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News Article
Muckamore inquiry: Staff accused of ignoring TB symptoms
Patient Safety Learning posted a news article in News
The mother of a patient at Muckamore Abbey Hospital has described how her son contracted tuberculosis (TB) while at the hospital. She said he had been left severely disabled after a series of associated strokes. Patient P116 is now 40 years old and has suffered from severe epilepsy since he was a baby. His mother told the inquiry into abuse at the hospital that her concerns over her son's health were ignored. She said that even after he began developing symptoms - including losing six stone (38kg) of weight - staff seemed "not to care". In the end, he was only diagnosed with TB after his mother took him to hospital herself. Due to the delay in the diagnosis and the way the family's complaint was handled, a serious adverse incident review was carried out and P116's mother received a letter of apology from the then permanent secretary at the Department of Health, Richard Pengelly, and Theresa Villiers, who was Northern Ireland secretary at the time. His mother told the inquiry her son's time in Muckamore remained a "major trauma" for the family and she still found it very difficult to talk about. She told the inquiry she felt strongly that "independent expert support" should be given to patients abused or neglected in Muckamore, including specialist counselling for the patients and their families. Read full story Source: BBC News, 12 October 2023 -
News Article
Three patients died after doctor failed to ensure bowel test follow-up treatment
Patient Safety Learning posted a news article in News
Three patients have died after being given a bowel test by a doctor who failed to ensure treatment needed was carried out, a health board has said. NHS Greater Glasgow and Clyde (NHSGGC) said three more patients suffered harm. The six patients were identified in a clinical review the health board carried out of 2,700 people the consultant carried out a colonoscopy on between 2020 and 2022. The consultant, who has not been named, was suspended in November 2022 and has since left the health board. NHSGGC deputy medical director Professor Colin McKay said: “We would like to offer our sincere apologies to patients who were not followed up appropriately and our condolences to the families of those patients who have died." “Our investigations found that the doctor did not consistently follow up the results of investigations that had been completed or requested and therefore missed the opportunity for patients to be treated, including a number of patients who went on to develop malignancy." Read full story Source: The Independent, 11 October 2023 -
News Article
Over 17 000 serious incidents reported in mental healthcare last year
Patient Safety Learning posted a news article in News
The UK’s largest mental health charity, Mind, has published previously unseen data laying bare the full scale of the emergency in mental healthcare, with staff reporting 17,340 serious incidents in 12 months. The Care Quality Commission (CQC) figures shows mental healthcare staff across England reported an incident two times every hour in the last year, where people are treated for issues including self-harm, eating disorders and psychosis. Incidents included: injuries to patients that caused likely long term sensory, movement or brain damage, or physically damaged their body prolonged physical pain or psychological harm, or shortened life expectancy cases of abuse, including those involving the police injuries for which the patient needed treatment to prevent them dying. All of these incidents involved care providers raising concerns with the CQC under their statutory duty under Regulation 18. Dr Sarah Hughes, Chief Executive of Mind, says: “It is deeply worrying that healthcare staff across the country are so concerned about the situation in mental health settings that they are reporting a serious incident once every half an hour. We knew this was a crisis – now we know the scale of this crisis. People seek mental healthcare to get well, not to endure harm. Families are being let down by a system that’s supposed to protect their loved ones when they are most sick. The consequences can be and have been fatal". Read full story Source: Mind, 10 October 2023 -
News Article
Hospital chief quits in protest at ‘cover-up’ over baby deaths
Patient Safety Learning posted a news article in News
An NHS hospital has been accused of posing a continuing risk to patients by “covering up” leadership failures, including not properly investigating the deaths of two babies. Dr Max Mclean, chairman of Bradford Teaching Hospitals trust, has quit in protest at the conduct of the trust’s chief executive, Professor Mel Pickup, after no action was taken over serious concerns about her performance. In a blistering resignation letter, Mclean said he “cannot, in good conscience, work with a CEO who has fallen so short of the standards expected of her role that there is a genuine safety risk to patients and colleagues”. He is calling for senior national NHS figures to establish new leadership at the trust, and has written to the head of NHS England to share his concerns about Pickup, who has been in post since 2019. Mclean told The Times there were parallels with the Lucy Letby scandal, when management ignored the concerns of whistleblowers. “Patients are at risk, babies are at risk, and there could be avoidable deaths unless there is a change of leadership,” he said. The former detective chief superintendent who has chaired the trust since 2019, raised nine serious issues about Pickup’s performance, which he said were confirmed by an independent investigation that concluded last month. However, the trust’s board met on October 2 and decided there would be no further action against Pickup, leaving Mclean with “no option” but to resign and speak publicly. Read full story (paywalled) Source: The Times, 10 October 2023 -
