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Found 1,556 results
  1. News Article
    A shortage of more than 2,000 midwives means women and babies will remain at risk of unsafe care in the NHS despite an inquiry into the biggest maternity scandal in its history, health leaders have warned. A landmark review of Shrewsbury and Telford hospital NHS trust, led by the maternity expert Donna Ockenden, will publish its final findings on Wednesday with significant implications for maternity care across the UK. The inquiry, which has examined more than 1,800 cases over two decades, is expected to conclude that hundreds of babies died or were seriously disabled because of mistakes at the NHS trust, and call for changes. But NHS and midwifery officials said they fear a growing shortage of NHS maternity staff means trusts may be unable to meet new standards set out in the report. “I am deeply worried when senior staff are saying they cannot meet the recommendations in the Ockenden review which are vital to ensuring women and babies get the safest possible maternity care,” said Gill Walton, chief executive of the Royal College of Midwives (RCM). The number of midwives has fallen to 26,901, according to NHS England figures published last month, from 27,272 a year ago. The RCM says the fall in numbers adds to an existing shortage of more than 2,000 staff. Experts said the shortage was caused by the NHS struggling to attract new midwives while losing existing staff, who felt overworked and fed up at being spread too thinly across maternity wards. Read full story Source: The Guardian, 29 March 2022
  2. News Article
    A damning report into hundreds of baby deaths has condemned the trust at the centre of the biggest maternity scandal in the history of the NHS for blaming mothers while repeatedly ignoring its own catastrophic blunders for decades. The independent inquiry into maternity practices at Shrewsbury and Telford hospital NHS trust uncovered hundreds of cases in which health officials failed to undertake serious incident investigations, while deaths were dismissed or not investigated appropriately. Instead, grieving families were denied access to reviews of their care and mothers were blamed when their babies died or suffered horrific injuries. A combination of an obsession with natural births over caesarean sections coupled with a shocking lack of staff, training and oversight of maternity wards resulted in a toxic culture in which mothers and babies died needlessly for 20 years while “repeated failures” were ignored again and again. Tragically, it meant some babies were stillborn, dying shortly after birth or being left severely brain damaged, while others suffered horrendous skull fractures or avoidable broken bones. Some babies developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries. The report, led by the maternity expert Donna Ockenden, examined cases involving 1,486 families between 2000 and 2019, and reviewed 1,592 clinical incidents. “Throughout our final report we have highlighted how failures in care were repeated from one incident to the next,” she said. “For example, ineffective monitoring of foetal growth and a culture of reluctance to perform caesarean sections resulted in many babies dying during birth or shortly after their birth. “In many cases, mother and babies were left with lifelong conditions as a result of their care and treatment. The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the trust and a culture of not listening to the families involved. “There was a tendency of the trust to blame mothers for their poor outcomes, in some cases even for their own deaths. What is astounding is that for more than two decades these issues have not been challenged internally and the trust was not held to account by external bodies. “This highlights that systemic change is needed locally, and nationally, to ensure that care provided to families is always professional and compassionate, and that teams from ward to board are aware of and accountable for the values and standards that they should be upholding. Going forward, there can be no excuses.” Read full story Source: The Guardian, 30 March 2022
  3. News Article
    An ambulance trust has appointed a former senior trust executive to lead an independent investigation into the circumstances surrounding the unexplained death of a staff member, HSJ has learned. East of England Ambulance Service Trust also shared the terms of reference for the investigation withHSJ, which follows the trust being forced to launch a similar probe in 2020 after three young staff members died in 11 days in December 2019. The latest investigation is into the death of Nick Lee, 46, from Ovington in west Norfolk, who died on 3 December 2021. Mr Lee was an operations manager for the trust in the west Norfolk area and had worked for the trust for nearly 20 years. The cause of death is yet to be officially established. Margaret Pratt has been appointed by the trust to lead the investigation. A trust statement issued to HSJ said: “The purpose of the investigation is to look at the events leading up to the death, review the circumstances of the death and consider whether there is anything that the trust can learn to contribute to improving the support provided to staff.” The investigation follows a prolonged period of years in which the trust has been dogged by high-profile and deeply ingrained cultural and bullying problems. Read full story (paywalled) Source: HSJ, 29 March 2022
