Search the hub
Showing results for tags 'Investigation'.
Found 1,557 results
-
News ArticleA compensation scheme for thousands of people affected by the infected blood scandal, described as the biggest treatment disaster in the history of the NHS, will reportedly be announced within weeks. Ministers will set up an arm’s-length body to administer the funds, which could run into hundreds of millions of pounds, and recognise culpability for the scandal for the first time, according to the Sunday Times. As many as 30,000 people became severely ill after being given factor VIII blood products that were contaminated with HIV and hepatitis C imported from the US in the 1970s and 80s, or after being exposed to tainted blood through transfusions or after childbirth. On average, one person affected is dying every four days, with approximately 3,000 having died to date. Last year, before the then health secretary Matt Hancock’s appearance at the public inquiry into the scandal, the paymaster general, Penny Mordaunt, announced the appointment of Sir Robert Francis QC to examine options for a framework for compensation before the inquiry reports its findings. A Cabinet Office spokesperson confirmed the review would be published shortly. “The government intends to publish the study by Sir Robert Francis QC in time for the inquiry and its core participants to consider it before Sir Robert gives evidence to the inquiry in July,” they said. “Government will give full consideration to Sir Robert’s recommendations and evidence to the inquiry.” Read full story Source: The Guardian, 29 May 2022
-
News Article
Woman stored baby’s remains in fridge after London hospital refused them
Patient Safety Learning posted a news article in News
A London hospital has launched an investigation after a woman whose baby died in the womb had to deliver her son at home due to lack of beds and keep his remains in her fridge when A&E staff said they could not store them safely. Laura Brody and her partner, Lawrence, said they were “tipped into hell” after being sent home by university hospital Lewisham to await a bed when told their baby no longer had a heartbeat but no beds were immediately available to give birth, the BBC reported. Two days later, after waking up in severe pain, Brody, who was four months into her pregnancy, gave birth in agony on the toilet in their bathroom. “And it was then,” she told the broadcaster, “I saw it was a boy”. The couple, who wanted investigative tests to be carried out at a later time, dialled 999 but were told it was not an emergency. They wrapped their baby’s remains in a wet cloth, placed him in a Tupperware box, and went to A&E where they were told to wait in the general waiting room, they said. She was eventually taken into a bay and told she would require surgery to remove the placenta. But, with the waiting room hot and stuffy and staff refusing to store the remains or even look inside the Tupperware box, they decided as it got to midnight they had no option but for her partner to take their baby’s remains home. Brody said the whole experience “felt so grotesque”. “When things go wrong with pregnancy there are not the systems in place to help you, even with all the staff and their experts – and they are working really hard – the process is so flawed that it just felt like we had been tipped into hell,” she told Radio 4’s Today programme. The case is said to have raised wider concerns among campaigners who argue that miscarriage care needs to be properly prioritised within hospitals including A&E. Read full story Source: The Guardian, 30 May 2022 -
News Article
Ambulance trust covered up paramedics’ fatal errors like a ‘criminal gang’
Patient Safety Learning posted a news article in News
An ambulance trust has been accused of acting like a “criminal gang” and lying to dead patients’ families by an employee who repeatedly warned about paramedics’ mistakes being covered up. Paul Calvert, a coroner’s officer whose job was to produce reports on deaths, tried to raise concerns about managers at the North East Ambulance Service (NEAS) for three years before walking out last year on the verge of a breakdown. “My life was being made a misery,” said Calvert, who was previously a detective with Northumbria police. “They were basically like a criminal gang. I had tried everything I could to warn the proper authorities about how the service was destroying and concealing evidence meant for the coroner. I spoke to my managers, to human resources, to external auditors. I even made disclosures to the Care Quality Commission and Northumbria police. Nothing was done about it.” Despite their denials of a large-scale cover-up of mistakes, the NEAS this year offered Calvert £41,000 as part of a non-disclosure agreement it asked him to sign. One of the clauses meant destroying all the evidence he had collected. Another tried to stop him making any further disclosures to police. Reports and witness statements from ambulance staff were not being disclosed to the coroner “on a daily basis”, according to Calvert, amounting to key pieces of evidence relating to deaths being hidden from the public. Read full story (paywalled) Source: The Times, 29 May 2022 -