News Article
NHS ombudsman warns Sciensus that patients ‘should not be ignored’
Patient Safety Learning posted a news article in News
The boss of Britain’s biggest medicines courier has been told to urgently improve its complaints system by the NHS ombudsman amid concerns patients let down by missing deliveries are repeatedly ignored. In a highly unusual development, Darryn Gibson, the chief executive of Sciensus, has received a written warning from Rob Behrens, the parliamentary and health service ombudsman (PHSO). It says patients “should not be ignored” and must be “listened to and taken seriously” or he will consider taking further action. The PHSO investigates complaints that have not been resolved by the NHS or by private providers of NHS care. Sciensus is the single largest provider of homecare medicines services to the NHS and has contracts worth millions of pounds. In an email seen by the Guardian, Behrens told Gibson he had been unable to investigate most reports received about Sciensus because patients had not been able to complete the company’s complaints process. “That is not acceptable or fair to complainants,” Behrens wrote. In a statement, Sciensus said it worked “very hard” to ensure NHS patients received their medicines on time. Its services had “a 95% satisfaction rating”, it added. The move follows a Guardian investigation that exposed how Sciensus put NHS patients at risk of harm with delayed, missed or botched deliveries of medicines for conditions including cancer, heart disease, diabetes, dementia and HIV. It also uncovered how patients’ alarm at vital drugs and medical devices not arriving at their home was often compounded by a struggle to reach Sciensus to complain and fix the problems. Read full story Source: The Guardian, 19 October 2023 -
News ArticleFinancial directors need to take responsibility for safety, which should be at the core of how the NHS runs services, the leadership of the Health Services Safety Investigations Body (HSSIB) said at its launch Wednesday. The Healthcare Safety Investigation Branch is now an independent body – and has been renamed HSSIB – although maternity investigations are hosted by the Care Quality Commission. Questioning how many finance directors across the NHS take responsibility for safety, HSSIB’s interim chief investigator Rosie Benneyworth said: “We need a position where finance directors in every organisation are as responsible for safety as the person leading the safety agenda and vice versa, the safety person works with the finance agenda to support them. “Often you see the finance director and safety lead don’t work effectively together and we need to change that.” Dr Benneyworth said progress will not be made unless operational delivery, financial delivery and safety are tackled “in the same breath”. HSSIB’s new chair Ted Baker also called for safety to become a core part of running services “in the way running the accounts is”, as it is currently still seen “as an add-on”. He stressed that safety “drives efficiencies, enables innovation and saves costs”. Read full story (paywalled) Source: HSJ, 19 October 2023
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News Article
‘High use of agency staff’ contributed to care failings exposed by hidden cameras
Patient Safety Learning posted a news article in News
High use of agency staff contributed to the care failings exposed at a mental health trust by undercover reporters, an internal inquiry has found. Essex Partnership University Trust was at the centre of a Channel 4 documentary last year which raised concerns over care, including the use of restraints and patient observations. The trust initially refused to release the final report after a freedom of information request by HSJ, but has now released a redacted version on appeal. The report identified a number of concerns in relation to patient and staff safety, saying factors that contributed to these concerns included high usage of temporary staff and high patient acuity on the two acute mental health wards recorded. The internal inquiry looked into allegations of the inappropriate use of restraints raised in the documentary. This section, which contained redactions, found restraint was taught to be used as a last resort, but suggested high temporary staffing levels and a “lack of confident and adequately skilled staff” contributed to guidance not being followed. Another concern was around staff sleeping on duty and the use of mobile phones during patient observations. The internal inquiry found there was an “absence of visible leadership and role modelling” to ensure this did not happen during clinical practice. Read full story (paywalled) Source: HSJ, 17 October 2023 -
News Article
Patient declared dead woke up in hospital
Patient Safety Learning posted a news article in News
An ambulance trust has apologised after a patient who was declared "dead" later woke up in hospital. As first reported by The Northern Echo, the individual was taken by paramedics to Darlington Memorial Hospital on Friday. The newspaper reported they had been declared dead following an incident earlier that day. The North East Ambulance Service (NEAS) apologised to the patient's family and said an inquiry had begun. The patient has not been identified or their current condition revealed. NEAS director of paramedicine Andrew Hodge said: "As soon as we were made aware of this incident, we opened an investigation and contacted the patient's family. "We are deeply sorry for the distress that this has caused them. "A full review of this incident is being undertaken and we are unable to comment any further at this stage. "The colleagues involved are being supported appropriately and we will not be commenting further about any individuals at this point." Read full story Source: BBC News, 17 October 2023 -
