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News ArticleThe Department of Health and Social Care (DHSC) has been criticised by the national health ombudsman for the ‘maladministration’ of a 2018 review into the death of a teenage girl under the care of one of England’s top specialist hospitals, HSJ can reveal. The Parliamentary and Health Service Ombudsman (PHSO) came to the conclusion after investigating a DHSC review into the 1996 death of 17-year-old Krista Ocloo which had been requested by her mother. Krista died at home of acute heart failure in December 1996. She had been admitted to the Royal Brompton Hospital with chest pains in January of that year. The PHSO report states her mother was told “there was no cause for concern” and that another appointment would be scheduled in six months. This follow-up appointment did not happen. The young woman’s death was considered by the hospital’s complaints process, an independent panel review and an inquiry into the hospital’s paediatric cardiac services. They concluded the doctor involved was not responsible for Krista’s death – though the paediatric services inquiry criticised the hospital for poor communication. A coroner declined to open an inquest into the case. Civil action against the hospital, brought by Ms Ocloo, found Krista’s death could not have been prevented. However, a High Court judge found that the failure to arrange appropriate follow-up by the RBH was “negligent”. A spokeswoman for PHSO said: “Our investigation found maladministration by the Department for Health and Social Care, which should have been more transparent in its communication. The department’s failure to be open and clear compounded the suffering of a parent who was already grieving the loss of her child.” A DHSC spokeswoman said: “We profoundly regret any distress caused to Ms Ocloo. “[The PHSO] report found that in communicating with Ms Ocloo the department’s actions were – in places – not consistent with relevant guidance. The department has writen to Ms Ocloo to apologise for this and provide further information about the review.” Read full story (paywalled) Source: HSJ, 12 November 2020
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News Article
Nurse Lucy Letby charged with murder after Chester hospital baby deaths
Patient Safety Learning posted a news article in News
A nurse is due in court charged with eight counts of murder following an investigation into baby deaths at the Countess of Chester hospital neonatal unit in Cheshire. Lucy Letby, 30, is due to appear at Warrington magistrates court on Thursday. She was arrested for a third time on Tuesday as part of the investigation into the hospital, which began in 2017. A force spokesman said: “The Crown Prosecution Service has authorised Cheshire police to charge a healthcare professional with murder in connection with an ongoing investigation into a number of baby deaths at the Countess of Chester hospital.” He said Letby was facing eight charges of murder and 10 charges of attempted murder relating to the period from June 2015 to June 2016. On Tuesday, police said parents of all the babies involved were being kept fully updated on developments and were being supported by officers. Read full story Source: The Guardian, 11 November 2020 -
News Article
Author of gov review forms group to fight ‘woeful’ DHSC response
Patient Safety Learning posted a news article in News
A Tory peer has attacked the Department of Health and Social Care’s ‘woeful’ response to the patient safety review she authored and has revealed she intends to create a cross-party group to force action. Baroness Julia Cumberlege - who led the “First Do No Harm” report on device and medicine safety– has said she has “not had a whisper” from the department over the report’s key recommendations since it was published in July. She told HSJ’s Patient Safety Congress she is setting up a cross-party parliamentary group to “pressure” the department to adopt the report’s recommendations. The report arose from The Independent Medicines and Medical Devices Safety Review, which spoke to more than 700 people, mostly women, who suffered avoidable harm from surgical mesh implants, pregnancy tests and the anti-epileptic drug sodium valproate. The report discovered “a culture of dismissive and arrogant attitudes” including the unacceptable labelling of many symptoms as “attributable to ‘women’s problems’”. It concluded that the NHS has “either lost sight of the interests of all those it was set up to serve or does not know how best to do this.” Health and social care secretary Matt Hancock and minister Nadine Dorries have apologised to the women who were harmed but the department has so far not responded to the report’s other eight recommendations in detail. Baroness Cumberlege said the cross party group would “[try] to open up a firmly shut departmental door. A department that doesn’t seem to get it.” She said: “We have been disappointed [in the department’s response] because we hoped by now we would have some sort of inclination about what’s going on." “The response from the department on the other key recommendations has been woeful. The reason they give is ‘there is a terrible amount of work to do’”. Read full story (paywalled) Source: HSJ, 11 November 2020 -