  4. News Article
    A doctor's bid to be voluntarily removed from the medical register on health grounds has been rejected. It means Dr Heather Steen, who is accused of failings following the death of Claire Roberts in 1996, will still face a fitness to practice tribunal. The tribunal would have been halted if she had been removed from the register, as she would no longer have been a doctor. Claire Roberts died at the Royal Belfast Hospital for Sick Children, where Dr Steen worked, in October 1996. The nine-year-old's death was examined as part of the hyponatraemia inquiry. Her father Alan said his family welcomed the decision to refuse the paediatrician's application. He said the tribunal hearing was "in the public interest" and should proceed "to maintain public confidence in the medical profession, the regulatory process and to ensure that professional standards are upheld". Read full story Source: BBC News, 28 March 2022
  5. News Article
    A whistleblower who worked at a hospital trust where hundreds of babies died or were left brain-damaged says there was "a climate of fear" among staff who tried to report concerns. Bernie Bentick was a consultant obstetrician at the Shrewsbury and Telford NHS Trust for almost 30 years. "In Shrewsbury and Telford there was a climate of fear where staff felt unable to speak up because of risk of victimisation," Mr Bentick said. "Clearly, when a baby or a mother dies, it's extremely traumatic for everybody concerned. "Sadly, the mechanisms for trying to prevent recurrence weren't sufficient for a number of factors. "Resources and the institutionalised bullying and blame culture was a large part of that." More than 1,800 cases of potentially avoidable harm have been reviewed by the inquiry. Most occurred between 2000 and 2019. Mr Bentick worked at the Trust until 2020. He said from 2009 onwards, he was raising concerns with managers. "I believe there were significant issues which promoted risk because of principally understaffing and the culture," he said. He also accuses hospital bosses of prioritising activity - the number of patients seen and procedures performed - over patient safety. "I believe that the senior management were mostly concerned with activity rather than safety - and until safety is on a par with clinical activity, I don’t see how the situation is going to be resolved," he said. Read full story Source: Sky News, 27 March 2022
  6. News Article
    An investigation has been launched after a woman died during childbirth at a hospital's maternity unit. It was the third death of a mother in just over three years at Basildon University Hospital in Essex, in addition to a newborn baby's death. The trust that runs the hospital said it could not comment on the case while it was under investigation. Basildon University Hospital is part of Mid and South Essex NHS Foundation Trust, which also runs Southend and Broomfield hospitals. The latest fatality follows the death of 36-year-old Gabriela Pintilie in February 2019. Ms Pintilie died after losing six litres of blood giving birth to her second child at the unit. In separate incidents, a mother died and another woman had a stillborn baby at the unit in March 2019, while the trust was being inspected by the Care Quality Commission (CQC) following Ms Pintilie's death. The unit at Basildon had its rating upgraded from "inadequate" to "requires improvement" in December by the CQC. The hospital also apologised for the death of newborn Frederick Terry after he suffered a brain haemorrhage during a failed forceps delivery in November 2019. Read full story Source: BBC News, 27 March 2022
  7. News Article
    When Debbie Greenaway was told by doctors that she should try to deliver her twin babies naturally, she was nervous. But the doctor was adamant, she recalls. “He said: ‘We’ve got the lowest caesarean rates in the country and we are proud of it and we plan to keep it that way'." For Greenaway, labour was seemingly endless. She was given repeated doses of syntocinon, a drug used to bring on contractions. By the second day, the midwife was worried for one of the babies, whom the couple had named John. “She was getting really concerned that they couldn’t find John’s heartbeat.” Her husband remembers “the midwife shaking her head”. “She said a number of times that we should be having a caesarean.” By the time doctors finally decided to perform an emergency C-section, it was too late. Starved of oxygen, baby John had suffered a catastrophic brain injury. When he was delivered at 3am, he had no pulse. Efforts to resuscitate him failed. Their son’s death was part of what is now recognised as the largest maternity scandal in NHS history. The