News ArticleDonna Ockenden, the midwife who investigated the Shopshire maternity scandal, has been appointed to lead a review into failings in Nottingham following a dogged campaign by families. The current review will be wound up by 10 June after concerns from NHS England and families that it is not fit for purpose. It was commissioned after revelations from The Independent and Channel Four News that dozens of babies had died or been brain-damaged following care at Nottingham University Hospitals Foundation Trust. In a letter to families on Thursday, NHS England chief operating officer David Sloman said: “I want to begin by apologising for the distress caused by the delay in our announcing a new chair and to take this opportunity to update you on how the work to replace the existing Review has been developing as we have taken on board various views that you have shared with us.” “After careful consideration and in light of the concerns from some families, our own concerns, and those of stakeholders including in the wider NHS that the current Review is not fit for purpose, we have taken the decision to ask the current Review team to conclude all of their work by Friday 10 June.” “We will be asking the new national Review team to begin afresh, drawing a line under the work undertaken to date by the current local Review team, and we are using this opportunity to communicate that to you clearly.” Ms Ockenden said: “Having a baby is one of the most important times for a family and when women and their babies come into contact with NHS maternity services they should receive the very best and safest care." “I am delighted to have been asked by Sir David Sloman to take up the role of Chair of this Review and will be engaging with families shortly as my first priority. I look forward to working with and listening to families and staff, and working with NHS England and NHS Improvement to deliver a Review and recommendations that lead to real change and safer care for women, babies and families in Nottingham as soon as possible.” Read full story Source: BBC News, 26 May 2022
-
News Article
Bristol surgeon ‘harmed’ 203 women with unnecessary operations
Patient Safety Learning posted a news article in News
More than 200 women were harmed when a rogue surgeon carried out operations on them unnecessarily, an NHS inquiry has found. Some of the women were left with life-changing physical problems or unable to work, while many also suffered trauma and serious psychological harm as a result. Overall, 203 women on whom Anthony Dixon performed procedures between 2007 and 2017 came to harm, according to a review by the North Bristol NHS trust (NBT). Dixon, who for years was Britain’s most influential pelvic surgeon, worked for both the trust and the private Spire hospital in the city. In 2017, NBT launched a review of Dixon’s performance and suspended him after dozens of women he had performed procedures on complained that they had experienced appalling consequences, including unmanageable pain and incontinence. The Guardian revealed in late 2017 that 100 women were suing him for medical negligence. Some cases have since been settled, but dozens are ongoing. NBT sacked Dixon in 2019 and he is currently banned from practising in the UK. During the review, 378 women were recalled and asked to set out their dealings with Dixon. All had undergone a procedure called laparoscopic ventral mesh rectopexy (LVMR), in which plastic mesh is inserted to repair weakened tissue in the pelvic floor. In papers presented to NBT’s board on Thursday, board members were told that the inquiry had concluded. “The trust has notified 203 NHS patients that, although their LVMR operation was carried out satisfactorily, they should have been offered alternative treatments before proceeding to surgery. We have defined these patients as suffering ‘harm’ as a result,” it said. Read full story Source: The Guardian, 26 May 2022 -
News ArticleThe former health secretary Jeremy Hunt has claimed the government snubbed bereaved families’ requests for Donna Ockenden to chair a review into maternity services in Nottingham as she is “too independent”. Hundreds of families involved in the Nottingham maternity scandal review have called for Ms Ockenden, chair of the Shrewsbury maternity scandal inquiry, to take over the investigation. NHS England had attempted to appoint a former healthcare leader, Julie Dent to chair the review. However, following pressure from families not to accept, Ms Dent announced shortly after she would be declining the role. Following the families’ calls for Ms Ockenden, Mr Hunt, chair of the government’s health committee, said on Wednesday: “I can’t see any other barriers to appointing her but sounds like she still won’t be. For some reason the Department of Health appears to think she is too independent – which is of course precisely why Nottingham families do have confidence in her. It feels like another own goal.” Families involved in the Nottingham maternity review, which will now cover almost 600 cases, have said they’ve been left in limbo by NHS England after if informed them of an interim report which has been completed by the review team. This follows several letters from families to health secretary Sajid Javid raising concerns over the review and calls for it to be overhauled. Speaking with The Independent, a couple whose son died under the care of Nottingham University Hospitals Foundation Trist said: “The key to successful long term change is developing a relationship with harmed families, built on trust, sensitivity and understanding. The current review does not command this. The relationship is untenable.” Read full story Source: The Independent, 26 May 2022
-
News Article
Safety regulator refused to investigate some NHS staff Covid deaths
Patient Safety Learning posted a news article in News
Britain’s safety at work regulator refused to investigate reports from NHS trusts that 10 frontline staff had died as a result of catching Covid-19 during the pandemic. The Health and Safety Executive (HSE) declined to look into at least 89 dangerous incidents that NHS trusts said involved healthcare workers being exposed to Covid, including 10 deaths. The stance taken by the HSE, which oversees workplace health and safety and can bring prosecutions, is disclosed in freedom of information requests by the Pharmaceutical Journal. It has prompted concern that the regulator is too strict in its definition of workplace harm. It found that 173 trusts in England submitted at least 6,007 reports about employees’ exposure to Covid-19 in the course of their duties to the HSE between 30 January 2020 and 11 March 2022, under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR). They included 213 “dangerous occurrences”, which are incidents that have the potential to cause significant harm; 5,753 cases where a staff member had caught Covid-19; and 41 deaths among people who had been exposed to the disease at their workplace. However, the HSE refused to look into five Covid deaths reported under the RIDDOR scheme by the Yorkshire ambulance service (YAS) because of what it considered a lack of evidence. The regulator also decided not to look into the Covid deaths of five staff at University College London hospital acute trust, despite the trust’s belief they had caught it at work. “The HSE found that there was no reasonable evidence that the infection was contracted at work,” a trust spokesperson said. Shelly Asquith, the health, safety and wellbeing officer at the Trades Union Congress, said the HSE’s decisions and claimed lack of evidence was “really concerning”. It suggested a continued “element of denial about Covid being airborne and it not being possible to necessarily pinpoint where exactly somebody was exposed once it’s in the air”, she added. Read full story Source: Guardian, 26 May 2022 -
News Article
'I will never be the same': RaDonda Vaught speaks out after sentencing
Patient Safety Learning posted a news article in News
RaDonda Vaught has spoken out about her criminal case for the first time last week in an exclusive interview with ABC News. Ms. Vaught, 38, was sentenced to three years of supervised probation on 13 May. She was convicted of criminally negligent homicide and abuse of an impaired adult for a fatal medication error she made in December 2017 after overriding an electronic medical cabinet as a nurse at Vanderbilt University Medical Center in Nashville, Tenn. The error, in which vecuronium, a powerful paralyser, was administered instead of the sedative Versed, led to the death of 75-year-old Charlene Murphey. "I will never be the same person," Ms. Vaught told ABC News, "It's really hard to be happy about something without immediately feeling guilty. She could still be alive, with her family. Even with all the system errors, the nurse is the last to check." Ms. Vaught immediately took responsibility for the medication error after it occurred but contends that her actions alone did not cause the error. Her case has spurred an outcry from nurses across the country, many of whom have expressed concerns about the likelihood of similar mistakes under increasingly difficult working conditions. "So many things had to line up incorrectly for this error to have happened, and my actions were not alone in that," Ms. Vaught said. When Ms. Pilgrim asked her if she felt like a scapegoat, Ms. Vaught said, "I think the whole world feels like I was a scapegoat." "There's a fine line between blame and responsibility, and in healthcare, we don't blame," she said. "I'm responsible for what I failed to do. Vanderbilt is responsible for what they failed to do." Read full story Source: Becker's Hospital Review, 23 May 2022 -
News Article
North East Ambulance Service: Cover-up claims to be probed by government
Patient Safety Learning posted a news article in News
