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News Article
No. 10 criticised for failing to respond to damning MP report on Covid
Patient Safety Learning posted a news article in News
The government has been criticised for failing to respond to a damning parliamentary report that accused ministers of mishandling the early stages of the pandemic. The report, compiled by the Health and Science and Technology Committees, found the government’s initial response to Covid-19 “amounted in practice” to the pursuit of herd immunity, with the delayed decision to lock down ranking as one of the “most important public health failures the United Kingdom has ever experienced”. More than 50 witnesses contributed to the cross-party report, including ministers, NHS officials, government advisers and leading scientists, with the authors saying it was was “vital” that lessons were learnt from the failings of the past 18 months. The findings from the joint inquiry were published on 12 October and a deadline for an official government response was set for 12 December. However, that date has now passed and the committees have yet to formally hear back from ministers, according to the parliamentary website, which states that a response is now “overdue”. Covid-19 Bereaved Families for Justice said the government’s failure to “meet a very reasonable deadline” called into question the willingness of ministers to engage with the coming independent public inquiry into the UK’s handling of the pandemic. "The government have had months to get a response delivered to the Health and Science and Technology committees following their lessons leant from the pandemic report,” said Jo Goodmand, co-founder of the campaign group. “Unfortunately those of us who have lost loved ones are far too used to this with responses to FOIs late and it taking far too long to announce the inquiry. Read full story Source: 30 December 2021 -
News Article
Immensa lab closed one month after ‘unusual’ Covid results first detected
Patient Safety Learning posted a news article in News
Authorities were aware of discrepancies in Covid test results across England one month before the lab responsible was ordered to shut down its operations, legal papers show. An estimated 43,000 incorrect false negative tests were processed for the NHS by the Immensa laboratory in Wolverhampton between 8 September and 12 October. UK Health Security Agency became aware of an “unusual spike” in suspicious test results on 14 September, with large numbers of people testing positive on lateral flow devices but negative via PCR. It took a month before the UKHSA determined that the “likely cause was a technical issue at the Immensa laboratory”, according to court papers filed by the government in response to a lawsuit. The Independent also revealed in October how machines at the Wolverhampton lab were poorly maintained, concerns over quality control dismissed and untrained staff regularly “left to their own devices”. Samples at the site were wrongly processed or cross-contaminated, leading to incorrect test results, while faulty air conditioning and fluctuating humidity levels within the lab also led to spoiled tests, whistleblowers said. Read full story Source: The Independent, 22 December 2021 -
News Article
Care home under investigation following claims of unsafe conditions
Patient Safety Learning posted a news article in News
A care home with some of the highest Covid death rates recorded in the pandemic is facing whistleblower claims over unsafe conditions. Golfhill Nursing Home, in Dennistoun in Glasgow's East End, Scotland, is run by Advinia Healthcare, which confirmed a "large scale" investigation was taking place. A report by the Crown Office, published in April, showed Golfhill care home recorded 11 deaths related to coronavirus, among the highest rates. The Care Inspectorate investigation is said to have followed "months of complaints" about sub-standard and unsafe conditions at the home, including residents being admitted to hospital suffering from dehydration. The problems are said to centre on the intermediate care unit, where elderly residents are transferred after being discharged from hospital, requiring a higher level of care and remaining there for around a month before being sent home or into long-term care. According to a source, the unit has been short staffed "almost on a daily basis" because employees were being transferred to other areas of the home. Read full story Source: The Scotsman, 17 December 2021 -
News Article
Autistic man was 'loneliest man in the hospital'
Patient Safety Learning posted a news article in News
A whistle-blower in the case of an autistic man who has been detained in hospital since 2001 says he feels complicit in his "neglect and abuse". A BBC investigation found 100 people with learning disabilities have been held in specialist hospitals for 20 years or more, including Tony Hickmott. His parents are fighting to get him rehoused in the community. A support worker at a hospital where Mr Hickmott has been detained said he was the "loneliest man in the hospital". Mr Hickmott was sectioned under the Mental Health Act in 2001. His parents, Pam and Roy Hickmott, were told he would be treated for nine months, and then he would be able to return home. He is now 44 - and although he was declared "fit for discharge" by psychiatrists in 2013, he is still waiting for authorities to find him a suitable home with the right level of care for his needs. Following the report, Phil Devine, who worked in the hospital as a cleaner and a support worker, came forward to talk about conditions at the hospital. Mr Devine said only Mr Hickmott's basic needs were met. "Almost like an animal, he was fed, watered and cleaned. If anything happened beyond that, wonderful, but if it didn't, then it was still okay." In 2020, the hospital was put into special measures because it did not always "meet the needs of complex patients". A report highlighted high levels of restraint and overuse of medication, a lack of qualified and competent staff and an increase of violence on many wards. The hospital has now been taken out of special measures but still "requires improvement", according to the Care Quality Commission. Read full story Source: BBC News, -
