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Found 1,558 results
  1. News Article
    Nearly 200 families have now reported experiences of poor maternity and neonatal care in East Kent, according to the family whose baby’s death sparked both an independent investigation and a court case against the trust. Baby Harry Richford died seven days after his birth at the Queen Elizabeth, the Queen Mother, Hospital in Thanet in 2017. Next week, the Care Quality Commission is taking East Kent Hospitals University Foundation Trust to court, alleging it failed to meet fundamental standards of care in the treatment of both Harry and his mother Sarah. An independent investigation, led by Bill Kirkup, is also looking into maternity and neonatal services at the trust. In a statement, the Richford family told HSJ they had had numerous contacts from other families who had had bad experiences of maternity and neonatal care at the trust. “We have encouraged such families to come forward to the Kirkup Inquiry and now believe that the number of families is approaching 200,” they said. Read full story (paywalled) Source: HSJ, 16 April 2021
  2. News Article
    A care home under investigation over a resident's death has been rated inadequate for the second time. Merseyside Police began investigating Prescot's Griffin House after the death of a 90-year-old man in June 2020. The Care Quality Commission (CQC) rated it inadequate in September, highlighting safety concerns and a report from February, released on 9 April, found it had not improved. The inspection on 24 February found management had failed to adequately address the problems previously identified by the CQC and there were new concerns relating to staff recruitment. Inspectors found medicines were not always administered safely, COVID-19 guidance was not always followed and there was not always enough staff on duty. They also noted some staff had not had proper background checks before starting work, but added that since the inspection, a new system had been introduced to ensure checks were carried out. The report said the home's management "refused to follow government guidelines and participate in lateral flow testing for visitors to the home as they did not believe these tests were accurate". Read full story Source: BBC News, 13 April 2021
  3. News Article
    A public inquiry into the infected blood scandal has been told some patients were used as "guinea pigs" at Belfast's Royal Victoria Hospital. The inquiry is looking at how haemophilia patients across the UK were treated with Hepatitis C infected blood or HIV in the 1970s and 1980s. Among the correspondence presented to the inquiry this week was a letter, dated 1988, sent by Dr Elizabeth E Mayne, consultant/director at the Department of Haematology in the Royal Victoria Hospital, to Professor Ludlam at the Royal Infirmary in Scotland. The letter was part of discussions about a potential switch between an NHS product and a commercial product, Profilate Factor 8. Dr Mayne explained that "complications may arise with this product or indeed a safer product may become available". She added: "I am happy for us to try this arrangement as long as the treatment of the children here and the small number of other patients is safeguarded." She concluded "It would be interesting to see the reactions of the patients to this change over and to see if the number of units consumed is reduced." After the letter was read into the record of the inquiry, the chairman, Sir Brian Langstaff, said: "There is also the implicit suggestion there that the patients will not have been asked in advance. "It is going to be given to them and they wait to see what the reaction is." Counsel to the inquiry, Jenni Richards QC, replied "Yes, there doesn't appear to have been an element of choice." Read full story Source: The Independent, 1 April 2021
  4. News Article
    A witness to an inquiry into deaths at England’s largest mental health trust has been intimidated by “cruel and calculated pressure”, with messages described by the man leading the investigation as “truly shocking”. In a statement at the start of hearings into the quality of care at Southern Health Foundation Trust, inquiry chairman Nigel Pascoe QC said one witness had received threatening telephone calls, messages and emails, which he said were “totally unacceptable, damaging and deeply disturbing”. Mr Pascoe said the inquiry had been told Beth Ford, whose job title at the trust is service user involvement facilitator, had been intimidated by members of the public. Ms Ford, who has autism, was admitted to hospital for her mental health earlier this month as a result of the abuse, but has now returned home. It’s the latest incident to hit the controversial inquiry, which has itself faced fierce criticism from the families of five patients who died between 2011 and 2015. The families have pulled out of the inquiry and accused the investigation and NHS England of bullying them and going back on promises to properly investigate the deaths of their relatives. Maureen Rickman, whose sister Jo Deering died in 2011, told The Independent she didn’t believe any of the main families were involved in intimidating witnesses. Read full story Source: The Independent, 29 March 2021