News Article
Basildon maternity unit handed 'urgent' safety deadline
Patient Safety Learning posted a news article in News
An NHS hospital where a woman bled to death in childbirth has been given an "urgent" deadline to keep patients at its maternity unit safe. A letter seen by the BBC reveals the Care Quality Commission (CQC) found unsafe staffing levels at the unit at Basildon Hospital throughout August. The CQC said the trust that runs it had until next Monday to implement appropriate measures. The trust said it had a "robust improvement plan in place". The seven-page document, sent by the CQC on 7 October, puts the Mid and South Essex NHS Foundation Trust on notice that it has to "implement an effective governance system", among other measures. Consequences for missing the deadline were not stated, but the CQC said it was using its powers under the Health and Social Care Act to impose conditions on the trust's registration. The Act does allow the CQC to temporarily close health services. Read full story Source: BBC News, 3 November 2020 -
News Article
CQC orders staffing and safety improvements at trust scrutinised over deaths
Patient Safety Learning posted a news article in News
A mental health trust has been told to make ‘urgent improvements’ by regulators after a fourth inpatient death occurred with similar themes to three other patients dying within 12 months. The warning, issued by the Care Quality Commission (CQC) to Devon Partnership Trust, was made after an unannounced inspection at the trust’s Langdon Hospital – following the death of a patient who died by suspected suicide in July. Last week HSJ revealed how the death was the fourth inpatient death within the last 12 months at the trust, with each incident having recurring themes. The latest death happened at Langdon Hospital in Dawlish, on one of the trust’s medium secure wards (Ashcombe), with the patient using a ligature point. It was a similar incident to another serious incident in May on a different ward (Holcombe) at the hospital, and it prompted the inspection from the CQC in mid-August. While the death remains under investigation by the trust, early details shared with the CQC reveal that the incident happened in an area of the ward which had been changed to an “isolation area” under the trust’s COVID-19 infection prevention strategy. However, this meant there were not “good lines of sight” for staff monitoring patients – according to the CQC’s inspection report. There were also “low staffing levels on the wards”, according to staff which spoke to the CQC. The staff also told inspectors they were “stressed, exhausted and burnt out following the demands of the pandemic”. According to the CQC, some staff had concerns about areas on the ward where patients had “unrestricted access to items including sports equipment that could be used as weapons for self-harm”. Although the ward’s ligature assessment claimed those areas were always supervised by staff, this was disputed by the staff themselves, the report said. Read full story Source: HSJ, 3 November 2020 -
News ArticleA fourth suspected suicide has occurred at a mental health trust which was recently warned by the Care Quality Commission after three other similar inpatient deaths in quick succession, HSJ can reveal. All four deaths at Devon Partnership Trust had common themes, including the use of ligatures, and occurred amid a year-long delay to the trust’s plan to reduce ligature risks. Figures obtained by HSJ under freedom of information laws also reveal the trust took nearly a year to investigate the first two deaths. The target is 90 days. The trust told HSJ it had faced “humongous” problems addressing ligature risks and had been too “patient” with another trust which was helping to investigate the deaths. Read full story (paywallled) Source HSJ, 27 October 2020
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News ArticleA hospital that was at the centre of a major inquiry into unsafe maternity care five years ago is facing new questions over its safety after bosses admitted a baby boy would have survived if not for mistakes by hospital staff. Jenny Feasey, from Heysham in Lancashire, is still coming to terms with the loss of her son Toby who was stillborn at the Royal Lancaster Infirmary, part of the University Hospitals of Morecambe Bay Foundation Trust in January 2017 after a series of mistakes by staff who did not act on signs she had pre-eclampsia. Jenny, 33, has backed The Independent’s campaign for improved maternity safety and called on midwives to learn lessons after what happened to her family. She added: “This was an easily avoidable situation. They just didn’t piece it together, all they had to do was carry out a test and I lost my son because of it." Read full story Source: The Independent, 25 October 2020
