “something of a hostage to fortune”. Read full story Source: The Guardian, 14 January 2022
  21. News Article
    East of England Ambulance Service Trust has launched an ‘independent investigation into the circumstances’ surrounding the death of a staff member, its chief executive told a board meeting today. Nick Lee, 46, from Ovington in west Norfolk, died on 3 December. The cause of death is yet to be officially established. He was a leading operations manager for west Norfolk, and hospital ambulance liaison officer at Queen Elizabeth Hospital King’s Lynn Foundation Trust and had worked for the ambulance trust for nearly 20 years. This is not the first time the trust, which has faced significant cultural problems in recent years, has been required to investigate the circumstances surrounding the deaths of members of their workforce. The trust launched an investigation into the “underlying factors associated with” the sudden deaths of three of its employees in November 2019, HSJ exclusively revealed in January 2020. A whistleblower alleged in 2019 that staff at the ambulance provider were at risk of suicide because of its “completely toxic culture”. A month after the allegations were reported in October, three young staff members died suddenly in 11 days. The deaths happened while the trust was transitioning to a new staff welfare provider. The staff who died were ambulance dispatcher Luke Wright, aged 24, and paramedics Christopher Gill, from Welwyn Garden City, and Richard Grimes, from Luton. Read full story (paywalled) Source: HSJ, 13 January 2022
  22. News Article
    Two paramedics have been sentenced to five years in prison for stealing medication from terminally ill patients. Ruth Lambert, 33, and Jessica Silvester, 29, of the South East Coast Ambulance Service (Secamb), preyed specifically on people receiving end-of-life care packages, Kent Police said in a statement. The pair, who live together at Gap Road in Margate, accessed addresses of patients in the east Kent area through their work and posed as nurses to gain access to patients’ homes to steal morphine and other painkillers. They worked in tandem, one researching the addresses and sending details to the other who would visit and steal the medication, police said, with victims being targeted in Thanet, Canterbury, Whitstable, Faversham and Herne Bay. Evidence gathered from the pair’s mobile phones showed they had also conspired to steal from Secamb by taking medication from ambulances when on duty. Detective sergeant Jay Robinson, from Kent Police, described the offences as “an astonishing abuse of position”. “Many of their victims have since passed away and will never know that justice has been done,” he said. “Our investigation was carried out, knowing we had to represent those victims and do the very best for them.” Dr Fionna Moore, medical director for Secamb, added that Lambert and Silvester’s behaviour was a “clear and targeted abuse of their position and does not reflect the commitment and integrity of our staff”. Read full story Source: The Independent, 12 January 2022
  23. News Article
    A nurse who was struck off for refusing to admit a woman to a mental health unit before she killed herself said 'leave her, she will faint before she dies' before he kicked her out of the facility. Paddy McKee allegedly made the comment as Sally Mays, 22 - who had mental health issues - tried to strangle herself when she was refused admission. Ms Mays killed herself at home in Hull in July 2014 after being refused a place at Miranda House in Hull by McKee and another nurse. Despite her being a suicide risk, they would not give her a place at the hospital after a 14-minute assessment. Her parents Angela and Andy have fought for several years for improvements to be made and lessons to be learnt from her death. McKee was this month struck off following a Fitness to Practice hearing conducted by the Nursing and Midwifery Council. The report by the NMC was this week published and condemned McKee, saying 'he treated her in a way that lacked basic kindness and compassion'. The NMC found his actions to refuse Ms Mays' admission had contributed to her death. Read full story Source: Mail Online, 12 January 2022
  24. News Article
    A surgeon who burned his initials on to the livers of two patients during transplant surgery has been struck off the medical register. Simon Bramhall, 57, admitted using an argon beam – used to stop livers bleeding during operations and to highlight an area to be worked on – to sign “SB” into his patients’ organs in 2013 while working at Birmingham’s Queen Elizabeth hospital. On Tuesday, a review by the Medical Practitioners Tribunal Service (MPTS) concluded Bramhall’s actions were “borne out of a degree of professional arrogance” and that they “undermined” public trust in the medical profession. Bramhall, of Tarrington, Herefordshire, was first suspended from his post as a consultant surgeon in 2013 after another surgeon spotted the initials during follow-up surgery on one of his patients. A photograph of the 4cm-high branding was taken on a mobile phone. During his sentencing hearing in 2018, Bramhall was told one of the victims suffered serious psychological harm as a result of the branding. The surgeon later told police he branded the organs to relieve operating theatre tensions following difficult and long transplant operations. Read full story Source: The Guardian, 11 January 2022
  25. News Article
    An inmate gave birth to a stillborn baby in shocking circumstances in a prison toilet without specialist medical assistance or pain relief, an investigation by the Prisons and Probation Ombudsman (PPO) has found. A prison nurse who did not respond to three emergency calls from a prison officer to come to the woman’s aid when she developed agonising stomach cramps has been referred to the Nursing and Midwifery Council. Louise Powell, 31, was unaware that she was pregnant. She gave birth on a prison toilet on 18 June 2020 at HMP & YOI Styal in Cheshire. She previously said she believed her baby girl could have survived had she had more timely and appropriate medical intervention. Her lawyer said they had obtained expert evidence that also suggested that the baby, who Powell named Brooke, may have survived had things been handled differently. The report is the second by the PPO in six months to investigate the death of a baby in prison. While Tuesday’s report found that there had not been failures before the day Powell gave birth, the ombudsman, Sue McAllister, found there were missed opportunities to establish that she needed urgent clinical attention in the hours beforehand. “It’s not safe to have pregnant women in prison, we are just treated like a number,” Powell told the Guardian in a previous interview. “I can’t grieve for my baby yet because there are still things I don’t know, like why an ambulance wasn’t called. I want to get justice for Brooke and I decided to go public in the hope that things will change and pregnant women will stop being imprisoned.” Read full story Source: The Guardian, 11 January 2022
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