five-year investigation will reveal that the experiences of 1,500 families at Shrewsbury and Telford Hospital Trust between 2000 and 2019 were examined. At least 12 mothers died while giving birth, and some families lost more than one child in separate incidents, the report is expected to show. The expert midwife Donna Ockenden and a team of more than 90 midwives and doctors will deliver a damning verdict on the Shrewsbury trust, its culture and leadership — and failure to learn from mistakes or listen to families. At its heart is how a toxic obsession with “normal birth” — fuelled by targets and pressure from the NHS to reduce caesarean rates — became so pervasive that life-or-death decisions on the maternity ward became dangerously distorted for nearly two decades. Read full story (paywalled) Source: The Times, 26 March 2022
  8. News Article
    More than 1,500 patient deaths are to be investigated in the largest-ever independent inquiry into “unacceptable” mental health care. A probe into the deaths of patients who were cared for by NHS mental health services across Essex has revealed its investigation will cover deaths from 2000 to 2020. All 1,500 people died while they were a patient on a mental health ward in Essex, or within three months of being discharged from one. In 2001, following an investigation into 25 deaths, police criticised the trust for “clear and basic” failings but did not pursue a corporate manslaughter prosecution. And in 2021, the Health and Safety Executive fined the trust £1.5m due to failures linked to the deaths of 11 patients. The regulator said the trust did not manage the risks of ligature points for a period of more than 10 years. In January 2021, following pressures, former patient safety minister Nadine Dorries commissioned former NHS England mental health director Dr Geraldine Strathdee to chair an independent inquiry. While it is not known yet how many of the 1,500 deaths were caused by neglect, Dr Strathdee said evidence had so far shown some “unacceptable” and “dispassionate” care. Melanie Leahy, who has campaigned for change within Essex mental health services since her son died in 2012, has been leading the call for it to become a public inquiry on behalf of the families. Her son, Matthew Leahy, died as an inpatient at the Linden Centre, following multiple failings in his care. A 2018 parliamentary health service ombudsman report on his death, and that of another young man called Richard Wade, identified “systemic” failings on behalf of the trust. These included the failure to manage his risk level, to look after his physical health and to take action when he reported being raped in the unit. Read full story Source: The Independent, 28 March 2022
  9. News Article
    The government’s upcoming Covid-19 public inquiry must include the effect of the pandemic on children and young people, a group of leading doctors and scientists have said. The draft terms of reference for the inquiry were published on 15 March but made no specific mention of children or young people other than a single reference to “restrictions on attendance at places of education." “There is no doubt that school closures and broader lockdowns harmed children,” said the letter to the Times signed by 50 people including Russell Viner, former president of the Royal College of Paediatrics and Child Health, and Andrew James, president of the Royal College of Psychiatrists. “Educational losses have been most marked in children from deprived families and in vulnerable children.” They pointed out that mental health problems increased from being experienced by one in nine children and young people before the pandemic to one in six during 2020 and 2021. Childhood obesity rates last year were at least 20% above previous years. One of the signatories to the letter, education committee chair Robert Halfon, has also written directly to the inquiry chair Heather Hallet.3 “The closure of schools and the restrictions placed on education settings has been nothing short of a national disaster for children and young people, not only in terms of their educational attainment but also with regards to their mental health and wellbeing, their life chances, and their safety,” he wrote. Read full story Source: BMJ, 24 March 2022
  10. News Article
    A senior medic has won a whistleblowing case after judges ruled she was dismissed after raising concerns about a new procedure her department was using. An employment tribunal found consultant nephrologist Jasna Macanovic was fired from Portsmouth Hospitals University Trust in March 2018 after telling bosses a dialysis technique called “buttonholing”, which had been “championed” there, was potentially dangerous. The trust’s case was that the way she had gone about raising concerns had made for an untenable working environment in the Wessex Kidney Centre. The process saw a Care Quality Commission complaint, an independent investigation and multiple referrals to the General Medical Council. Employment Judge Fowell said: “The plain fact is that after over twenty years of excellent service in the NHS, Dr