News Article
NHS whistleblower in West Suffolk will ‘never be the same again’
Patient Safety Learning posted a news article in News
A whistleblower at the centre of a bullying scandal at West Suffolk hospital says she will “never be the same again” after being “pursued” by NHS managers when she raised concerns about a doctor injecting himself with drugs while on duty. Dr Patricia Mills was exonerated last week in an independent NHS review that was highly critical of the way she was ignored and then subjected to disciplinary investigation that verged on “victimisation”. The review, by Christine Outram, chair of the Christie NHS foundation trust, said Mills’s concerns about the self-injecting doctor were “well founded” and yet, instead of acting on them, managers subjected her to an investigation that lacked “fairness, balance and compassion”. It included what Outram called the “incendiary” and “extremely ill-judged” demand to Mills and other doctors for fingerprint samples as part of a management hunt for an anonymous letter-writer who had tipped off a grieving family about a potentially botched operation. “I do feel vindicated,” Mills, a 53-year-old anaesthetist, told the Guardian, but she said the 21-month investigation into her conduct, which was only formally dropped in September, has had a lasting impact. “I will never be the same again. To be absolutely pursued like that by your employer inevitably has long-term consequences in terms of psychological wellbeing. It was an orchestrated campaign that really floored me.” Read full story Source: The Guardian, 17 December 2021 -
News Article
Government blocks ‘blanket’ rule to suspend all staff where safety is at risk
Patient Safety Learning posted a news article in News
The government has rejected advice from an independent inquiry into the actions of disgraced surgeon Ian Paterson to suspend all healthcare professionals who are suspected of posing a risk to patient safety. The Department of Health and Social Care today published its response to 15 recommendations from the inquiry, which found Mr Paterson, jailed for 20 years in 2017 for 17 offences of wounding with intent, may have conducted up to 1,000 botched and unnecessary operations over a 14-year period. Of its 15 recommendations, the DHSC accepts nine in full, five in principle, rejects one entirely and there is another further point which it is keeping under review. In particular, the inquiry panel members recommended that when a hospital investigates a healthcare professional’s behaviour, including the use of an HR process, any perceived risk to patient safety should result in the suspension of that healthcare professional. DHSC chiefs said they agree practice exclusions and restriction can be necessary, and in some cases immediate exclusion is an appropriate response while an investigation is ongoing. But they added: “However, we do not believe it would be fair or proportionate to impose a blanket rule to exclude practitioners in such cases. “Such a step may inadvertently cause a chilling effect, dissuading healthcare professionals from raising concerns and negatively impacting patient safety.” Read full story (paywalled) Source: HSJ, 16 December 2021 -
News Article
Scathing review slams West Suffolk’s ‘intimidating’ hunt for whistleblower
Patient Safety Learning posted a news article in News
West Suffolk Foundation Trust’s investigation to find a whistleblower was “intimidating…flawed and not fit for purpose”, according to a damning review which is highly critical of the organisation’s leadership. The long-awaited review, published today, was triggered by ministers back in January 2020 following allegations that trust directors had ordered staff to give fingerprints and handwriting samples during a “witch hunt” for a whistleblower. The review, led by Christine Outram, has corroborated many of the allegations. It concluded trust leaders’ investigation to uncover the identity of the author of an anonymous letter sent to a patient’s family was “intimidating, flawed and not fit for purpose… impractical and unwise.” It said: “The decision to use fingerprinting and handwriting analysis in an NHS hospital, in the context of an anonymous letter and where no crime has been committed, was highly unusual and without doubt extremely ill-judged.” Read full story (paywalled) Source: HSJ, 9 December 2021 -