  5. News Article
    A French court has fined one of the country’s biggest pharmaceutical firms €2.7m (£2.3m) after finding it guilty of deception and manslaughter over a pill linked to the deaths of up to 2,000 people. In one of the biggest medical scandals in France, the privately owned laboratory Servier was accused of covering up the potentially fatal side-effects of the widely prescribed drug Mediator. The former executive Jean-Philippe Seta was sentenced to a suspended jail sentence of four years. The French medicines agency, accused of failing to act quickly enough on warnings about the drug, was fined €303,000. The amphetamine derivative was licensed as a diabetes treatment, but was widely prescribed as an appetite suppressant to help people lose weight. Its active chemical substance is known as Benfluorex. As many as 5 million people took the drug between 1976 and November 2009 when it was withdrawn in France, long after it was banned in Spain and Italy. It was never authorised in the UK or US. The French health minister estimated it had caused heart-valve damage killing at least 500 people, but other studies suggest the death toll may be nearer to 2,000. Thousands more have been left with debilitating cardiovascular problems. Servier has paid out millions in compensation. “Despite knowing of the risks incurred for many years, … they [Servier] never took the necessary measures and thus were guilty of deceit,” said the president of the criminal court, Sylvie Daunis. Read full story Source: The Guardian, 29 March 2021
  6. News Article
    Doctors and nurses were absent from crucial meetings about oxygen supplies to hospital wards in the run up to the coronavirus crisis, a safety watchdog has warned. At one hospital trust, which was forced to declare a major incident during the second wave of the crisis, doctors had not attended the hospital’s medical gas committee (MGC) since 2014. The Healthcare Safety Investigation Branch (HSIB) said it had discovered a similar lack of input at other NHS trusts and also warned that none of the urgent alerts and guidance from NHS England ahead of the Covid surge had been discussed at the committee. HSIB has launched an investigation into the failure of oxygen piping systems during the Covid surge after a number of hospitals were forced to declare major incidents and divert patients to other hospitals. Read full story Source: The Independent, 24 March 2021
  7. News Article
    A previously secret report into children’s services at a scandal-hit NHS hospital has revealed concerns over the safety of services including care of seriously ill babies were raised with managers back in 2015. A report by the Royal College of Paediatrics and Child Health (RCPCH) raised serious concerns over children’s services at East Kent Hospitals University Trust in 2015 including senior consultants refusing to work beyond 5pm and a shortage of nurses and junior doctors. It also found the neonatal intensive care unit was being staffed by general paediatric doctors instead of specialist neonatal consultants. The confidential report was given to The Independent and posted on the trust’s website this week after being mentioned in the terms of reference for an independent inquiry examining dozens of baby deaths at the trust. It had never been published by the trust, which three years later had its children’s services rated inadequate. A second major report by the Royal College of Obstetricians and Gynaecologists in 2016 highlighted concerns that were not acted on and later featured in the avoidable death of baby Harry Richford, in 2017 which sparked the scandal into dozens more deaths and brain injuries. Bill Kirkup, who is leading the inquiry into East Kent’s maternity services, previously recommended Royal College reviews be registered with the CQC and shared openly by NHS trusts. In its report, the RCPCH said there was “resistance from some consultants to work extended hours” across the trust’s different services with signs of clinicians worked in silos at the different hospitals run by the trust. It warned that paediatric consultants were “spread too thinly across the service” and consultants were providing specialist clinics based on their interests rather than local need. There was “insufficient middle grade doctors to cover both sites” and there were “too few skilled nurses on the wards.” Read full story Source: The Independent, 24 March 2021
  8. News Article