Macanovic was dismissed from her post shortly after raising a series of protected disclosures about this one issue. It is no answer to a claim of whistleblowing to say that feelings ran so high that working relationships broke down completely, and so the whistleblower had to be dismissed.” Dr Macanovic resigned from the regional renal transplant team in July 2016 when she discovered two incidents had occurred that “had not been reported by either surgeon” and felt that one of the surgeons had misled the medical director over the issue, the tribunal heard. In an email sent after the resignation meeting, Dr Macanovic said the practice was considered inappropriate by the vast majority of experts in the field and that no other renal unit in England was using it. The case exposes some worrying governance, both within the trust and between it and the Care Quality Commission, with which the issues were raised in 2016. When the CQC asked the trust for more information the unit’s clinical director responded that in his view that the deaths and infections were not due to the buttonholing. The CQC made no further enquiries and wrote back saying “they were satisfied that there were no safety concerns and that appropriate governance had been followed”. Read full story Source: HSJ, 24 March 2022
  11. News Article
    A nurse who admitted she was unfit to practise after dragging a patient with dementia to her room and forcefully attempting to administer a sedative has been suspended for a year by the nursing regulator. Carol Picton was working in the stroke unit at the Western General Hospital in Edinburgh in November 2017 when colleagues raised concerns about her treatment of a vulnerable older woman. Witnesses who gave evidence to an NMC fitness to practice (FtP) panel said they heard the patient screaming in distress after being roughly dragged by her arm back to her room by Ms Picton. The nurse then attempted to forcefully administer the anti-psychotic drug Haloperidol without checking the correct dosage, the hearing was told. She tried to give the drug orally using a 2ml injection syringe rather than an oral syringe. Ms Picton denied forceful mistreatment and panel found no evidence she had shown insight into her misconduct When the patient spat out the drug Ms Picton gave her more without knowing how much she had ingested, risking an overdose, the panel heard. Ms Picton, who was referred to the NMC by her employer following an internal investigation, was also said to have tilted the patient’s bed to prevent her getting out and leaving her room. The panel, which found five charges proven, concluded that Ms Picton’s actions were ‘deplorable’ and amounted to harassment and abuse. Read full story Source: Nursing Standard, 21 March 2022
  12. News Article
    A young woman died following “gross failings” and “neglect” by a mental health hospital in Essex which is also facing a major independent inquiry into patient deaths. Bethany Lilley, 28, died on 16 January whilst she was an inpatient at Basildon Mental Health unit, run by Essex Partnership University Hospitals. The inquest examined the circumstances of her death this week and concluded that her death was contributed by neglect due to a “plethora of failings by Essex University Partnership Trust”. Following the three week inquest, heard before coroner Sean Horstead, a jury found “neglect” contributed to Ms Lilley’s death and identified “gross failures” on behalf of the trust. The jury identified a number of failings in her care including evidence that cocaine had made its way onto a ward where she was an inpatient. There was evidence of “very considerable problems in the record-keeping at EPUT psychiatric units.” It was also concluded staff failed to carry out a risk assessment of Ms Lilley in the days leading up to her death, and failed to carry out observations. Ms Lilley’s death is one of a series of patients who have died under the care of mental health services in Essex, which have been brought into the light following the campaigning of bereaved families. Read full story Source: The Independent, 19 March 2022
  13. News Article
    A paediatrician who was at the centre of one of Northern Ireland's longest running public inquiries will appear before a professional misconduct panel. Dr Heather Steen is accused of several failings following the death of Claire Roberts at the Royal Belfast Hospital for Sick Children in October 1996. The nine-year-old's death was examined by the hyponatraemia inquiry, which lasted 14 years. It examined the role of several doctors. Among his findings, the inquiry's chairman Mr Justice O'Hara said there had been a "cover-up" to "avoid scrutiny." Monday's tribunal will inquire into allegations that, between 23 October 1996 and 4 May 2006, Dr Steen "knowingly and dishonestly carried out several actions to conceal the true circumstances" of the child's death. Also that the doctor provided inappropriate, incomplete and inaccurate information to the child's parents and GP regarding the treatment, diagnosis, clinical management and cause of her death. The tribunal website adds: "It is also alleged that Dr Steen inappropriately recommended a brain-only post-mortem for Patient A (Claire Roberts) when a full post-mortem was necessary. "In addition, it is alleged that Dr Steen failed to refer Patient A's death to the coroner, inappropriately completed the medical certificate of cause of death and inaccurately completed the autopsy request form for Patient A. "Furthermore, it is alleged that during a review of Patient A's notes, Dr Steen failed to consult with the necessary colleagues and medical teams and provided a statement and gave evidence to the coroner's inquest into Patient A's death which omitted key information." Read full story Source: BBC News, 21 March 2022