News ArticleA trust will not face a second prosecution over the death of a baby seven days after a chaotic birth at one of its hospitals, unless new evidence emerges. Kent police had been looking into incidents at the maternity services department of East Kent Hospitals University Foundation Trust. These incidents include the death of Harry Richford, who was born at Queen Elizabeth, the Queen Mother, Hospital in November 2017. A coroner found a string of failures in his care amounted to neglect. The trust pleaded guilty to failing to meet fundamental standards of care and was fined £733,000 in a case brought by the Care Quality Commission earlier this year. But detective chief superintendent Paul Fotheringham, head of major crime at Kent Police, said: “After careful consideration and following consultation with the Crown Prosecution Service, we took the decision that a criminal investigation would not be undertaken at this time as there is no realistic prospect of conviction against any individual or organisation based on the evidence currently available." In a statement, Harry’s family said: “We are disappointed that Kent Police, in collaboration with the CPS special crime unit in London, have not been able to take forward a charge of corporate manslaughter for Harry at this time. They have assured us that they will keep an open mind on this matter, and any other appropriate charges as and when new evidence is brought before them. “We believe that the Kirkup inquiry and investigation may allow them to revisit a raft of charges on behalf of harmed babies in east Kent in due course. Only when senior leaders are properly held to account, will there be lasting change.” Read full story (paywalled) Source: HSJ, 9 December 2021
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News Article"You hear his heartbeat and the next thing you know, you've got nothing." A woman whose son was stillborn has said she wants to change the law to enable an inquest to investigate the circumstances surrounding his death. Katie Wood's son Oscar was stillborn on 29 March 2015, but under law in England and Wales, inquests for stillborn babies cannot take place. A consultation was put out by the UK government in March 2019, but the findings have yet to be published. The UK government said it would set out its response in due course, but this delay was criticised by the House of Commons justice committee in September. Katie and her family said they have never received satisfactory answers about why Oscar died. Her pregnancy, while challenging, had not given any serious cause for concern. An investigation by the Aneurin Bevan health board found a number of failings in Katie's care. A post-mortem examination suggested a condition known as shoulder dystocia, where the baby's shoulder becomes stuck during birth, may have contributed, but this is rarely fatal. The health board said it conducted a serious incident investigation into Oscar's death and added: "Whilst we seek to find answers during any investigation, in some cases, a full understanding around the cause of death may not always be achieved and we accept the unavoidable distress this may pose for families." Clinical negligence and medical law specialist, Mari Rosser, says allowing coroners to look into the reasons for a baby's death is long overdue. "Currently parents who suffer a still birth can have the circumstances investigated, but the circumstances are investigated by the health board and of course that's less independent," she said. Read full story Source: BBC News, 9 December 2021
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News ArticleA vulnerable man detained for 10 years was failed by a system meant to care for him, an independent NHS investigation has found. Clive Treacey, a man who lived his life in the care of NHS and social care authorities, experienced an “unacceptably poor quality of life”, and was not kept safe from harm before his death at just 47. The findings of the independent review, The Independent and Sky News can reveal, have concluded Mr Treacey’s death was “potentially avoidable” and comes after years of his family “fought” for answers. His family are now pursuing a second inquest into his death after the review found a pathologist report and post-mortem used by coroners did not follow guidelines, along with new CCTV footage from the night he died. NHS England commissioned the review, under the Learning Disability Mortality Review Programme, in January 2020 – three years after Mr Treacey’s death and after his family was initially denied a review. In an exclusive interview with The Independent, Mr Treacey’s sister, Elaine Clark said: “We have fought on because Clive deserved nothing less. He spent his entire life being incarcerated and so did we, his entire family. He didn’t matter. His voice didn’t matter. His human rights didn’t matter. His life choices didn’t matter. The system and its people believed he did not matter and nobody in it had enough ambition to do anything differently." “Well Clive did matter. It matters what happened to him. It matters that it’s still happening to other people. And it matters that nothing seems to be changing we are one family but there are many others like us.” Read full story Source: The Independent, 9 December 2021
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News Article
‘Sheer desperation’ felt by A&E staff admitted by trust
Patient Safety Learning posted a news article in News
