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Found 1,557 results
  1. News Article
    A 65-year-old man died after doctors failed to notice serious abnormalities on his X-ray, an investigation by the Parliamentary and Health Service Ombudsman (PHSO) has revealed. The investigation comes a year after a landmark report by the Ombudsman highlighted failings in how X-rays and scans are reported and followed up in the NHS. Mr B, who was admitted to University Hospitals Birmingham NHS Foundation Trust in May 2019, had been unwell for several days. He was admitted to hospital suffering from abdominal pain and vomiting. An X-ray of his abdomen was taken, which two doctors said did not show any apparent abnormalities. The following day the man’s condition deteriorated. He suffered a heart attack and died. A PHSO investigation found the Trust failed to notice a blockage in his intestine on the X-ray. Because of this failure, Mr B did not receive treatment that could have saved his life. Speaking on this case Ombudsman Rob Behrens said: “The case of Mr B highlights the devastating impact mistakes like this can have. If the Trust had picked up the abnormalities on his X-ray sooner, Mr B could still be with his family today. “As the NHS faces the challenge of rebuilding after the pandemic, it must not lose momentum in improving the way X-rays and scans are handled during a patient’s care.” Progress has been made by the NHS in implementing recommendations made by the Ombudsman in the report; however, Rob Behrens has said more needs to be done to protect patients from serious harm. “Attention and buy-in from the NHS’s senior leaders is crucial if we want to see sustained and meaningful change in how X-rays and scans are managed during a patient’s care. We need more collaboration across clinical specialties, looking at the whole patient journey once a scan has been carried out. "I want to see the NHS treating complaints as a source of insight to drive improvements in patient care. Not learning from mistakes will mean missed opportunities to diagnose patients earlier. In the most serious cases, like that of Mr B, it will mean a death which should never have happened.” Read full story Source: PHSO, 20 July 2022
  2. News Article
    Staff at a mental health trust, run by Norfolk and Suffolk NHS Foundation Trust, falsified records that they had checked on a vulnerable patient the night he died, an inquest has heard. Eliot Harris was found dead in his room at Northgate Hospital in Great Yarmouth, Norfolk, in April 2020. A police witness statement detailed how CCTV footage contradicted 19 log entries. Mr Harris, 48, was admitted to hospital after the care home where he was a resident requested an urgent mental health assessment, an inquest into his death at Norfolk Coroner's Court heard. He had been diagnosed with paranoid schizophrenia, had a history of epileptic seizures and had not been taking his medication. Mr Harris was deemed to be high risk and was supposed to be on regular checks four times an hour. In a witness statement read out in court, Det Sgt Nick Appleton described how police had cross referenced logs of his observations with CCTV recordings. Det Sgt Appleton listed 19 instances in which the observation record was signed by a staff member that night, indicating Mr Harris had been checked, but was not backed up by the CCTV record. He identified a number of "points of concern" in his evidence in which falsifying logs was "normal" and "standard practice" on wards. Read full story Source: BBC News, 1 August 2022
  3. News Article
    Three former health secretaries have called on the government to urgently pay compensation to victims of the contaminated blood scandal. The chairman of the public inquiry into the scandal, Sir Brian Langstaff, has recommended that each victim should receive a provisional sum of £100,000. One woman who developed hepatitis C from infected blood told the BBC the news was "incredibly significant". The government has said it will urgently consider any recommendations. Former health secretaries Andy Burnham, Jeremy Hunt and Matt Hancock told the BBC it was important to act quickly because the life expectancy of many victims had been shortened by infections they had contracted. A lawyer representing about 15,000 claimants also argued that victims should receive compensation "immediately". Des Collins said payment must be made within "days or weeks", and he would step up pressure from Monday. Read full story Source: BBC News, 31 August 2022
  4. News Article