    Long delays for coronavirus patients to get through to NHS 111 call handlers while other seriously ill patients were told to stay at home have prompted a safety watchdog to launch an investigation of the phone triage service. The Healthcare Safety Investigation Branch (HSIB) has launched an inquiry into the handling of coronavirus calls by NHS 111 – the first port of call for patients when they become unwell. During the pandemic the NHS 111 service set up a dedicated COVID-19 Clinical Assessment Service (CCAS) but concerns over the safety of advice given to patients saw nurses and non-medical staff stopped from taking patient calls in August last year. Now concerns from a number of patients and families have led the independent HSIB to launch a review of the service and to identify any learning and improvements. HSIB told The Independent the investigation was at an early stage and it was not yet certain of any direct link to patient harm. It said the number of patient cases could grow but that it had initial family concerns related to difficulties getting through to NHS 111, long delays in getting clinical call backs after an initial triage call and concerns that some patients were told to stay at home when they were seriously ill. Read full story Source: The Independent, 23 March 2021
  9. News Article
    Ministers have been accused of “knowingly exposing” NHS and private patients to safety risks after delaying again a full response to the inquiry into the Ian Paterson scandal. Victims of rogue surgeon Ian Paterson, who was jailed in 2017 for carrying out unnecessary surgery on patients, told The Independent there was a “clear and present danger” of similar crimes being committed without urgent action being taken. On Tuesday, the government released a partial response to an independent inquiry, led by Reverend Graham James, which reported in February last year. It revealed Paterson was able to carry out unnecessary surgery on more than 1,000 patients over a 14 year period due to a “dysfunctional” health system and the wilful blindness of managers. The government response addressed only three recommendations directly with ministers promising a full response later this year. David Rowland, director at the Centre for Health and the Public Interest criticised the lack of action as the NHS sends more patients to private hospitals in the wake of the coronavirus pandemic. Read full story Source: The Independent, 23 March 2021
  10. News Article
    A trust being investigated over maternity care failings was urged six years ago to strengthen its neonatal staffing, HSJ can reveal. An external review into East Kent Hospitals University Foundation Trust — conducted in 2015 and kept under wraps until now — said it had insufficient staffing, and that medical consultants felt a lack of engagement with senior managers. The trust released the review yesterday after its existence became public for the first time earlier this month. Last year, the trust was heavily criticised at the inquest of baby Harry Richford, who died seven days after he was born at the Queen Elizabeth, the Queen Mother, Hospital in Thanet. The Care Quality Commission is taking the trust to court over the case, and is the subject of an external inquiry. Among the recommendations of the review, carried out by the Royal College of Paediatrics and Child Health, were that consultants and junior doctors covering the neonatal intensive care unit “should have responsibilities solely to that specialty”. Such a move would improve the quality and safety of the service, the review suggests. Read full story (paywalled) Source: HSJ, 22 March 2021
  11. News Article
    There was a "gross failure in basic care" which led to a baby being starved of oxygen during birth, a coroner said. Zak Ezra Carter died at the Royal Gwent Hospital, Newport, two days after being born in July 2018 at Ystrad Fawr Hospital in Caerphilly county. Gwent coroner Caroline Saunders said the monitoring of Zak and his mother Adele Thomas fell "well below the standards expected". She said she was reassured the health board had taken steps to improve care. Ms Thomas told the Newport hearing she felt "scared" and staff "didn't care" when she arrived to give birth on 20 July 2018. In a statement to the inquest she described being turned away from the centre after going into labour on three occasions, before being admitted on the fourth. Ms Thomas said she was initially offered paracetamol as pain relief at the midwife-led centre. She described "a lot of arguing between nurses", one of whom was "bolshie and rude and rough handled me", adding the midwives "did not appear to be in any rush". When Zak was born, he was described as being "white and pale" and without a heartbeat. He did not cry and was taken away to a room for resuscitation. Zak was transferred to the Royal Gwent Hospital where he died two days later. During the first stage of labour, Prof Sanders said "everything was progressing at a normal healthy rate and the fetal heart rate was recorded as completely normal". But she said it was "highly unusual" for the heart rate to not be documented contemporaneously, and the midwives had not been able to explain why they had not done so. Recording a narrative conclusion, Ms Saunders said the monitoring of Ms Thomas and her baby had "fallen well below the standards expected", leading to a "gross failure in basic care" of them in the later stages of labour. Read full story Source: BBC News, 18 March 2021