News Article
Jasper Brooks inquest: Baby died due to 'neglect' at hospital
Patient Safety Learning posted a news article in News
A coroner has found neglect contributed to a baby's death at the hospital where he was born. Jasper Brooks died at the Darent Valley Hospital in Kent on 15 April 2021. The coroner found gross failures by midwives and consultants at the hospital and says Jasper's death was "wholly avoidable". Jasper was a second child for Jim and Phoebe Brooks. Due to a complication during pregnancy of her first child, Phoebe was booked in to have an elective Caesarean section to deliver Jasper. But in April 2021 those plans changed overnight. A check-up found Phoebe had raised blood pressure. She was told to remain in hospital and that the C-section would happen the following morning - nine days earlier than planned - when there were more staff on duty. Jasper's parents say the midwives caring for Phoebe repeatedly failed to listen to her and Jim's concerns - that she was shaking violently, feeling sick, and thought she was bleeding internally. "We felt like an inconvenience - no-one wanted to deal with me that night," Phoebe says. "The doctor didn't want to do my C-section, the midwife that's meant to be looking after me, she just doesn't really care. "I remember saying clearly to her, 'my whole body is shaking - something's happening, and no-one's taking the time to listen to what I'm saying or listen in on my baby'." At the inquest hearing, midwife Jennifer Davis was accused by the family's barrister, Richard Baker KC, of "failing to act on signs of blood loss, failing to determine if Phoebe was in active labour, and failing to call a senior doctor when necessary". Jasper was born without a heartbeat, so a resuscitation team was called. But during the inquest, the family learned that further errors were made because the correct people failed to attend the resuscitation. There was no consultant neonatologist on site - a doctor with expertise in looking after newborn infants or those born prematurely. Intubation, the process of placing a breathing tube into the windpipe - which should only take a few minutes - did not occur for 18 minutes. There was also a delay in administering adrenaline to try to stimulate Jasper's heart. Read full story Source BBC News, 24 October 2023 -
News ArticleThe Health and Social Care Select Committee have commissioned an Expert Panel to consider the Government’s progress against accepted recommendations from public inquiries and reviews on patient safety. The Panel will consider a range of recommendations made by public inquiries and reviews on both patient safety and whistleblowing and subsequently select a number of these for evaluation. The Panel will in its final report provide a rating of the Government’s progress against each of these recommendations. Panel members are: Professor Dame Jane Dacre (Chair). Sir Robert Francis KC Anita Charlesworth Professor Stephen Peckham Sir David Pearson Professor Emma Cave Read full story Source: House of Commons Health and Social Care Select Committee, 24 October 2023
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News Article
East Kent NHS Trust: Lessons not learned at maternity trust, mum says
Patient Safety Learning posted a news article in News
Lessons still have not been learned at a Kent hospital trust which was criticised in a damning report, a mother has said. Dr Bill Kirkup's review found at least 45 babies might have survived with better care at East Kent NHS hospitals. Victoria, whose six-year-old daughter needs 24-hour support, said: "I've had no contact from anyone from the trust." Her case was one of 202 that were examined by Dr Kirkup in his report, which was published exactly a year ago. Victoria, whose daughter is living with the consequences of failings in her care during her birth, said: "Our children have become unwell because of what has happened to them. "I don't feel lessons have been learned whatsoever. "Treatment hadn't been made available as easily as it should have done for children that are still living this experience every day." Read full story Source: BBC News, 19 October 2023 -
News Article
BMA demands investigation into vaccination programme ‘mismanagement’
Patient Safety Learning posted a news article in News
The BMA’s GP Committee (GPC) has demanded an investigation into the Government and NHS England’s ‘mismanagement’ of this year’s vaccination programmes. A motion was passed at the GPC England meeting today which called for a review of the ‘circumstances which led to muddled and mismanaged communications’ and for reflection on how to ‘prevent a repeat occurrence’. Last month, there was confusion over the start date for the adult flu and Covid vaccination programmes, which usually start in September. NHS England said the programmes would start in October this year – a move which the BMA said would cause ‘serious disruption’. But the Government then announced that vaccination will begin on 11 September, in what the BMA has called a ‘u-turn’, following the identification of a new Covid variant. GPs were asked to vaccinate ‘as many people as possible’ by the end of October. The GPC has said today that these ‘conflicting instructions’ led to confusion among GPs while also impacting on patient safety. Read full story Source: Pulse, 21 September 2023 -
News Article
Trans woman’s death ‘preventable with right support’, mother says
Patient Safety Learning posted a news article in News