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News ArticleA major acute trust has confirmed the health service inspectorate has begun a criminal investigation into three incidents at its hospitals. University Hospitals Birmingham FT told HSJ the Care Quality Commission (CQC) has started a criminal investigation into incidents involving potential errors around the provision of anti-coagulant medication. The trust received a letter from the CQC this month informing it that the regulator has begun the investigation under regulation 22 of the Health and Social Care Act 2008 (regulated activities) regulations 2014. The incidents happened at Queen Elizabeth Hospital in Birmingham and Good Hope Hospital — the trust’s two main sites. Regulation 22 says: “In order to safeguard the health, safety and welfare of service users, the registered person must take appropriate steps to ensure that, at all times, there are sufficient numbers of suitably qualified, skilled and experienced persons employed for the purposes of carrying on the regulated activity.” The CQC launched a prosecution into East Kent Hospitals University FT this month for failing to meet fundamental standards of care. The regulator also successfully prosecuted University Hospitals Plymouth Trust in September after it pleaded guilty to breaching the duty of candour. Read full story (paywalled) Source: HSJ, 23 October 2020
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News ArticleThe staff-side committee of a major hospital trust has stopped working with its leadership, with its chair alleging an ‘endemic’ culture of ‘racism, discrimination and bullying’. Irene Pilia, staff-side committee chair at King’s College Hospital Foundation Trust, told colleagues that the decision was taken “in the interests of staff”, especially black, Asian and minority ethnic workers, and expressed concerns about the organisation’s disciplinary procedures. She said the decision had the backing of staff committee officers and delegates. Ms Pilia, who is also the senior KCHFT Unite representative, said she was open to resuming partnership working again, but told trust executives: “I have lost trust and confidence in the ability of [KCHFT] to conduct fair, impartial and no-blame investigations. “Until there is tangible and credible evidence that racist behaviour at all levels is proactively eliminated, such that perpetrators face real consequences (including to the detriment of their careers) for their actions and are no longer allowed to behave in racist ways with impunity, I take a stand for the hundreds, possibly thousands of KCHFT staff whose voices are not being heard." Read full story (paywalled) Source: HSJ, 22 October 2020
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News ArticleAn independent review found that commissioners’ investigation of a young boy’s death was ‘mismanaged’, and heard allegations that the person who coordinated it was bullied over the contents. The independent review, commissioned by NHS England, has published its final report following an investigation into Bristol, North Somerset and South Gloucestershire clinical commissioning group’s LeDer review into the death of Oliver McGowan. Chaired by Fiona Ritchie, the independent review was commissioned last year after evidence emerged that the CCG had rewritten earlier findings of the review, removing suggestions his death at North Bristol Trust in 2016 was avoidable. Oliver died in November 2016 after being given anti-psychotic medication against his own and his parents’ wishes and despite medical records showing he had an intolerance to anti-psychotics. He developed severe brain swelling because of the drugs and died.A local LeDer review — part of a programme aimed at improving care based on deaths among people with learning disabilities — was launched in 2017, seven months after his death, by the CCG (then operating as three separate organisations), then published in 2018. In 2018, a coroner concluded Oliver’s care prior to his death was “appropriate” and made no recommendations. His death is also currently the subject of a police investigation. The lead reviewer (Ms A) stated in her panel interview that during the time she was undertaking this LeDeR she had felt bullied, overworked and overly stressed by the demands placed on her by the various correspondences with solicitors and her line management. The fact that Ms A believed she was isolated and unsupported during this review illustrates evident failures in the CCG assurance and management processes at the time. In a final report by the subsequent independent review, published today, the panel led by Ms Ritchie “unanimously” agreed Oliver’s death was “potentially avoidable”. Read full story (paywalled) Source HSJ, 20 October 2020