  12. News Article
    The COVID-19 Bereaved Families for Justice group has told Downing Street it wants a statutory public inquiry led by a senior judge to “determine a definitive, official, evidence-based narrative of what did and did not happen, independent of political influence” during the pandemic. The group considers it potentially cathartic and wants the families’ grief heard. Frontline health workers also want a wide-ranging inquiry to provide a platform for their experiences, while minority ethnic leaders believe an inquiry can only determine what went wrong if wider societal inequalities relating to work, health and housing are investigated. But while there is no dissent about the need for an inquiry, others fear this remit might be too broad – and fear lessons have to be learned now so the UK can properly protect itself from any future health emergency. Sir John Bell, the regius professor of medicine at Oxford University, and Lord O’Donnell, head of the civil service under Tony Blair, Gordon Brown and David Cameron, want a different model more narrowly focused on determining future actions. Ultimately the decision will be for Boris Johnson, who has significant latitude to set the terms and scope of any inquiry, including selection of its chair. Read full story Source: The Guardian, 16 March 2021
  13. News Article
    Hospitals and care homes are failing to properly investigate incidents before referring nurses to their regulator, fuelling a blame culture and repeat failures, the head of the nursing watchdog has told The Independent. In her first national interview, Andrea Sutcliffe, head of the Nursing and Midwifery Council (NMC) said some employers were referring nurses without any investigation at all, while half of initial enquiries to the NMC were rejected or required further work. She told The Independent this emphasis on blaming the individual meant underlying causes of safety errors were being missed and so they were likely to be repeated. Her ambition is to transform the nursing regulator, which oversees 725,000 nurses and midwives across the UK, into a more forceful watchdog that will flag systemic issues of concern with NHS trusts and care homes. In a wide-ranging interview, Ms Sutcliffe called on ministers to ensure that planned legislation to reform the way clinicians are regulated be made transparent and maintain the public’s confidence. She also stressed that the impact of coronavirus on nurses mental health meant rushing to restart routine operations in the NHS had to be carefully planned to avoid driving nurses out of the health service. Read full story Source: The Independent, 16 March 2021
  14. News Article
    An inquiry into dozens of baby deaths at an NHS trust will examine failings from “ward to board” covering a period of more than a decade, it has emerged. The independent inquiry into poor maternity care at East Kent Hospitals University Trust published its terms of reference and scope for how it will carry out its work on Thursday. The probe, led by Dr Bill Kirkup, was commissioned by the government after The Independent revealed more than 130 infants suffered brain injuries during birth at the trust over several years. The scandal was exposed by the family of baby Harry Richford who died after a catalogue of errors by maternity staff in November 2017. A coroner ruled his death was the result of neglect and “wholly avoidable”. Several other families have also spoken out over the deaths of their babies, with evidence emerging the trust’s managers were warned about safety concerns but failed to take action. In October, the Care Quality Commission (CQC) said it intended to prosecute the trust over the death of Harry Richford. It is understood that since the inquiry was launched, a significant number of families have come forward with concerns but the inquiry has refused to say what the total number of cases is. Read full story Source: The Independent, 11 March 2021
  15. News Article
    A doctor told a panel investigating an NHS trust there has been a "cultural shift" in the way staff communicate with patients and their families. Southern Health NHS Foundation Trust is being investigated after failures in its care of five patients who died between 2011 and 2015. Dr Susie Carman said staff went through a "rough patch" when they "felt worried about doing the wrong thing". She said there was "more confidence" among staff to communicate better. The inquiry, which is due to last six weeks, is probing how the trust currently handles complaints, communicates with families of patients, and carries out investigations. It follows a report by Nigel Pascoe QC that found Southern Health, one of the biggest psychiatric trusts in England, acted with "disturbing insensitivity and a serious lack of proper communication" to family members. Dr Carman said there had since been a "genuine culture shift from the top of the organisation". She believed the trust could "still do things better" in its communication methods but said there was "more will about understanding why it (communication) is so important". The inquiry heard that a patient's "consent to share" information or not could present an "obstacle" in communicating with families and carers. Ahead of the inquiry, the bereaved families decided to withdraw from the process after they claimed to have been "misled, misrepresented and bullied" by the NHS. Read full story Source: BBC News, 10 March 2021