The government is to investigate claims an ambulance service covered up details of the deaths of patients following mistakes by paramedics. It follows the Sunday Times report that North East Ambulance Service (NEAS) withheld information from coroners. Labour's shadow health secretary Wes Streeting described the alleged cover-up as "a national disgrace". Health minister Maria Caulfield said she was "horrified" and there would be a further investigation. The newspaper reported that concerns were raised about more than 90 cases and whistleblowers believed NEAS had prevented full disclosure to relatives of people who died in 2018 and 2019. Speaking in the House of Commons, Mr Streeting asked why the regulator - the Care Quality Commission (CQC) - had failed to take action. Ms Caulfield said that while both the NEAS and the CQC had both reviewed the allegations, further investigation was required. The minister said non-disclosure agreements have "no place in the NHS", adding: "Reputation management is never more important than patient safety." Read full story Source: BBC News, 23 May 2022 -
News ArticleContractors could be required to provide trusts with the findings of criminal records checks on their employees, an update from Michael inquiry into mortuary security has suggested. The independent inquiry, chaired by Sir Jonathan Michael, was set up to examine the implications of the sexual assaults on the bodies of women and children in hospital mortuaries by maintenance supervisor and convicted murderer David Fuller. A progress report published this month by the inquiry highlighted “responsibilities between trusts and contractors” as an area of concern. The report said expectations around information sharing should be made clear in policy and, if sharing is deemed necessary, consideration should be given to what checks and evidence is needed to show this is taking place. HSJ understands that Mr Fuller did not declare previous convictions for burglary when he was first employed at the Kent and Sussex Hospital in Tunbridge Wells in 1989. Other issues flagged to NHS England by the inquiry included how access to “high-risk areas” is monitored and who requires access to these areas. It added that consideration should be given to monitoring access, involving a review of CCTV and swipe card use. Read full story (paywalled) Source: HSJ, 20 May 2022
-
News Article
NHS ambulance service doctored documents to cover up truth about deaths
Patient Safety Learning posted a news article in News
Quinn Evie Beadle died in 2018. Her parents later found out that the “kind, caring” 17-year-old had been failed by a paramedic at the scene of her death — and that the ambulance service altered documents to try to stop them finding out the truth. The teenager, who dreamt of becoming a medic but suffered poor mental health, was found after she hanged herself near her home in Shildon, Co Durham, on the evening of 9 December 2018. The paramedic who attended the scene made basic mistakes, and made no effort to clear her airway or continue with basic life support — despite the fact her heart was still active. But instead of attempting to learn lessons, bosses at the North East Ambulance Trust (NEAS) set out to prevent the family learning what happened. They changed a key witness statement given to the coroner at her first inquest, removing references to mistakes the paramedic had made and inserting the claim that any life support offered would “not have had a positive outcome”. They also withheld from the coroner a key piece of evidence — a reading from a heart monitor — which demonstrated Quinn’s heart activity. It is thought Quinn’s death could be one of more than 90 cases in the past three years in which the NEAS failed to provide families with the whole truth about how their relatives died. Senior managers repeatedly withheld key evidence from coroners about deaths linked to service failures, an internal report shows. In some cases, bosses doctored or suppressed evidence to cover up failures by staff. An independent report into a small number of the cases, including Quinn’s, raised by whistleblowers found that, as in her case, statements were changed or suppressed and pieces of key evidence not disclosed. Read full story (paywalled) Source: The Sunday Times, 22 May 2022 -
News Article
Birmingham Children's Hospital worker held on suspicion of poisoning child
Patient Safety Learning posted a news article in News
A health worker has been arrested on suspicion of administering poison with intent to endanger life after a child died at Birmingham Children's Hospital. The 27-year-old woman was arrested on Thursday and has been suspended from her role at the hospital. The child was being treated in the Paediatric Intensive Care Unit, a spokesperson for the hospital said. Police said the woman had been released while investigations continued and forensic tests were being examined. A spokesperson for Birmingham Women's and Children's NHS Foundation Trust said it was "supporting the infant's family at this distressing time and ask that privacy is respected during this process". "Following the death of an infant at our Paediatric Intensive Care Unit at Birmingham Children's Hospital, we have asked West Midlands Police to examine what has happened, in line with our own safeguarding policy," it added. "The staff member involved has been suspended by the Trust following the national process on the sudden unexpected death of a child." Read full story Source: BBC News, 23 May 2022 -