  14. News Article
    The parents of a baby boy who lived for just 27 minutes have told an inquest they were "completely dismissed" throughout labour. Archie Batten died on 1 September 2019 at the Queen Elizabeth the Queen Mother Hospital (QEQM) in Margate, Kent. His inquest began on Monday at Maidstone Coroner's Court. The East Kent Hospitals University NHS Foundation Trust has already admitted liability and apologised for Archie's death. The coroner heard Archie's mother Rachel Higgs was frustrated at being turned away from the maternity unit in the morning, when she had gone to complain of vomiting and extreme pain. She was told she was not far enough into labour to be admitted. She returned home to Broadstairs with her partner Andrew Batten, but continued to feel unwell so phoned the hospital. She was told the unit was now closed. Instead, two community midwives were sent to their home, where they attempted to deliver the baby but could not find a heartbeat. Andrew Batten told the inquest the midwives looked "terrified," and that there was "an air of panic", with the midwives whispering in the hallway instead of telling him and Ms Higgs what was happening. Under examination from the family's barrister Richard Baker, Victoria Jackson, the midwife who had originally seen Ms Higgs, admitted the high number of patients she was having to deal with had affected her ability to spend time with her. Read full story Source: BBC News, 14 March 2022
  15. News Article
    A midwife found guilty of misconduct over the death of a baby six years ago is to be struck off. Claire Roberts was investigated by the Nursing and Midwifery Council (NMC) for failures in the care she gave to Pippa Griffiths - who died a day after being born at home in Myddle, Shropshire. An independent disciplinary panel described the midwife as "a danger to patients and colleagues". Ms Roberts and fellow midwife Joanna Young failed to realise the "urgency" of medical attention needed, following the birth, the panel said. They had failed to carry out a triage assessment, after Pippa's mother called staff for help because she was worried about her daughter's condition. The panel concluded Ms Roberts's fitness to practise was impaired. Inaccurate record-keeping by Ms Roberts represented "serious dishonesty", panel chair David Evans said, adding she had carried it out "in order to protect herself from disciplinary action". Her failures had represented a "significant departure from standards expected by a registered midwife," he added. Her colleague Ms Young, whose case was also heard by the panel, faced strong criticism on Wednesday, but was told she would face no sanction after the hearing concluded she had shown remorse and undergone extra training since 2016. Kayleigh Griffiths said she and her husband welcomed the findings and sanctions. "We're really relieved that one of the midwives has been struck off and actually we're also relieved to find that the other midwife has learnt and feels significant remorse for the event that took place," she said. "We realise people do make mistakes and I think how you deal with those mistakes is really important. "All we do ask is that learning was made from those and I think in one of the instances it did occur and in the other it didn't - so I think the right outcome has been found." Read full story Source: BBC News, 10 March 2022
  16. News Article
    The draft terms of reference for the UK public inquiry into the government's handling of the Covid-19 pandemic have been published. The inquiry, due to start in the spring, will play a key role in "learning lessons" from the pandemic and for the future, it said. The terms of reference were published after a consultation with inquiry chairwoman and former High Court judge Baroness Hallett, and with ministers in the devolved nations. The Scottish government has already published the terms of reference for its own Covid-19 inquiry, to be led by Judge Lady Poole. The UK-wide inquiry proposes examining a broad range of issues including: 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. The inquiry aims to produce "a factual, narrative account" covering decision-making at all levels of government and the response of the health and care sector as well as identifying the "lessons to be learned". Becky Kummer, spokesperson for Covid-19 Bereaved Families for Justice, said the publication was a "huge step forward" and the organisation looked forward to contributing to the consultation on the terms. Chris Hopson, chief executive of NHS Providers, which represents hospital trusts, said there was much the NHS did well during the pandemic but: "It is right the inquiry looks at areas where there were major challenges - such as infection prevention and control, access to PPE, testing, and robust epidemiological modelling." Read full story Source: BBC News, 11 March 2022