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News ArticleThe parents of a three-year-old boy whose death was part of an alleged NHS cover-up have won a six year battle for the truth about how he died. Shropshire coroner John Ellery backed the parents of three-year-old Jonnie Meek in a second inquest into his death on Thursday and rejected evidence from nurses about what happened at Stafford Hospital in August 2014. Jonnie, who was born with rare congenital disability De Grouchy syndrome, died two hours after being admitted to hospital to trial a new feed which was being fed directly into his stomach. His parents, John Meek and April Keeling, from Cannock in Staffordshire, have always maintained their son died after a reaction to the milk feed caused him to vomit and suffocate. But they have been forced to battle what they believe was an attempt to hide what happened after they discovered attempts to alter their son’s medical history with claims he had experienced several cardiac arrests requiring resuscitation which never happened. In 2015, healthcare assistant Lauren Tew, who was with Jonnie and his mother when he died, told the HSJ that a statement in her name submitted to a child death overview panel stating Jonnie had died from a sudden cardiac arrest was false and she had never made such a statement. Another statement said Jonnie had been admitted to hospital for three weeks months before his death which also never happened. After his parents exposed the false statements an independent inquiry was launched, with three independent experts agreeing with Jonnie’s parents, and in April last year the High Court quashed the original inquest verdict that Jonnie died of natural causes and pneumonia. Speaking to The Independent Jonnie’s father said: “This does bring us some peace after six years. For the coroner to say he believes April over the nurses after all this time is a big weight lifted off her. “The hospital definitely decided to try and cover up what happened to Jonnie. We have always said we knew what happened and this has been a massive waste of resources. I am still very concerned about how these things can happen in the first place.” Read full story Source: The Independent, 15 October 2020
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News ArticleAn NHS trust has offered an unreserved apology to an elderly patient and his family after they accused hospital staff of restraining him 19 times in order to forcibly administer treatment. East Kent Hospitals University NHS Foundation Trust admitted that care for the man, who has dementia, “fell far short” of what patients should expect. The 77-year-old had been admitted to the William Harvey Hospital last November for urinary retention problems, according to a recent BBC investigation. In February, The Independent revealed that a police investigation had been launched into an alleged assault against an elderly man at the hospital after nurses and carers were filmed by hospital security staff holding the man’s arms, legs and face down while they inserted a catheter. A whistleblower told The Independent that the incident was being covered up by the trust and staff were told: “Don’t discuss it, don’t refer to it at all.” On Wednesday, the trust said its investigation had found a failure to alert senior medics to the difficulties being experienced in caring for the patient. Changes to dementia care including ward reorganisation, training and recruitment are underway, said a spokesperson, who added: “We apologise unreservedly to the patient and his family for the failings in his care, this fell far short of what patients should expect.” Read full story Source: The Independent, 14 October 2020
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News Article
‘Babies are still being damaged’ Tory peer warns ‘evasive’ ministers
Patient Safety Learning posted a news article in News
The government has been told it is ‘not sustainable’ to continue to delay its response to a major review on patient safety as ‘babies are still being damaged’. The Independent Medicines and Medical Devices Safety Review spoke to more than 700 people, mostly women who suffered avoidable harm from surgical mesh implants, pregnancy tests and an anti-epileptic drug, and criticised “a culture of dismissive and arrogant attitudes” including the “unacceptable labelling of many symptoms as “attributable to ‘women’s problems’”. The review’s author Baroness Julia Cumberlege told HSJ that “time is marching on” for the Department of Health and Social Care to implement the recommendations of her July report, which include setting up a new independent patient safety commissioner. The Conservative peer said pressure was building on government to adopt the findings of the review, since it had been endorsed by Royal Colleges and has already been adopted by the Scottish government. She said the government had given “evasive” answers in parliament on the issue. In an exclusive interview with HSJ, Baroness Cumberlege said: There is a crowded field of regulators but “there’s a void” for a service that listens and responds to patients’ safety concerns. She feels “diminished” that women’s concerns are still being dismissed by clinicians, but said young doctors are a cause for hope. She is “very optimistic” report will be implemented – but the NHS has to have the will to make changes. Read full story (paywalled) Source: HSJ, 13 October 2020 -
News Article
Maternity scandal hospital fined for not triaging A&E patients fast enough
Patient Safety Learning posted a news article in News