The family of a young trans woman who is believed to have taken her own life have said she was “failed by those tasked with her care”, as the coroner investigating her death described services for transgender people as “underfunded and insufficiently resourced”. Alice Litman had been waiting to receive gender-affirming healthcare for more than three years when she died in Brighton at the age of 20 in May 2022. Ahead of an inquest which began in Hove on Monday, her mother, Dr Caroline Litman, described Alice’s death as “preventable with access to the right support”. Adjourning the inquest on Wednesday to give a narrative conclusion in two weeks’ time, the coroner Sarah Clarke told the court: “It seems to me that all of these services are underfunded and insufficiently resourced for the level of need that the society we live in now presents". Describing the trans healthcare system as “not fit for purpose”, Alice's family, who are being supported by the Good Law Project, added: “We are grateful that the coroner has agreed that the conditions of Alice’s death warrant a report to prevent future deaths.” Read full story Source: The Guardian, 20 September 2023 -
News Article
Patient's water drinking death was preventable
Patient Safety Learning posted a news article in News
The death of a mentally ill teenager who died after drinking an excessive amount of water was preventable, an investigation has found. The 18-year-old, known at Mr D, was being detained under the Mental Health Act at the time of his death. An inquiry by the Mental Welfare Commission said he had previously been treated for drinking too much water. It found several areas where a different course of action could have prevented his death. The teenager was admitted out-of-hours to an adult mental health service (AMHS) inpatient unit in a health board neighbouring his own on 5 December 2018 as there were no local beds available. This move was described in the report as a "high-risk action". On the evening of 7 December he suffered a seizure after drinking too much water and was transferred to intensive care. He died three days later from the consequences of water intoxication. Suzanne McGuinness, executive director (social work) at the Mental Welfare Commission, said: "This was a tragic death of a young man while he was being cared for in hospital. "We found that a more assertive approach to the treatment of Mr D's psychotic illness in the two years before his death was warranted. The risks associated with psychotic illness were not coherently managed." Read full story Source: BBC News, 21 September 2023 -
Content ArticleThis is the first report of a national confidential enquiry specifically focussed on child deaths. Confidential enquiries have already contributed to major improvements in obstetrics, neonatal, and perioperative care in the UK. However they are time consuming and require extensive collaboration between various professional groups as well as the attention of a dedicated full-time research team. Hence, when planning a confidential enquiry in a new patient group, it is pertinent to investigate both feasibility and utility at its outset. The aim of this enquiry was to evaluate the feasibility of using this methodology to reduce the number of child deaths and make a significant contribution to child health in the UK. The basic functions of a confidential enquiry are: To develop and maintain a register of the cases under scrutiny. To subject cases in the register (or a specific sample of them) to review by a panel of experts with a focus on identifying avoidable factors where there have been adverse outcomes. Subsequent recommendations are then derived from both the analysis of the register and the conclusions of the expert review panels. This report presents the findings of a feasibility study “The Child Death Review” in which confidential enquiry methodology was applied to child deaths (28 days to 17 years 364 days) occurring in three regions of England, all of Wales and Northern Ireland in the calendar year 2006. A surveillance programme was mounted in order to determine where and when deaths occurred. A comprehensive core dataset was developed and then collected on all deaths. A sample, designed to have an even spread across age groups and the geographical areas involved, was then subjected to more detailed enquiry. This involved scrutiny of the available records by a multidisciplinary panel in each case.
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Content ArticleNHS England published the new Patient Safety Incident Response Framework (PSIRF) in August 2022 outlining how organisations providing NHS-funded care should respond to patient safety incidents to facilitate ongoing learning and improvement. From Autumn 2023, PSIRF will replace the current Serious Incident Framework. It will change the way all healthcare providers, which deliver NHS funded care, including independent healthcare organisations respond to patient safety incidents. Linda Jones, Head of Patient Safety & Quality Governance at Independent Healthcare Providers Network (IHPN), writes about the significant changes that introducing a new approach to managing risk and patient safety will entail for the independent sector, and how we’re supporting members to be ready.
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Content Article
This blog captures a recent discussion at a Patient Safety Management Network (PSMN) meeting, where members of the network raised a number of important questions and issues relating to the Patient Safety Incident Response Framework (PSIRF). PSIRF is currently being rolled out across all NHS trusts in England and takes a new approach to investigating patient safety incidents.- Posted
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Content ArticleCarl Heneghan discusses the role of modelling in the Covid-19 pandemic.