  17. News Article
    The publication of a report into failures of maternity care at an NHS trust has been delayed again. Senior midwife Donna Ockenden has been investigating hundreds of cases in which mothers and babies may have been harmed at Shrewsbury and Telford Hospital NHS Trust (SaTh). Her report had been due to be published on 22 March after being postponed from December. In a letter to families, Ms Ockenden said that date "can no longer happen". She added it was down to "parliamentary processes" which have to happen before the final report can be published. A written statement to Parliament on Tuesday by patient safety minister Maria Caulfield said the NHS had been working to get indemnity cover. She said it would be to cover any potential legal action following the publication of the report and had been agreed in principle by the Treasury. Ms Ockenden's team has been examining 1,862 cases and it is thought to be the largest ever review of maternity care in the NHS. Her interim report published in December 2020 found some mothers were blamed for their babies' deaths. In her letter about the delay, Ms Ockenden said she and her team were "also very disappointed in the delay" and would be working to agree a new publication date. Read full story Source: BBC News, 9 March 2022
  18. News Article
    Serious failings by healthcare staff at Broadmoor Hospital were likely to have contributed to the death of a patient from self-asphyxiation, a jury has found. Following a two-week inquest at Reading Coroner’s Court, a jury found staff failed to recognise and reduce the risks that acutely unwell patient Aaron Clamp presented to himself in the minutes leading to his death. Mr Clamp died on 4 January 2021 after choking in his room at the NHS-run high secure mental health hospital Broadmoor. In the weeks prior to his death, Mr Clamp’s mental health had deteriorated. He was transferred into a “psychiatric intensive care” ward at Broadmoor Hospital and placed in long-term segregation. A summary of the jury’s findings shared with The Independent has found there was “a serious failure in the timely manner to recognise and reduce the level of risk, and a serious failure to recognise and execute the steps to remove the item of fabric” that Mr Clamp choked on. “This omission probably contributed to the death,” the jury said. It was also found there was “insufficient” recording by the trust of previous incidents of self-asphyxiation by Mr Clamp when he died. Jurors said the plan for staff to carry out constant eyesight observations was appropriate, but not all aspects of the plan were adequately followed by staff members. Read full story Source: The Independent, 7 March 2022
  19. News Article
    A 13-year-old girl who died after contracting sepsis in an NHS hospital probably would have survived if doctors had identified the warning signs and transferred her to intensive care earlier, a coroner has ruled. Martha Mills was the first ever child to die at King’s College hospital (KCH) with a pancreatic injury of the type she sustained in a fall from her bike on an off-road family trail in Wales while on holiday last year. She was transferred to the south London hospital because it is one of three national centres for the care of children with pancreatic trauma. An inquest at St Pancras coroner’s court, north London, heard that several opportunities were missed to refer Martha to intensive care, which probably would have saved her life. In an emotional witness statement, Martha’s mother, Merope, said that after their daughter contracted an infection on 21 August last year, she and her husband, Paul Laity, raised concerns about Martha’s deteriorating health a number of times but doctors sought to reassure them rather than escalate her care. Mills said in her statement that she explicitly raised her fears about Martha going into septic shock over the bank holiday weekend. On 29 August, Martha had high fever, low blood pressure, a racing heart and a rash, which was misdiagnosed by a junior doctor despite Mills voicing her concern that it was caused by sepsis. It was only the next day that Martha was admitted to paediatric intensive care. “I felt that my anxieties about all of Martha’s symptoms, and especially what they might mean when put together and considered in the round, weren’t given proper acknowledgement,” Mills told the court. Prof William Bernal, who produced a serious incident report on Martha’s death for KCH, said there were at least five occasions when she should have had a critical care review. He wrote that Martha’s chances of survival “would have been greatly increased” if she had been admitted to critical care earlier. The inquest heard that KCH was making changes in the wake of Martha’s death, including improving diagnostics and taking account of parents’ views. Read full story Source: The Guardian, 3 March 2022