An NHS hospital which has faced repeated criticism by regulators for poor standards of care has been fined £4,000 for failing to assess A&E patients quickly enough. The Shrewsbury and Telford Hospitals Trust has been fined by the Care Quality Commission (CQC) after patients were not triaged within 15 mimutes of arrival in A&E – in breach of conditions set by the regulator last year and a national target. The care of emergency patients at the hospital trust, which is also facing an inquiry into poor maternity care, has been a long running concern for the watchdog which has rated the trust inadequate and put it in special measures in 2018. Earlier this year the CQC’s chief inspector of hospitals, Professor Ted Baker, wrote to NHS England warning of a “worsening picture" at the Midlands hospital and demanding action be taken. The CQC said it had issued the fixed penalty notice to the trust because it failed to comply with national clinical guidance that all children and adults must be assessed within 15 minutes of arrival. It also failed to implement a system that ensured all children who left the emergency department without being seen were followed up. After inspections in April 2019 and November 29 the CQC imposed seven conditions on the hospital over emergency care. The regulator said it was now clear the trust had not stuck to the conditions and had breached them both at Royal Shrewsbury Hospital and Princess Royal Hospital. Professor Baker said: "The trust has not responded satisfactorily to previous enforcement action regarding how quickly patients are assessed upon entering the urgent and emergency department." “We have issued a penalty notice due to the severity of the situation and to ensure the necessary, urgent improvements are made. It is essential that patients are seen in a timely way when they arrive at an emergency department; failure to do so could result in deteriorating health, harm, or even death, which is why national guidelines exist and must be followed." Read full story Source: The Independent, 12 October 2020 -
News ArticleAn urgent investigation into blanket orders not to resuscitate care home residents has been launched amid fears some elderly people may still be affected by the “unacceptable” practice. After COVID-19 cases rose slightly in care homes in England in the last week, with 116 residences handling at least one infection, the Care Quality Commission (CQC) said it was developing the scope of its investigation “at pace” and it would cover care homes, primary care and hospitals. In March and April, there were reports that some GPs had applied “do not attempt resuscitation” (DNAR) notices to groups of care home residents that meant people would not be taken to hospital for potentially life-saving care. This was being done without their consent or with little information to allow them to make informed decisions, the CQC said. Cases emerged in care homes in Wales and East Sussex. Care homes said the blanket use of the orders did not appear to be as prevalent ahead of a possible second wave of infections and families were reporting fewer concerns, although that could be because visiting restrictions meant they had less access to the homes and were getting less information. There are also concerns that steps may not have been taken to review DNAR forms added to care home residents’ medical files, and so they could remain in place, without proper consent. The CQC review will examine the use of “do not attempt cardiopulmonary resuscitation” (DNACPR) notices, which only restrict chest compressions and shocks to the heart. Dr Rachel Clarke, a palliative care expert in Oxford, has described the CPR process as “muscular, aggressive, traumatic” and said it often resulted in broken ribs and intubation. The review will also investigate the use of broader do not resuscitate and other anticipatory care orders. “We heard from our members about some pretty horrific examples of [blanket notices] early in the pandemic, but it does not appear to be happening now,” said Vic Rayner, the executive director of the National Care Forum, which represents independent care homes. “DNAR notices should not be applied across settings and must be only used as part of individual care plans.” It will also investigate the use of broader do not resuscitate and other anticipatory care orders. Read full story Source: The Guardian, 12 October 2020
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News ArticleThe announcement on Friday by the Care Quality Commission (CQC) that it will bring criminal charges against an NHS trust for failing to provide safe care to a patient is a hugely significant milestone in efforts to bring about greater accountability and safer care in the health service. The CQC has had the power to bring such prosecutions against hospitals since April 2015 when it was given a suite of new legal powers to hold hospitals to account on the care they give to their patients. Bringing in the new laws, the so-called fundamental standards of care, was one of the most significant actions taken after the care disaster at the Mid Staffordshire NHS Trust, where hundreds of patients suffered shocking neglect, with some dying as a result. Prosecuting East Kent Hospitals University Trust over the tragic 2017 death of baby Harry Richford is a big step for the CQC and a consequence of the long-forgotten battles of many patients and families in Stafford who were told they were wrong in their complaints against the hospital. It will almost certainly lead to more calls