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Content ArticleThe Thirlwall Inquiry has been set up to examine events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital. This document sets out the terms of reference for this inquiry, following an engagement process led by the inquiry’s independent chair, Lady Justice Thirlwall, with the affected families and other stakeholders.
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Content ArticleHealthcare is starting to embrace a shift towards Just Culture. In England, the new Patient Safety Incident Response Framework (PSIRF) prioritises respect, compassion, and systemic improvements. The potential benefits of this, and other initiatives, are significant, as Suzette Woodward reports
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Content ArticleSafety Management Systems (SMSs) are an organised approach to managing safety which are widely used in different industries. In this report, the Health Services Safety Investigations Body (HSSIB) identifies the requirements for effective SMSs, how these are used in other safety-critical industries and considers the potential of application of this approach in healthcare. It makes safety recommendations for NHS England and the Care Quality Commission in relation to this. See also HSSIB's video Introduction to safety management systems.
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Content ArticleIn this article for the Journal of Patient Safety, Alan Card from the Department of Pediatrics at the University of California, argues that the purpose of patient safety work is to reduce avoidable patient harm, and this requires us to slay dragons—to eliminate or at least mitigate risks to patients. He expresses the view that current practice focuses almost exclusively on investigating dragons—tracking reports on the number and type of dragons that appear, how many villagers they eat and where, whether they live in caves or forests and so on. He argues that while information about risks is useful to the extent that it informs effective action, it does nothing to make patients safer by itself: "We cannot investigate a dragon to death. No more can we risk assess our way to safer care."
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News Article
UK’s biggest GP chain replacing doctors with less qualified staff
Patient Safety Learning posted a news article in News
The UK's biggest chain of GP practices lets less qualified staff see patients without adequate supervision, an undercover BBC Panorama investigation has found. Operose Health is putting patients at risk by prioritising profit, says a senior GP. The company, with almost 600,000 NHS patients, is owned by US healthcare giant Centene Corporation. BBC Panorama sent undercover reporter Jacqui Wakefield to work as a receptionist at one of the UK company's 51 London surgeries. A GP working at the practice said they were short of eight doctors. The practice manager said they hired less qualified medical staff called physician associates (PAs), because they were "cheaper" than GPs. Physician associates were first introduced by the NHS in 2003, so that doctors could deal with more complex patient needs. PAs are healthcare professionals who have completed two years of post-graduate studies on top of a science degree, as opposed to 10 years education and training for GPs. They support GPs in the diagnosis and management of patients, but should have oversight from a doctor. Panorama gathered evidence that PAs were not being properly supervised at the Operose practice. The PAs told the undercover reporter they saw all sorts of patients, sometimes without any clinical supervision. They said the practice treated them as equivalent to GPs. Prof Sir Sam Everington, a senior practising GP at an unconnected partner-run practice, reviewed BBC Panorama's undercover footage and said he was concerned for patient safety. During the undercover investigation at the London practice, administrative workers also revealed a backlog of thousands of medical test results and hospital letters on Operose computer systems. One worker said they were tasked with getting through 200 documents a day, deciding which were important enough to be seen by a GP or pharmacist and which would be filed to the patient's records. One member of staff, worried about making mistakes said they sometimes used Google to help them work out what to do with the documents. Read full story Source: BBC News, 11 June 2022 -
Content ArticleFull opening statement of the Long Covid groups (Long Covid Support, Long Covid SOS and Long Covid Kids) to Module 2 of the Covid-19 Inquiry as representative organisations for nearly 2 million adults and children who have suffered from Long Covid.
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News Article
Messages revealed healthcare workers were drugging patients
Patient Safety Learning posted a news article in News
Two healthcare workers who exchanged vile texts while needless drugging sick people to ‘keep them quiet’ have been found guilty of ill-treating patients. Senior nurse Catherine Hudson, 54, was found to have regularly tranquillised patients unnecessarily for her own amusement and to have an ‘easy’ shift. While Charlotte Wilmot, 48, an assistant practitioner, wrote vile texts encouraging her to carry out the dangerous acts, with complete disregard for the consequences. Preston Crown Court heard the pair worked on the stroke unit at Blackpool Victoria Hospital and had carried out needless sedations between 2017 and 2018. Restrictions on prescription drugs were so lax in the stroke unit that staff would help themselves and self-medicate or steal drugs to supply to others, the court heard. Drugs such as Zopiclone, a powerful medicine used to treat insomnia, were often stolen and used to drug multiple patients. Police launched an investigation in November 2018 after a student nurse raised concerns about the treatment of patients in the stroke unit. A number of staff members were arrested during the course of the investigation and their mobile devices were seized. Read full story Source: The Independent, 6 October 2023