An investigation into whistleblowing claims which described patients “hanging off trolleys” and “vomiting down corridors” in a crowded emergency department has upheld most of the concerns. It comes after a staff member at Northern Lincolnshire and Goole Foundation Trust wrote to the chief executive and trust’s commissioners after working a weekend shift within the emergency department at Diana, Princess of Wales Hospital in Grimsby. In their original email, sent in January 2020, the anonymous whistleblower said they were writing out of “sheer desperation for the safety of patients”. They added: “I have never in my whole career seen patients hanging off trolleys, vomiting down corridors, having [electrocardiograms] down corridors, patients desperate for the toilet, desperate for a drink. Basic human care is not being given safely or adequately…" “Your hospital is full, your A&E department is over-flowing, you are expecting staff to manage treble the amount of patients in majors and resus than they would do normally, without breaks, this is not safe. They cannot provide that care – which is evident.” Read full story (paywalled) Source: HSJ, 7 November 2021 -
News Article
Stillborn baby's parents receive £2.8m from Nottingham hospital trust
Patient Safety Learning posted a news article in News
A couple whose child died in the womb after mistakes by maternity staff have received a £2.8m settlement. Sarah Hawkins was in labour for six days before Harriet was stillborn at Nottingham City Hospital in April 2016. Hospital bosses initially found "no obvious fault", but an external inquiry identified 13 failings in care. Solicitors representing Mrs Hawkins and husband Jack said it was believed to be the largest payout for a stillbirth clinical negligence case. Mrs Hawkins was nearly 41 weeks' pregnant when Harriet was delivered, almost nine hours after dying. The couple were first told their child had died of an infection but refused to accept this and launched their own investigation. A Root Cause Analysis Investigation Report published in 2018 concluded the death was "almost certainly preventable". The report said errors included a delay in applying appropriate foetal monitoring, the important omission of information on an antenatal advice sheet and a failure to follow the Risk Management Policy for maternity. It also found failures to record or pass on information correctly, failure to follow correct guidelines and delays in administering the correct treatment. Following the report's publication, the hospital trust apologised and said major changes would be made. Read full story Source: BBC News, 6 December 2021 -
News Article
HSIB launches national investigation into ambulance delays
Patient Safety Learning posted a news article in News
The national patient safety watchdog has launched an investigation into the “significant patient harm” caused by ambulances being forced to wait with patients outside of A&E. The Health and Safety Investigation Branch (HSIB) has confirmed it intends to launch an investigation after it received several alerts expressing concerns over the issue of ambulance delays this year. The investigation comes after The Independent revealed 160,000 patients had either died or come to harm as a result of delayed ambulance response times during 2020-21, which were being driven by delays in paramedics being able to hand over patients to hospitals. The damning report, from the Association of Ambulance Chief Executives, included examples of severely ill patients not being treated properly, being forced to go to the toilet in ambulances, and being denied food and drink, as well as antibiotics and fluids. There have been multiple reports of patients dying while waiting for ambulances or while waiting outside of A&Es on the back of ambulances. In a statement to The Independent, HSIB said: “We recognise that handover delays pose a serious safety risk, potentially leading to significant patient harm and impacting on the wellbeing of NHS staff. We welcome the review by AACE as they have provided detailed insight and highlighted key safety concerns. HSIB has already received several referrals expressing similar concerns, which will be taken forward to a national investigation. We will work with AACE and others across the NHS to provide systemic safety learning to help address the challenges created by handover delays.” Read full story Source: The Independent, 2 December 2021 -
News Article
Elizabeth Dixon: Lessons not learned after baby death cover-up, says family
Patient Safety Learning posted a news article in News
The family of a baby who died after errors in her care have criticised the failure of the NHS to learn lessons. Elizabeth Dixon died due to a blocked breathing tube shortly before her first birthday and a subsequent independent investigation found a 20-year cover-up. A year on, Elizabeth's mother Anne told the BBC: "My daughter has not been a catalyst for change." The Department of Health said it was working on the report's recommendations and will publish "a full response". Elizabeth Dixon, known as Lizzie, was born prematurely at Frimley Park Hospital, in Surrey, in December 2000. But a series of errors by the hospital and by Great Ormond Street Hospital, which took over her care shortly after birth, left Elizabeth with brain damage and needing to breathe through a tracheostomy. She was further let down by Nestor Primecare, a private nursing agency, which was hired to support her parents when Elizabeth returned home. She died 10 days before her first birthday. An official investigation, published last year, found a "20 year cover-up" by health workers, with some of those involved described as "persistently dishonest". "I would have expected them to take it seriously," Mrs Dixon said in response to the lack of action. She believes that if a similar incident happened today, there would be a danger it would also be covered up. "That's the default option - if its bad enough, they'll cover up," she said. Read full story Source: BBC News, 1 December 2021 -