  16. News Article
    A long-delayed review into West Suffolk Foundation Trust board members’ alleged bullying of whistleblowers is now due to be published ‘by the spring’, senior figures familiar with the process have told HSJ. The news comes amid calls from senior medics and a campaign group for the review — originally due for publication in April 2020 — to be published as soon as possible. The review was set up to investigate the “handling and circumstances surrounding concerns raised in a letter that was sent in October 2018, to the relative of a patient who had died in the Suffolk hospital”. The letter was sent to the family of Susan Warby, 57, who died at West Suffolk Hospital in August 2018 after suffering multi-organ failure and other complications. The letter’s anonymous author raised serious concerns about her treatment by the trust. The trust launched an investigation, involving fingerprinting and handwriting experts, to find the letter’s author. The process, led by the trust’s senior management, prompted staff to report they felt harassed and bullied, and unions to label the process a “witch hunt” (See box below: Timeline of West Suffolk bullying allegations). NHS England and Improvement is overseeing the probe, which was ordered by ministers in January 2020. The coronavirus pandemic caused publication to be pushed back until December, but no official reasons have been given for the further delay. Read full story (paywalled) Source: 9 March 2021
  17. News Article
    NHS hospitals have been forced to pay millions of pounds to regulators after wrongly claiming their maternity units were among the safest in the country. Seven NHS trusts, including some now at the centre of major care scandals, will have to pay back a total of £8.5m after self-assessments of their maternity services were found to be false. Families whose babies died as a result of avoidable errors at some of the hospitals told The Independent it was further evidence of poor governance and management failings. NHS Resolution, which acts as the health service’s insurer for clinical negligence, launched the maternity incentive scheme in 2018 in an effort to focus action on 10 key safety areas in maternity, including ensuring they have systems in place to review deaths, monitor women and plan staffing levels as well as reporting incidents to the Healthcare Safety Investigation Branch which investigates maternity incidents in the NHS. Among the trusts forced to give money back over the first two years of the scheme include Shrewsbury and Telford Hospital Trust, which paid back £953,000. An inquiry into its maternity service found a dozen women and more than 40 babies died as a result of poor care in one of the largest maternity scandals in NHS history. East Kent Hospitals University Trust, which is facing an inquiry into baby deaths and a criminal prosecution by the Care Quality Commission over the death of baby Harry Richford in 2017, face paying back £2.1m over two years. Derek Richford, who helped expose failings at East Kent after the death of his grandson, told The Independent it was “abhorrent” that the trust claimed “vital NHS funds by falsely claiming that they had achieved 10/10 for maternity safety when the truth was in fact 6/10. East Kent Trust did this two years running and even when asked to check their submission, reconfirmed the erroneous data to NHS Resolution.” An evaluation of the scheme by NHS Resolution said it was “recognised that recent examples of poor governance from trusts in relation to the certification of submissions require further action”. Read full story Source: The Independent, 7 March 2021
  18. News Article
    NHS Supply Chain has suspended supplies of some ultrasound gels over concerns they might be connected with outbreaks of bacterial infections in multiple hospitals. Thirty hospitals have reported 46 cases of Burkholderia contaminans between October last year and January 2021. No patients have died but some developed sepsis symptoms. NHS Supply Chain has suspended supplies of three ultrasound gels as a “precautionary measure” and guidance has been updated on the safe use of gel to reduce the risk of transmission of infection. Existing stocks have not been recalled and NHS Supply Chain is stocking similar products as alternatives. Public Health England has said its provisional investigation suggests a potential link with ultrasound or ultrasound-guided procedures as many of the infected patients had undergone these before the bacterium was identified. It is also investigating how many of the patients have spent time in intensive care or high dependency settings. A related bacteria, called Burkholderia cepacian, was also found in 27 cases. Read full story (paywalled) Source: HSJ, 4 March 2021