for criminal charges against hospitals from families who have been failed. There are countless examples of NHS trusts not acting on safety warnings and patients coming to harm as a result. Just this week an inquest into the case of baby Wynter Andrews at Nottingham University Trust revealed fears over safety had been highlighted to the trust board 10 months before her death. At Shrewsbury and Telford Hospitals Trust there are hundreds of families asking the same questions as more evidence emerges of long-standing failures to learn from its mistakes. CQC's chief executive, Ian Trenholm, has provoked anger among NHS leaders and clinicians when he advocated taking a tougher line when trusts break the law. But it is unlikely the CQC will launch a slew of prosecutions. It has said it will bring cases only where it sees patterns of behaviour and systemic failings. That is the correct approach as healthcare is complex and single errors will sadly happen despite everyone doing their best. Read full story Source: The Independent, 10 October 2020
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News ArticleThe Care Quality Commission (CQC) has launched the first prosecution of an acute trust for failing to meet fundamental standards of care. East Kent Hospitals University Foundation Trust faces two charges relating to the death of Harry Richford and the risks posed to his mother during his birth. Both charges are under regulation 12 of the Health and Social Care Act 2008. The trust is accused of failing to discharge its duty under regulation 12 in that it failed to provide safe care and treatment exposing Harry and his mother Sarah to a significant risk of avoidable harm. It is only the fourth prosecution of a trust over the “fundamental standards” which were brought in following the Mid Staffordshire care scandal and are meant to be enforced by the CQC. It is also thought to be the first related to the safety of clinical care. Read full story (paywalled) Source: HSJ, 9 October 2020
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News Article
Former ministers to hold 'rapid' inquiry into government's COVID-19 response
Patient Safety Learning posted a news article in News
A pair of Conservative former ministers have announced they are to lead a rapid, cross-party investigation into the UK’s handling of the coronavirus crisis, amid worries a government inquiry will take too long for lessons to be learned in time. In a rare set of joint hearings, the Commons health committee, led by ex-health secretary Jeremy Hunt, and the science committee, chaired by Greg Clark, who was business secretary, are to hear from witnesses in the hope of producing a report by the spring. Announcing the plan, Hunt and Clark said the inquiry would aim to produce interim recommendations along the way. It will hold weekly joint sessions, with early witnesses set to include Chris Whitty, the chief medical officer for England, and Patrick Vallance, the government’s top scientific adviser. Hunt said he would expect the inquiry to cover the need for regular, large-scale coronavirus testing, an issue he has repeatedly raised in parliament, and whether this could help people visit loved ones in care homes. The hearings begin next Tuesday with a session on social care. Other promised areas of examination include the efficacy of lockdown measures; how well modelling and statistics have been used; the efficacy of government messaging; wider preparedness for a pandemic; and the impact on BAME communities. Read full story Source: The Guardian, 8 October 2020 -
News Article
Baby died on maternity unit months after staff warned it was unsafe
Patient Safety Learning posted a news article in News
A baby died during birth because of systemic errors in one of Britain's largest NHS hospitals, months after staff had warned hospital chiefs that the maternity unit was “unsafe”, an inquest has found. A coroner ruled that neglect by staff at Nottingham University Hospitals Trust contributed to the death of baby Wynter Andrews last year. She was delivered by caesarean section on 15 September after significant delays. Her umbilical cord was wrapped around her neck and leg, resulting in her being starved of oxygen. In a verdict on Wednesday, assistant coroner Laurinda Bower said Wynter would have survived if action had been taken sooner, criticising the units “unsafe culture” and warning that her death was not an isolated incident. Wynter’s mother, Sarah Andrews, called on the health secretary, Matt Hancock, to investigate the trust’s maternity unit. She said: “We know Wynter isn’t an isolated incident; there have been other baby deaths arising because of the trust’s systemic failings. She was a victim of the trust’s unsafe culture and practices.” Read full story Source: The Independent, 7 October 2020 -
News Article
Care watchdog to target NHS maternity units after baby death scandals
Patient Safety Learning posted a news article in News