News ArticleA watchdog is "very concerned" about the safety of people using the services of Greater Manchester Mental Health NHS Trust. The damning report says inspectors found there was not always enough nursing staff and that permanent staff did not feel safe if bank or agency workers were used as they didn't have the relevant training. It follows an unannounced inspection in September by the Care Quality Commission "due to on-going concerns about the safety of services". Three young patients died in nine months at Prestwich Hospital, one of the Trust's units. A campaign group and the families are campaigning for a full investigation into those cases by NHS England. The CQC's two-day inspection of eight wards across five of the the Trust's seven sites found: The service did not always have enough nursing staff, who knew the patients or received basic and essential training to keep patients safe from avoidable harm. The environment on Poplar ward (Park House) was not clean on the first day of inspection and space on the ward was limited for patients. It was not clear that immediate concerns or learning from incidents was shared across the locations, although local learning and reviews were taking place. The wards did not all have up to date and recently reviewed ligature risk assessments. Staff on two wards could not locate the ligature risk assessments at the time of the inspection. Read full story Source: Greater Manchester News, 26 November 2021
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News Article
Covid inquiry must look at NHS 111 ‘mishandling’, bereaved families say
Patient Safety Learning posted a news article in News
The inquiry into the government’s handling of the Covid pandemic should look at the “mishandling” of the NHS 111 service, families bereaved during the crisis have said. In a scathing report, the COVID-19 Bereaved Families for Justice group said the service was inappropriately used to “alleviate the burden on the NHS” with “horrific” consequences. The report, based on a survey of families, said many believed that the service “failed to recognise how seriously ill their relatives were and direct them to appropriate care”. They argue that the service was also quickly “swamped” during the first wave despite the addition of 700 new call handlers, many of who were making life or death decisions with just 10 weeks training. The phone line is one of a number of areas the groups want the government’s inquiry to cover. Other areas include No 10’s level of pandemic preparedness, particularly PPE shortages, as well as an investigation into the disproportionate impact on ethnic minority groups and those with disabilities. Read full story Source: The Independent, 30 November 2021 -
News Article
Health regulator accused of moral corrupt
Patient Safety Learning posted a news article in News
A doctor has accused England's health and care regulator of "moral corruption". Consultant orthopaedic surgeon Shyam Kumar says the Care Quality Commission misled the public over patient safety. Mr Kumar alleges he was unfairly dismissed from his role as a special adviser to the CQC because he acted as a whistleblower. His claims were made during an employment tribunal hearing in Manchester. Seconded by his employer, University Hospitals of Morecambe Bay NHS Foundation Trust, Mr Kumar had been giving the CQC expert advice on surgical departments during hospital inspections. But he was dismissed from this role, in early 2019. The CQC said a letter he had written to a colleague he had been in dispute with at his trust was incompatible with the standards expected of its special advisers. But Mr Kumar claims he was dismissed because, in 2018, he raised concerns with senior CQC figures that he was expected to simply rubber-stamp the final report following an under-resourced inspection. And he accused the regulator of sweeping his concerns under the carpet and providing false assurances on patient safety. Read full story Source: BBC News, 25 November 2021 -
News ArticleOne hundred people with learning disabilities and autism in England have been held in specialist hospitals for at least 20 years, the BBC has learned. The finding was made during an investigation into the case of an autistic man detained since 2001. Tony Hickmott's parents are fighting to get him housed in the community near them. Mr Hickmott's case is being heard at the Court of Protection - which makes decisions on financial or welfare matters for people who "lack mental capacity". Senior Judge Carolyn Hilder has described "egregious" delays and "glacial" progress in finding him the right care package which would enable him to live in the community. He lives in a secure Assessment and Treatment Unit (ATU) - designed to be a short-term safe space used in a crisis. It is a two-hours' drive from his family. This week, Judge Hilder lifted the anonymity order on Mr Hickmott's case - ruling it was in the public interest to let details be reported. She said he had been "detained for so long" partly down to a "lack of resources". Like many young autistic people with a learning disability, Mr Hickmott struggled as he grew into an adult. In 2001, he was sectioned under the Mental Health Act. He is now 44. In addition to the 100 patients, including Mr Hickmott, who have been held for more than 20 years - there are currently nearly 2,000 other people with learning difficulties and/or autism detained in specialist hospitals across England. In 2015, the Government promised "homes not hospitals" when it launched its Transforming Care programme in the wake of the abuse and neglect scandal uncovered by the BBC at Winterbourne View specialist hospital near Bristol. But data shows the programme has had minimal impact. Read full story Source: BBC News, 24 November 2021