  19. News Article
    Patients with learning disabilities were pushed and dragged across the floor while others had their arms trapped in doors by staff working at a private hospital, the care watchdog has found. The Care Quality Commission said instances of abuse caught on CCTV had now been reported to police and staff working at St John’s House, near Diss in Norfolk, have been suspended. Police have said no further action will be taken. The regulator has rated the home, part of The Priory Group, inadequate and put it into special measures after inspectors found a string of failures at the 49-bed home during an inspection in December. According to the CQC’s report, inspectors reviewed CCTV footage of seven patient safety incidents between August and December last year. This showed “issues such as prolonged use of prone restraint, a patient being dragged across the floor despite attempting to drop their weight, a patient being pushed over and the seclusion room door trapping a patients arm and making contact with a patient’s head when closed”. The report said that although some staff had been suspended the hospital had not reported all the incidents to the police or the local council. It added: “Following CQC raising this as a concern, the provider has now reported incidents to the police, the safeguarding team and has suspended further staff pending investigation.” Read full story Source: The Independent, 5 March 2021
  20. News Article
    A healthcare professional at Blackpool Teaching Hospital Foundation Trust has been arrested on suspicion of murdering a stroke patient. Lancashire Police released a statement this evening which says the man has also been arrested on suspicion of two offences of rape and one offence of sexual assault. The suspect is currently in custody. He has also been suspended by the trust. It comes after a police investigation was launched in November 2018 into allegations of mistreatment and neglect on the stroke unit at Blackpool Victoria Hospital. As part of the probe, a number of post-mortem examinations were conducted, including for Valerie Kneale, 75, from Blackpool, who died from a haemorrhage caused by a non-medical related internal injury. Police said this led to a murder investigation, which is being treated separately to an ongoing investigation into allegations of poisoning and neglect on the stroke unit, in which a number of staff have previously been arrested. Detective chief inspector Jill Johnston, of Lancashire Police, said: “We understand this will cause some significant concern in the community but please be reassured we have a dedicated team of officers conducting a number of enquiries." “If you have any information or have worked on the stroke unit and can assist with our enquiries, please come forward and speak to police immediately.” Read full story (paywalled) Source: HSJ, 3 March 2021
  21. News Article
    A man was left in a care home for five months without regard for "basic human rights", an investigation has found. The Nottinghamshire man, who had dementia, was placed in the home for two weeks as respite for his family. But the county council failed to properly assess whether he could return home, leaving his family with a £15,000 care bill, the Local Government and Social Care Ombudsman said. The authority has apologised and said it would make improvements. The ombudsman launched an inquiry after complaints from the man's family. He was placed in the care home by his wife while she struggled to look after her son, who had been diagnosed with terminal cancer. The investigation found that after the first two weeks, the man's wife said she still could not cope with his return. But instead of carrying out a review or assessment to judge what support was needed for him to potentially go home, the council allowed the case to "drift". The ombudsman, Michael King, said: "The man had a right to respect for his family life, and to enjoy his existing home peacefully." "But the council did not have any regard for the man's human rights during those five months he was away from his family." In its report, the watchdog said it found "fault causing injustice". Read full story Source: BBC News, 4 March 2021
  22. News Article