News Article
Families dismay at interim report plans despite review ‘chaos’
Patient Safety Learning posted a news article in News
Families involved in a major review into maternity failings at Nottingham University Hospitals Trust (NUH) have criticised the decision of the review team to press ahead with the publication of an interim report, despite serious concerns about its terms of reference and methodology. A “thematic review” into NUH was first announced last year after reports that dozens of babies died or were brain damaged after errors were made at the trust over the last decade. More than 460 families have since contacted the review team. The review has been overseen by NHS England and local commissioners, but, in April, the families called for an independent inquiry and asked for it to be carried out by Donna Ockenden, the senior midwife who chaired the high-profile review of Shropshire maternity services, which reported in March. Last month, NHSE chief operating officer Sir David Sloman wrote to families and said former strategic health authority chair Julie Dent would be brought in to chair the review. However, Ms Dent stepped down from the role weeks later, citing “personal reasons”. A new chair is yet to be appointed. Despite these uncertainties, families have been told by the review team that an interim report will be issued shortly. Gary Andrews, whose daughter Wynter died after being delivered by caesarean section at NUH’s Queens Medical Centre in 2019, said to issue an interim report “seems at odds with the current situation” and risked causing “significant distress” to families. He added: “We need government to get to grips with this review. Put the brakes on, ensure its structure and design and objectives are fully supported by families, before any interim report can be issued.” Read full story (paywalled) Source: HSJ, 19 May 2022 -
News Article
Shrewsbury and Telford NHS Trust admits failures after two patients die
Patient Safety Learning posted a news article in News
A hospital trust has pleaded guilty to failures in care that contributed to the deaths of two patients. One of the charges related to the death of patient Mohammed Ismael Zaman in 2019 at the Royal Shrewsbury Hospital. The 31-year-old died of severe blood loss while undergoing dialysis, Telford Magistrates' Court heard. Max Dingle, in his 80s, died after his head became trapped between a mattress and bed rail while he was being treated at the Royal Shrewsbury Hospital. Shrewsbury and Telford Hospital NHS Trust (SaTH) admitted three counts of failing to provide treatment and care in a safe way, resulting in harm or loss, between October 2019 and May 2020. Representing the CQC, Ryan Donoghue said the failures in Mr Zaman's care "were the legal cause of his death, for which the trust is responsible". He said Mr Dingle, who had been admitted with chronic lung disease, died from a cardiac arrest after he was freed. "The basis [of the guilty plea] is that the failures exposed him to a significant risk of avoidable harm," Mr Donoghue said. As well as the two deaths, the CQC accused the trust of exposing other patients to significant risk of avoidable harm. Read full story Source: BBC News, 18 May 2022 -
News Article
Nurses take to streets ahead of RaDonda Vaught sentencing
Patient Safety Learning posted a news article in News
Nurses from across the country are heading to Washington, D.C., and Nashville, Tenn., this week to march for better working conditions and to show support for nurse RaDonda Vaught. Ms. Vaught, 38, was convicted of criminally negligent homicide and abuse of an impaired adult for a fatal medication error she made in December 2017 after overriding an electronic medical cabinet as a nurse at Vanderbilt University Medical Center in Nashville. Her case has spurred a national outcry from nurses who argue the ruling sets a dangerous precedent for the profession and will discourage nurses from speaking up about errors. Ms. Vaught's sentencing is scheduled for 13 May in Nashville, and she faces up to eight years in prison. Hundreds of nurses are planning to march in Nashville the day of the hearing to show their support for Ms. Vaught and to fight for better protection for nurses against criminal prosecution of errors. "We expect a large number of people to show up … just to show our strength in numbers and hope that the judge takes this into consideration and makes it slightly better by not sentencing her to any prison time," said Erica, a Las Vegas-based hospice nurse who is attending the sentencing. Read full story Source: Becker's Hospital Review, 13 May 2022 -