The Care Quality Commission (CQC) is to target poorly performing NHS maternity units after a series of maternity scandals. It is drawing up plans to spot high-risk maternity units and will use data on their patient outcomes and culture to draw up a list of facilities for targeted inspection. The watchdog has voiced concerns over the wider safety of maternity units in the NHS after a number of high-profile maternity scandals in the past year. Almost two-fifths of maternity units, 38%, are rated as “requires improvement” by the CQC for their safety. The Independent has joined with charity Baby Lifeline to call on the government to reinstate a national maternity safety training fund for doctors and midwives. The fund was found to be successful but axed after just one year. On Tuesday, the CQC’s chief inspector of hospitals, Professor Ted Baker, told MPs on the Commons Health and Social Care Committee that he was concerned about the safety of mothers and babies in some maternity units which had persistent problems. “Those problems are of dysfunction, poor leadership, of poor culture, of parts of the services not working well together,” he said. “This is not just a few units; this is a significant cultural issue across maternity services.” Now the CQC has confirmed it is planning to draw up a list of poor-performing units or hospitals where it suspects there could be safety issues. The new inspection programme will specifically look at issues around outcomes and teamworking culture although the full methodology has yet to be decided. Read full story Source: The Independent, 4 October 2020 -
News ArticleSending thousands of older untested patients into care homes in England at the start of the coronavirus lockdown was a violation of their human rights, Amnesty International has said. A report says government decisions were "inexplicable" and "disastrous", affecting mental and physical health. More than 18,000 people living in care homes died with COVID-19 and Amnesty says the public inquiry promised by the government must begin immediately. According to Amnesty's report, a "number of poor decisions at both the national and local levels had serious negative consequences for the health and lives of older people in care homes and resulted in the infringement of their human rights" as enshrined in law. Researchers for the organisation interviewed relatives of older people who either died in care homes or are currently living in one; care home owners and staff, and legal and medical professionals. Amnesty said it received reports of residents being denied GP and hospital NHS services during the pandemic, "violating their right to health and potentially their right to life, as well as their right to non-discrimination". It adds that care home managers reported to its researchers that they were "pressured in different ways" to accept patients discharged from hospital who had not been tested or had COVID-19. Amnesty says the public inquiry into the pandemic should begin with an "interim phase". "The pandemic is not over," it added. "Lessons must be learned; remedial action must be taken without delay to ensure that mistakes are not repeated." Read full story Source: BBC News, 4 October 2020
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News ArticleThe NHS 111 service has permanently stopped nurses and other healthcare professionals in a clinical division handling calls with people suspected of having COVID-19 after an audit of recorded calls found more than 60% were not safe. The audit was triggered in July after many of the medical professionals recruited to work in that clinical division of the 111 service sounded the alarm, saying they did not feel “properly skilled and competent” to fulfil such a critical role. An investigation was launched into several individual cases after the initial review found that assurances could not be given “in regard to the safety of these calls”, according to an email, seen by the Guardian, from the clinical assurance director of the National Covid-19 Pandemic Response Service. In a further email on 14 August, she told staff that after listening to a “significant number” of calls “so far over 60% … have not passed the criteria demonstrating a safe call”. A number of “clinical incidents” were being investigated, she said, because some calls “may have resulted in harm”. One case had been “escalated as a serious untoward incident with potential harm to the patient”. NHS England declined to answer questions about any aspect of these apparent safety failings, saying it was the responsibility of the South Central ambulance service (SCAS), which set up a section of NHS 111 called the Covid-19 Clinical Assessment Service (CCAS). Read full story Source: The Guardian, 1 October 2020