  20. News Article
    A man died after an NHS trust failed to diagnose and treat sepsis quickly enough, a Parliamentary and Health Service Ombudsman investigation has found. Stephen Durkin died after suffering organ failure from sepsis. Stephen’s wife Michelle made a complaint to the Ombudsman after she was left floored by his sudden death which she believed was avoidable. Stephen was an otherwise healthy 56-year-old when he attended Wye Valley Trust A&E in July 2017 with chest pain. Hospital staff suspected he had a major blood vessel blockage and admitted him to a ward overnight. The next morning his overall condition had worsened but staff did not monitor him more closely, as national guidance advises, and he continued to deteriorate throughout the day. The next day Stephen was admitted to intensive care and treated for sepsis but tragically died later that evening. In the space of 48-hours his condition deteriorated rapidly but staff did not act quickly enough and the critical care team attended Stephen ten hours too late. His wife Michelle arrived at the hospital to visit Stephen, only to find that he was critically ill and unresponsive. She was left devastated by his death and turned to the Ombudsman to look into what had happened with his care. Ombudsman Rob Behrens said: "Stephen’s tragic death could so easily have been avoided. His case shows why early detection of sepsis, as set out in national guidelines, is crucial." "Sadly, this is not the first time we have had to highlight this issue. There is clearly more the NHS needs to do. It is vital that NHS trusts ensure their staff are sepsis-aware to reduce the number of avoidable deaths from this life-threatening condition." Read full story Source: PHSO, 3 March 2022
  21. News Article
    A patient at Broadmoor Hospital has died after suffocating while staff were chatting outside of his room, an inquest has heard. Aaron Clamp, a patient at the notorious high security mental health hospital Broadmoor, died on 4 January 2021 after asphyxiating whilst in his room. The Independent understands Mr Clamp’s death may have been the first “non-natural” death since the new Broadmoor Hospital, run by West London Trust, opened in December 2019. According to evidence heard at the inquest, staff who were meant to be carrying out continuous “eyesight” observations on Mr Clamp, were having a conversation without direct sight into his room. Mr Clamp’s father told The Independent he was “tormented” by the criminal justice and mental health system which resulted in his “indefinite incarceration.” “Diagnosed with a mental illness, schizoaffective disorder, the purpose of treatment was rehabilitation. Psychiatric treatment is conventionally centred on medication to manage symptoms and risk," his father said. He acknowledged there is a balance to be struck between managing risks and restricting patients, but closer attention of holistic compassionate care should be given. Read full story Source: The Independent, 3 March 2022
  22. News Article
    More than a dozen families are seeking compensation following "significant failures" at NHS Lothian's hearing service for children. The health board apologised to more than 155 families after an independent investigation found serious problems diagnosing and treating hearing loss. Sophie was born partly deaf and failed repeated hearing tests for years. Her family say no help was offered by the paediatric audiology department at NHS Lothian who kept saying she would be fine. But her parents say she is not. Sophie is now seven. Her speech and language has not developed fully and is sometimes hard to understand. Her confidence has been affected. Her mum Sarah said: "They failed Sophie. You kind of trust what they were doing, you thought maybe she doesn't need hearing aids, maybe she will just catch up and now she's almost eight years old and she's still not caught up and you think 'OK, maybe there were mistakes made then'." An independent investigation by the British Academy of Audiology (BAA), published in December last year, found "significant failures" involving 155 children over nine years at NHS Lothian. Several profoundly deaf children were diagnosed too late for vital implant surgery. The health board has "apologised sincerely" to those affected. The BAA looked at more than 1,000 patient records finding "significant failures" in almost 14% of them. The BAA said it found "no evidence" that national guidelines and protocols on hearing tests for children had been followed or consistently applied "at any point since 2009". Read full story Source: BBC News, 2 March 2022
  23. News Article