News Article
Covid inquiry broadens scope to include children
Patient Safety Learning posted a news article in News
The scope of the UK public inquiry into the handling of the Covid pandemic has widened to include a focus on children. When the draft terms were published in March, there was criticism that they failed to even mention the impact on children and young people. But after a public consultation, the final terms have been published and now incorporate the effect on the health, wellbeing and education of children. The final terms of reference were decided following a four-week public consultation on the draft terms. As well as expanding the terms to include the impact on the health, wellbeing and education of children and young people, the inquiry will also look at the wider mental health impact across the population. The focus on inequalities will also be strengthened, the inquiry said, so that the unequal impact on different sections of society will be considered at all stages. Alongside these issues, the UK-wide inquiry will also look at the following issues which were included originally: the UK's preparedness for the pandemic the use of lockdowns and other "non-pharmaceutical" interventions, such as social distancing and the use of face coverings the management of the pandemic in hospitals and care homes the procurement and provision of equipment like personal protective equipment and ventilators support for businesses and jobs, including the furlough scheme, as well as benefits and sick pay. Read full story Source: BBC News, 12 May 2022 -
News ArticleOne in four older Americans covered by Medicare had some type of temporary or lasting harm during hospital stays before the COVID-19 pandemic, government investigators said in an oversight report published Thursday. The report from the U.S. Department of Health and Human Services Office of Inspector General said 12% of patients had “adverse events” that mainly led to longer hospital stays but also permanent harm, death or required life-saving intervention. Another 13% had temporary issues that could have caused further complications had hospital staff not acted. Investigators reviewed the medical records of 770 Medicare patients discharged from 629 hospitals in 2018 to formulate a national rate on how often patients were harmed, whether preventable or not. An earlier Inspector General review found 27% of patients experienced some type of harm – an investigation that led to new patient safety efforts and incentives. The incremental improvement follows intense focus on patient safety since at least 1999 when the then-Institute of Medicine published To Err is Human, a landmark report that estimated up to 98,000 deaths per year could be due to medical errors. Initiatives have since sought to improve patient safety by limiting medical errors, reducing medication mix-ups and holding hospitals with a poor record of patient safety accountable through Medicare's program to dock the pay of the worst performers on a list of safety measures. While Inspector General investigators noted improvements in certain safety measures, officials said the 25% harm rate is concerning and deserves renewed attention from hospitals and two federal agencies that oversee patient safety: the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality. "We still have a significant way to go in terms of improving patient safety," said Amy Ashcraft, a deputy regional inspector general. Read full story Source: USA Today News, 12 May 2022
-
News Article
Senegal midwives convicted over mother's death
Patient Safety Learning posted a news article in News
Three Senegalese midwives involved in the death of a woman in labour have been found guilty of not assisting someone in danger. They received six-month suspended sentences, after Astou Sokhna died while reportedly begging for a Caesarean. Her unborn child also died. Three other midwives who were also on trial were not found guilty The case caused a national outcry with President Macky Sall ordering an investigation. Mrs Sokhna was in her 30s when she passed away at a hospital in the northern town of Louga. During her reported 20-hour labour ordeal, her pleas to doctors to carry out a Caesarean were ignored because it had not been planned in advance, local media reported. The hospital even threatened to send her away if she kept insisting on the procedure, according to the press reports. Her husband, Modou Mboup, who was in court, told the AFP news agency that bringing the case to light was necessary. "We highlighted something that all Senegalese deplore about their hospitals," "If we stand idly by, there could be other Astou Sokhnas. We have to stand up so that something like this doesn't happen again." Read full story Source: BBC News, 11 May 2022 -