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News ArticleAs she lay dying in a Joliette, Que., hospital bed, an Atikamekw woman clicked her phone on and broadcast a Facebook Live video appearing to show her being insulted and sworn at by hospital staff. Joyce Echaquan's death on Monday prompted an immediate outcry from her home community of Manawan, about 250 kilometres north of Montreal, and has spurred unusually quick and decisive action on the part of the provincial government. The mother of seven's death will be the subject of a coroner's inquiry and an administrative probe, the Quebec government said today. A nurse who was involved in her treatment has been dismissed. But that dismissal doesn't ease the pain of Echaquan's husband, Carol Dubé, whose voice trembled with emotion as he told Radio-Canada his wife went to the hospital with a stomach ache on Saturday and "two days later, she died." Echaquan's relatives told Radio-Canada she had a history of heart problems and felt she was being given too much morphine. In the video viewed by CBC News, the 37-year-old is heard screaming in distress and repeatedly calling for help. Eventually, her video picks up the voices of staff members. One hospital staff member tells her, "You're stupid as hell." Another is heard saying Echaquan made bad life choices and asking her what her children would say if they saw her in that state. Dubé said it's clear hospital staff were degrading his wife and he doesn't understand how something like this could happen in 2020. Read full story Source: CBC News, 29 September 2020
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News ArticleThe surgeon at the centre of a body parts scandal operated on patients who were dangerously sedated so that their procedures could be carried out simultaneously, according to a leaked investigation seen by The Independent. Renowned hip surgeon Derek McMinn and two anaesthetists at Edgbaston Hospital, Birmingham, were accused of putting “income before patient safety” in the internal investigation for BMI Healthcare, which runs the hospital. It comes after a separate review found that McMinn had hoarded more than 5,000 bone samples from his patients without a licence or proper permission to do so over a period of 25 years, breaching legal and ethical guidelines. Police are investigating a possible breach of the Human Tissue Act. According to the report on sedation by an expert from another hospital, the two anaesthetists, Imran Ahmed and Gauhar Sharih, sedated patients for so long that their blood pressure fell to dangerous levels in order to allow McMinn to carry out near-simultaneous surgery. It found this meant long delays in the operations starting, with one sedated patient being subjected to prolonged anaesthesia for longer than one hour and 40 minutes – recommended best practice is 30 minutes. Another patient was apparently "abandoned" for an hour and 26 minutes after their surgery was only partially completed while McMinn began operating on another patient. The report’s author, expert anaesthetist Dr Dhushyanthan Kumar of Coventry’s University Hospital, said this was unsafe practice by all three doctors and urged BMI Healthcare to carry out a review of patients to see if any had suffered lasting brain damage. Both anaesthetists work for the NHS – Ahmed at Dudley Group of Hospitals, Sharih at University Hospitals Birmingham – without restrictions on their ability to practise. Read full story Source: The Independent, 30 September 2020
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News ArticleFor more than two decades, Derek McMinn harvested the bones of his patients, according to a leaked report – but it was not until last year that anyone challenged the renowned surgeon. The full scale of his alleged collection was apparently kept from the care regulator until just days ago, and thousands of those who went under his knife for hip and knee treatment still have no idea that their joints may have been collected in a pot in the operating theatre, and stored in the 67-year-old’s office or home. Clinicians and managers at the BMI Edgbaston Hospital, where McMinn carried out the majority of his operations, actively took part in the collection of bones and – even after alarms were raised – the hospital did not immediately act to stop the tissue being taken away, according to a leaked internal report seen by The Independent. An investigation found operating theatre staff at the private hospital left dozens of pots containing joints removed from patients femurs during hip surgery in a storage area, in some cases for months. According to the report, there had been warnings about their responsibilities under the Human Tissue Act when an earlier audit between 2010 and 2015 identified the storage of femoral heads, the joints removed in the procedure. The internal report said there was no evidence McMinn had carried out any research or had been approved for any research work – required by the Human Tissue Authority to legally store samples. It said one member of staff told investigators the samples were being collected for research on McMinn’s retirement. Although the Care Quality Commission knew about claims that a small number of bones being kept by McMinn, it is understood that the regulator received a copy of the BMI Healthcare investigation report only last Friday, after The Independent had made initial inquiries about the case. That report suggests a minimum of 5,224 samples had been taken by McMinn. The regulator confirmed to The Independent it had not been aware of the extent of McMinn’s supposed actions. An insider at BMI Healthcare accused the company of “covering up”, adding: “Quite senior staff at the hospital went along with it and just handed the pots over to his staff when they came to collect them.” Read full story Source: The Independent, 30 September 2020