    A bid for more control over the NHS by ministers risks undermining patient safety and sowing confusion over who is ultimately responsible for services, MPs have been warned. The Commons Health Select Committee was told the proposals, set out in a new white paper published last month, lacked detail on the involvement of patients in local services and needed urgent clarification of the new powers the health secretary will have. The plans will give ministers new powers over the independent Healthcare Safety Investigation Branch (HSIB), including being able to tell it what to investigate and the power to remove protections for NHS staff who give evidence in secret. Last week experts warned the plans for HSIB could undermine its role and have lasting consequences on efforts to encourage NHS staff to be honest about errors. Under the proposals the health secretary would be able to remove so-called “safe space” protections for evidence given by NHS workers. Chris Hopson, chief executive of NHS Providers, told the committee hospitals were worried about the plans. He said: “We are very nervous about this relationship between the secretary of state and HSIB. In order for it to be an effective independent organisation, it does need to be free from the appearance of any kind of political control. There's a very high degree of nervousness about the ability to somehow switch safe space on and off. People need to know where they stand.” Read full story Source: The Independent, 2 March 2021
  23. News Article
    NHS England has ordered an independent review into patient safety and governance concerns at an acute trust which had been resisting calls to take this step, HSJ has learned. The intervention at University Hospitals of Morecambe Bay Foundation Trust comes after pressure from staff and local MPs, who believe more extensive investigation is required into cases of patient harm within the trauma and orthopaedics division. The broad issues were first revealed by HSJ in November, with documents suggesting several patients were harmed after leaders failed to act on multiple concerns being raised about a surgeon. The trust has already commissioned one external review. This reported last year and found the service to be riven by “internecine squabbles”. However, the review was overseen by trust executives and the terms of reference were focused on incident reporting and culture within the department. It is understood that some consultants have since been pushing for further investigation into specific cases where patients were harmed, as well as concerns that managers or clinicians who were accused of failing to tackle the issues have since been promoted to more senior positions. Read full story (paywalled) Source: HSJ, 2 March 2021
  24. News Article
    A woman with dementia was effectively left housebound for the last eight years of her life due to surgical delays, an investigation found. The Public Services Ombudsman for Wales said the individual worried about being "caught short" due to incontinence and it affected her family relationships. Her son complained about the care she received at Glan Clwyd Hospital in Denbighshire, in particular. Betsi Cadwaladr University Health Board has since apologised to the family. Ombudsman Nick Bennett said it was clear there was "significant injustice" in the case of the individual, who was identified in the report findings as Mrs B. The patient's son complained there had been surgical delays for a rectal prolapse issue dating back to 2011, concerns over inpatient medical care provided by an elderly care consultant, and a delayed diagnosis of terminal ovarian cancer during a hospital stay. The ombudsman found that clinical decision-making by colorectal surgeons "was not in keeping with accepted clinical practice". Read full story Source: BBC News, 2 March 2021
  25. News Article
    Bereaved families have been left feeling like their efforts to improve patient safety have been ‘in vain’ as progress of a government programme instigated by Jeremy Hunt appears to have ‘stalled’. The Learning from Deaths programme board, which was set up in 2017 to develop guidance for trusts working with families on investigations of deaths, has not met since June 2019. Josephine Ocloo and David Smith, two bereaved family members who were on the board, have written to HSJ, saying the programme’s progress has “stalled”. They added many of the issues it was set up to consider have not yet been addressed, including the need for a national inquiry into unresolved historical cases, the independence of the NHS’ investigatory systems, lack of effectiveness of the duty of candour, and the disproportionate impact on ethnic minorities and those with mental ill-health or learning disabilities. They said: “We now have serious concerns that what these families went through [in November 2017] in recalling — and effectively reliving — their experiences, in order to ensure the terrible things that happened to them could not happen to others, was in vain… “If [the issues] are not to be addressed by the new board, the families will have every right to feel betrayed and to feel as if they have been used as pawns in a political game. Once again, harmed and let down by a system that has used us and then cast us aside.” Read full story (paywalled) Source: HSJ, 26 February 2021
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