News ArticleHeart surgery patients in London have died “unnecessarily” and faced increased risk of death as botched NHS investigations into dozens of deaths reduced a hospital’s ability to treat people, a coroner has warned. “Unnecessary” patient deaths have occurred as a result of heart surgery at St George’s University Hospital Trust being restricted and emergencies diverted to other “over stretched” hospitals, following investigations by national NHS bodies. The warning that deaths have occurred and may occur in the future, comes following the conclusion of a series of inquest hearings in March, during which it was found the NHS’ wrongly blamed a team of cardiac surgeons for the deaths of dozens of patients. Coroner Fiona Wilcox, in a report published on Wednesday, has now said the “inadequate” NHS led investigations, which criticised the care of 67 patients, led to people being put increased risk of death. The NHS’ investigations into the deaths of 67 patients ruled there were “shortcomings” in care. It led to complex operations being diverted elsewhere and doctors being referred to the General Medical Council. Two doctors have sinced been exonerated following GMC hearings. According to the coroner’s findings, capacity within cardiac surgery at the unit is down by 60% and staff are becoming “deskilled.” Read full story Source: The Independent, 11 May 2022
-
News Article
Nurse who filmed unconscious patients at hospital jailed for 12 years
Patient Safety Learning posted a news article in News
A nurse who filmed up the gowns of unconscious women patients and recorded staff using the toilet at a large teaching hospital has been jailed for 12 years by a judge who said he had "brought shame on an honourable profession". Paul Grayson, 51, was also told by the judge he must serve an extended licence period of 4 years when he is eventually released. The judge described how four patients were targeted as they recovered from surgery at Sheffield's Royal Hallamshire Hospital – one of whom has never been identified from the footage. Sentencing Grayson on Tuesday, Judge Jeremy Richardson QC said: "You have betrayed every ounce of trust reposed in you. Earlier this week, the court heard one victim, who was secretly filmed in the shower by Grayson over a number of years, face him directly in court as she told him his "sick and disgusting perversions" and "evil actions" were crimes that "have torn me into pieces". The court heard that one victim was unconscious after an eye operation when Grayson filmed her up her gown, and could be seen moving her underwear. The woman told police she had "put her trust in staff at the hospital to keep her safe". The victim said that she has since been due to have an operation at another hospital but she "can't bring myself to go". Read full story Source: Medscape UK, 11 May 2022 -
News Article
Plymouth maternity staff missed chances to save baby’s life, report finds
Patient Safety Learning posted a news article in News
A baby died after maternity staff repeatedly missed chances to intervene to save his life, an official investigation has found. Giles Cooper-Hall was just 16 hours old when he died after a catalogue of errors in the maternity care of his mother, Ruth Cooper-Hall, at Derriford hospital in Plymouth. A Healthcare Safety Investigation Branch (HSIB) report into the incident has exposed how inexperienced and overstretched staff failed to carry out proper checks, recognise there was an emergency or seek help from senior doctors until it was too late. It comes just weeks after the independent Ockenden report into more than 1,800 cases revealed serious failings in the maternity care provided at Shrewsbury and Telford hospital NHS Trust. It revealed how Ruth Cooper-Hall, then aged 37, was not personally seen by a consultant when she went into labour in October last year, despite recommendations made in the interim Ockenden report published in December 2020. The HSIB report also suggested Giles’ death could have been avoided if staff had known about the care plan for his mother’s labour. Instead, vital messages were not passed on, with the investigation finding this was likely to be because the staff responsible were “distracted” by other tasks. Read full story Source: The Guardian, 10 May 2022 -
News Article
Big rise in delayed GP referrals sparks safety warning
Patient Safety Learning posted a news article in News