    NHS England wants lessons learned by a trust overhauling its culture after a high-profile bullying scandal to be shared systemwide because similar problems have been evident at other trusts, the hospital’s boss has said. West Suffolk Foundation Trust interim chief executive Craig Black said the trust was getting national level “support” to help with a cultural overhaul after a scathing independent review published in December concluded the trust’s hunt for a whistleblower had been “intimidating… flawed, and not fit for purpose”. Mr Black said he thought NHSE would be “looking to learn from what we are doing” because senior managers viewed concerns raised in the West Suffolk review as having ”resonance with a number of organisations in the NHS at the moment”. As well as the specific “witch hunt” case, the review raises wider issues about how trusts respond to whistleblowing and other concerns about care and patient safety. West Suffolk’s executive director of workforce and communications Jeremy Over told the meeting the cultural change required was “organisational development which will take time, significant time”. The report, West Suffolk Review – organisational development plan, sets out nine broad themes of work, linked to the trust’s core functions, “that capture the priority areas for organisational and cultural development at WSFT in light of the learnings from the report”. The document sets out how the trust’s governance, freedom to speak up, HR, staff voice, patient safety and other parts of its corporate infrastructure failed and contributed to a scandal. Read full story (paywalled) Source: HSJ, 1 March 2022
  24. News Article
    Patient safety will be harmed and victims of medical negligence denied justice because of flaws in the government’s health and care bill, the NHS ombudsman has told the Guardian. Rob Behrens, the parliamentary and health service ombudsman, fears he and his staff will not be able to get to the bottom of clinical blunders because under the bill he will be denied potentially vital information collected by the NHS’s Healthcare Safety Investigation Branch (HSIB). The ombudsman said the legislation would allow the HSIB to “operate behind a curtain of secrecy” and undermine his own investigations into lapses in patient safety and could deny grieving families the full truth about why a loved one died. Behrens has spoken out because he is concerned about government plans for NHS staff involved in an incident to give evidence about mistakes privately in a “safe space” to the HSIB, which cannot be shared with anyone else except coroners. His exclusion from seeing material gathered in that way could force him to take the agency to the high court to access it, he said. “If the ‘safe space’ provisions become law as drafted there is a real risk to patient safety and to justice for those who deserve it. This is a crisis of accountability and scrutiny,” he said. Julia Neuberger, a crossbench peer who chairs University College hospitals NHS trust, has tabled an amendment to the bill in the House of Lords seeking to give the ombudsman access to information obtained via “safe space” processes. Unless ministers rethink the plan “there could be serious consequences for members of the public who use the ombudsman service”, she recently told a Lords debate. “If the ombudsman is unable to investigate robustly all aspects of complaints about the NHS, except with the permission of the high court, patients may find it harder to get access to justice. The NHS may well become less accountable for its system failings,” she said. Peter Walsh, chief executive of patient safety charity Action Against Medical Accidents, backed Behrens. “The so-called safe space is a red herring with serious unintended consequences. There is no evidence staff do not take part in investigations for fear of information being known. It is bullying employers and over-zealous regulators that staff fear. Denying people their right to have the ombudsman investigate properly does nothing to address that.” Read full story Source: The Guardian, 28 February 2022
  25. News Article
    The police are investigating the death of a young person at a mental health hospital, The Independent can reveal. Police are investigating the death of a young girl at The Huntercombe Maidenhead mental health hospital in February. In a statement to The Independent: Thames Valley Police, said: “Thames Valley Police is conducting an investigation after the death of a girl following an incident at Huntercombe Hospital in Maidenhead on Saturday 12 February. The girl’s next of kin have been informed and our officers are supporting them. Our thoughts remain with them at this very difficult time. An investigation is ongoing to understand the circumstances around this tragic incident.” The Care Quality Commission has also said it was notified of the young girls death. The care regulator said it could not comment further. The NHS confirmed to The Independent admissions to one of the hospital’s wards have been suspended. The 60-bed hospital was rated Inadequate and placed in special measures by the CQC in February 2021 following serious concerns over care of patients. Read full story Source: The Independent, 26 February 2022
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