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News Article
Trust focused on ‘reputation’ failed to address patient harms
Patient Safety Learning posted a news article in News
A focus on “reputation management” was a factor in how an acute trust failed to properly investigate serious safety concerns in a dysfunctional department where consultants were “divided along ethnic lines”. An external review into the urology services at University Hospitals of Morecambe Bay Foundation Trust has identified 520 cases where patients suffered “actual or potential harm”, including several cases where patients died. The review, commissioned by NHS England, has found there were “multiple individual, team, organisational, and regulatory shortfalls which have resulted in a systemic failure to deliver good urological care at all times”. Much of the report focuses on the trust’s failure to properly investigate concerns being raised, and to sort out poor relationships within the department which dated back 20 years. Read full story (paywalled) Source: HSJ, 24 November 2021 -
News ArticleMidwives across England are still not receiving enough essential safety training with the pandemic leaving hospitals delivering less training than three years ago. A new report from the charity Baby Lifeline, based on an investigation of 124 NHS trusts in England, found 9 in 10 units had training affected by the pandemic with staff shortages named as a major factor in preventing workers from taking time out for learning. This was cited by 72% of units as a problem. The average spend on maternity training was significantly lower in 2020-21 at £34,290 compared to £59,873 in 2017-18, with NHS trusts delivering less training to staff than they did in 2017-18. Despite concerns over the poor quality of safety investigations in the NHS, fewer than a third of NHS units trained staff in how to carry out investigations. Judy Ledger, chief executive and founder of Baby Lifeline, said: “Today’s report highlights how gaps and variation in the delivery of maternity training across the NHS continues to impact on the safety and care women and babies receive. Time and again evidence shows that training investment can save lives, and the pandemic has widened existing, detrimental gaps that years of chronic under-funding and staff shortages have created. Read full story Source: The Independent, 23 November 2021
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News ArticleThe family of a woman who died after being repeatedly overdosed with paracetamol in an NHS hospital have demanded action over her death amid allegations of an NHS cover up. Laura Higginson, a trainee solicitor and mum of two, died after seeking medical help for sickness and pneumonia. She died two weeks later from multi-organ failure and sepsis. Whiston Hospital, in Merseyside, has admitted to the overdose but denied it caused her death and rejects any suggestion of wrong doing. But expert reports, seen by The Independent, including from a liver specialist, questions the trust’s account of what happened, the quality of its post-mortem and concludes the mother-of-two – who only weighed 36kg – suffered liver failure after too much paracetamol in April 2017. The overdose mistake was recognised by staff on the third day but Laura’s family were never told. The trust did not record the error as an incident and only started an investigation 14 months later when concerns were raised by Laura’s family. Her husband Antony Higginson says the subsequent investigation report is “littered with inaccuracies.” He told The Independent: “We just want justice; we don’t care about money. Laura died needlessly and all these institutions charged with ensuring safe care and accountability have point blank failed and have rendered Laura’s life as essentially worthless and that she didn’t matter, when she did matter.” Read full story Source: The Independent, 21 November 2021
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News Article
'Some progress' made at failing Shropshire hospital trust
Patient Safety Learning posted a news article in News
An inspection at a failing hospital trust has identified "some progress" but its services are still inadequate. The Care Quality Commission (CQC) inspected the Shrewsbury and Telford Hospital NHS Trust (SaTH) in August. The Trust has been in special measures since 2018 and its maternity services are subject of a review following a high rate of baby and maternal deaths. The CQC said SaTH still had "significant work to do" to improve its patient care and safety standards. Inspectors highlighted particular concerns around risk management at the Trust which it said was "inconsistent" and and urgent and emergency care where patients "did not always receive timely assessment". The CQC also reported a shortage of staff working in end-of-life care and midwifery, however maternity staff were said to have "an exceptionally dedicated and caring approach". "I recognise the enormous pressure NHS services are under across the country and that usual expectations cannot always be maintained, but it is important they do all they can to mitigate risks to patient safety while facing these pressures," chief inspector of hospitals, Ted Baker, said. "While the trust continues to have significant work to do to provide care that meets standards people have a right to expect, it is providing more effective care overall. "However, its risk management remains inconsistent and we are not assured it is doing all it can to ensure people's safety." Read full story Source: BBC News, 18 November 2021 -