A big rise in GP referrals being deferred because no appointment slots are available, in the wake of the covid pandemic, has sparked concerns that patients are going undiagnosed and missing out on the correct treatment. Outpatient referrals are typically classed as having an “appointment slot issue” when no booking slot is available within a timeframe specified by the provider, under the NHS e-referral system. The latest NHS Digital figures, analysed by HSJ, show the number of ASIs was 52% higher in March 2022 than February 2020 — up from 245,582 to 374,209. The statistics suggests appointment slot issue accounted for 77% of all bookings in March 2022, 26% of all referrals and 19% of bookings and referrals combined. In February 2020, this was 32%, 17% and 11% respectively. The Royal College of GPs told HSJ there was a risk of patients “simply disappearing” off lists if the issue was not properly managed, while charity Patient Safety Learning said the issue was a “growing problem” which NHS England must “urgently investigate”. Patient Safety Learning chief executive Helen Hughes said: “NHS England needs to urgently investigate, quantify the scale of the problem and take action if we are to prevent these capacity problems resulting in avoidable harm for patients. “Patients who cannot access outpatient services may deteriorate further while they wait for care, and it is not clear that in these cases there is the appropriate support available for them. There is also the potential for patients to be misdiagnosed and receive inappropriate treatment without specialist involvement, and the potential of a postcode lottery of care emerging for some conditions.” Read full story (paywalled) Source: HSJ, 6 May 2022 Read Patient Safety Learning's blog: Rejected outpatient referrals are putting patients at risk and increasing workload pressure on GPs -
News Article
‘Staff holidays’ delay death review by up to nine months
Patient Safety Learning posted a news article in News
A coroner has expressed ‘serious concern’ after a trust-wide safety review – prompted by the death of a young mother – was delayed by up to nine months due to ‘staff holidays’. An inquest heard that 25-year-old Natasha Adams, who died by suicide in August 2021, had had her level of care downgraded by Birmingham and Solihull Mental Health Foundation Trust a month earlier, in July, something her family suggested had a “dramatic impact”. She was moved from a “care programme approach” (known as CPA, which involves enhanced care for people with complex needs and/or safety concerns) to “care support” (a non-clinical programme for people with lower-level concerns and complexities). An earlier investigation into her death by the trust, finalised in December, said the trust should audit other cases to check whether the trust’s 2019 “care management and CPA/care support policy” was being complied with. Now Birmingham and Solihull coroner James Bennett has criticised a delay in carrying out the trust-wide audit – writing in a prevention of future deaths report that, as of last month, four months after the report investigating Ms Adams’ care was completed, “no action has been taken”. Read full story (paywalled) Source: HSJ, 5 May 2022 -
News Article
Hospital staff charged over patient mistreatment
Patient Safety Learning posted a news article in News
Five healthcare staff have been charged with criminal offences as part of a major investigation into the ill-treatment of hospital patients. Concerns had been raised over the welfare of some patients on the stroke unit at Blackpool Victoria Hospital. Three nurses and two healthcare assistants will appear at court for offences including unlawful sedation of patients and theft, police said. The charges relate to a period between August 2014 and November 2018. Those charged are Catherine Hudson, 52, of Coriander Close, Blackpool; Charlotte Wilmot, 47, of Bowland Crescent, Blackpool; Matthew Pover, 39, of Bearwood Road in Smethwick; Victoria Holehouse, 31, of Riverside Drive, Hambleton, and Marek Grabianowski, 45, of Montpelier Avenue, Bispham. They face charges including ill-treatment or wilful neglect, encouraging a nurse to sedate a patient, theft, supplying drugs and perverting the course of justice. Read full story Source: BBC News, 6 May 2022 -
News Article
Maternity scandal review chair resigns after pressure from families
Patient Safety Learning posted a news article in News
The newly appointed chair of a major review into poor maternity care in Nottingham has resigned following mounting pressure from families. Julie Dent was appointed by the NHS just two weeks ago to lead a review into hundreds of cases of alleged poor care at Nottingham University Hospitals NHS Trust. On 7 April, more than 100 families called for Ms Dent to decline the offer after they had previously urged NHS England to appoint Donna Ockenden, who chaired the Shrewsbury and Telford maternity inquiry. In a letter to families on Wednesday, the chief operating officer of NHS England and NHS Improvement, David Sloman, said: “After careful consideration and further conversations with her family, Julie Dent has, for personal reasons, decided not to proceed as chair of the independent review of maternity services at Nottingham University Hospitals NHS Trust.” The letter said that NHS England and NHS Improvement would still have “oversight” of the independent review, and that a new review process was being established. Mr Sloman said he would write to families to inform them of the next stage in the review “shortly”. The Nottingham independent maternity review was launched in July last year, and since then more than 500 families have come forward, the majority in the last two months. Read full story Source: The Independent, 4 May 2022