News Article
Widow demands answers over Covid official's death
Patient Safety Learning posted a news article in News
The widow of a top Scottish government official, who died after contracting Covid, believes the full details of his illness were concealed to protect the reputation of a troubled hospital. Andrew Slorance, Scottish government's head of response and communication unit, in charge of its handling of the Covid pandemic, went into Glasgow's Queen Elizabeth University Hospital for cancer treatment a year ago. His wife Louise believes he caught Covid there as well as another life-threatening infection. Andrew went in to the £850m flagship Queen Elizabeth University Hospital (QUEH) at the end of October 2020 for a stem cell transplant and chemotherapy as part of treatment for Mantle Cell Lymphoma (MCL). He died nearly six weeks into his stay, with the cause of his death listed as Covid pneumonia. But after requesting a copy of his medical notes, Mrs Slorance discovered her husband had also been treated for an infection caused by a fungus called aspergillus, which had not been discussed with either of them during his hospital stay. The infection is common in the environment but can be extremely dangerous for people with weak immune systems. Mrs Slorance questions whether it may have played a part in her husband's death, and if so, why she was not told? She told the BBC: "I think somebody and probably a number of people have made an active decision not to inform his family of that infection, either during his admission or post-death." Mrs Slorance believes that officials wanted to protect the hospital, which is already the subject of a public inquiry, and its reputation, "no matter what the cost". Mrs Slorance says a full investigation should take place into incidences of aspergillus at the hospital campus. In response, NHS Greater Glasgow and Clyde said: "We are sorry that the family are unhappy with aspects of Mr Slorance's treatment, details of which were discussed with the family at the time. "While we cannot comment on individual patients, we do not recognise the claims being made. We are confident that the appropriate care was provided. There has been a clinical review of this case and we would like to reassure the family that we have been open and honest and there has been no attempt to conceal any information from them." Read full story Source: BBC News, 18 November 2021 -
News Article
Landmark sickle cell disease inquiry finds evidence of racism in patient care
Patient Safety Learning posted a news article in News
A groundbreaking inquiry into sickle cell disease has found “serious care failings” in acute services and evidence of attitudes underpinned by racism. The report by the all-party parliamentary group (APPG) on Sickle Cell and Thalassaemia, led by Pat McFadden MP, found evidence of sub-standard care for sickle cell patients admitted to general wards or attending A&E departments. The inquiry also found widespread lack of adherence to national care standards, low awareness of sickle cell among healthcare professionals and clear examples of inadequate training and insufficient investment in sickle cell care. The report notes frequent disclosures of negative attitudes towards sickle cell patients, who are more likely to be people with an African or Caribbean background, and evidence to suggest that such attitudes are often underpinned by racism. The inquiry also found that these concerns have led to a fear and avoidance of hospitals for many people living with sickle cell. Care failings have led to patient deaths and “near misses” are not uncommon, leading to a cross-party call for urgent changes into care for sickle cell patients. Read full story Source: The Independent, 15 November 2021 -
News Article
Alder Hey NHS Trust must pay boy £27m over brain injuries
Patient Safety Learning posted a news article in News
A boy who suffered "catastrophic brain injuries" when doctors failed to see he had a virus and sent him home after he had a seizure has been awarded £27m. The boy, who cannot be identified but is now 13, suffered seizures as a toddler more than a decade ago. Details of the settlement between the boy's father and Liverpool's Alder Hey Children's NHS Foundation Trust were published in a written ruling. High Court judge Mr Justice Fordham said it was a "sensible settlement". Trust bosses admitted "breach of duty" and "causation of loss and damage", the judge said. The judgment, from the hearing in Manchester, said the boy had suffered a seizure at 17 months old on 19 September 2009 and was taken to Alder Hey Children's Hospital. He suffered a second seizure in the accident and emergency department which was seen by medical staff. The boy was sent home and, despite going back to hospital, was not diagnosed with a virus until 24 September. Read full story Source: BBC News, 12 November 2021