    Almost 75 years since its foundation, the NHS is struggling with delays caused by the coronavirus pandemic and the “greatest workforce crisis” in its history. A report from MPs on the health committee this week showed 105,000 vacancies for doctors, nurses and midwives, as thousands quit owing to burnout, bullying, pension rules and low pay. Jeremy Hunt, the committee’s chairman, said that the “persistent understaffing in the NHS poses a serious risk to staff and patient safety”. Lawyers warned that the crisis risked increasing the number of negligence claims. Spending on claims by NHS Resolution rose to £2.5 billion in 2021-22 compared with £2.3 billion in the previous year, according to its annual report published last week. The bill increased despite initiatives to cut the number of cases going to court and foster greater collaboration with claimant lawyers. Claimant lawyers welcomed NHS Resolution’s more collaborative approach and desire to resolve cases sooner. They argued, however, that the defensive culture remained and suggested there should be a greater focus on patient safety and learning from mistakes. John McQuater, president of the Association of Personal Injury Lawyers, said that NHS Resolution’s denials and delays meant that injured patients had to turn to lawyers to find answers. He said that earlier investigation into patient safety incidents and earlier admissions of liability by NHS trusts would speed up the system, cutting costs and human misery. Read full story (paywalled) Source: The Times, 28 July 2022
  5. News Article
    Former Health Secretary Jeremy Hunt has told a public inquiry institutions and the state can sometimes "close ranks around a lie". Giving evidence at the infected-blood inquiry, he said it could be seen as a "huge failing of democracy" that victims had waited so long for justice. At least 5,000 people contracted HIV or hepatitis C in the 1970s and 80s, after being given contaminated blood products and transfusions on the NHS. More than 2,400 have died as a result. Jenni Richards QC asked whether a 2012 briefing for new ministers in the health department - "almost certainly" not shown to Mr Hunt at the time - stating, under a heading "Key facts", hepatitis C and HIV (Human Immunodeficiency Virus) infection had been a problem in the 1970s and 80s, "before it was possible to screen donors and make products safer", suggested the contamination had been an "unavoidable problem". Mr Hunt, health secretary for six years until July 2018, replied: "I mean, that briefing is wrong and it shouldn't say that. "At the very least, ministers should be aware as politicians that this is contentious and disputed by families - but I'm afraid it tries to suggest the issue is closed when it is not." Read full story Source: BBC News, 27 July 2022
  6. News Article
    Families who lost loved ones during the pandemic have demanded to play a central role in the UK’s Covid-19 inquiry, which launches its investigative phase tomorrow. The inquiry has already consulted with different groups, businesses, academics and officials from a variety of sectors involved in the pandemic response to review which areas warrant scrutiny and how to structure proceedings. This includes Covid-19 Bereaved Families for Justice, a campaign group of over 6,000 people who have lost a loved one to coronavirus. The group has repeatedly sought assurances from the inquiry it will be granted a ‘core participant’ status once applications open. This which would allow families to give evidence, ask questions during proceedings, access all disclosed documents, and recommend people to be interviewed. However, Elkan Abrahamson, a lawyer who is representing the group in the inquiry, said it was unclear how the inquiry would select core participants and expressed concern that the bereaved families won’t play a central role. “The feeling from the bereaved at the consultation stage was that the chair was sympathetic. They were happy with how that went,” Mr Abrahamson said. “[But] given we represent the largest group of bereaved in the UK, we’re not experiencing a sense of co-operation that we would normally expect to have reached by this stage. Their lawyers are happy to meet with us, but the questions we ask them aren’t being properly answered.” Read full story Source: The Independent, 20 July 2022
  7. News Article
    A paediatrician has been struck off for falsely diagnosing children with cancer to scare their parents into paying for expensive private treatment. Dr Mina Chowdhury, 45, caused "undue alarm" to the parents of three young patients - one aged 15 months - by making the "unjustified" diagnoses so his company could cash in by arranging tests and scans, a medical tribunal found. Chowdhury, who worked as a full-time consultant in paediatrics and neonatology at NHS Forth Valley, provided private treatment at his Meras Healthcare clinic in Glasgow. But the clinic made losses, despite "significant" potential income from third-party investigations and referrals for treatment – with patients charged a mark up fee of up to three times the actual cost. In all three cases, Chowdhury gave a false cancer diagnosis, without proper investigation, before recommending “unnecessary and expensive” private tests and treatment in London. Parents previously told the tribunal of their shock and upset at receiving Chowdhury’s diagnoses during consultations between March and August 2017. He told the parents of a 15-month-old girl - known as Patient C - that a lump attached to the bone in her leg was a "soft tissue sarcoma" and a second lump had developed. Chowdhury urged them to see a doctor in London who could arrange an ultrasound scan, a MRI scan and biopsy in a couple of days, saying: "If things are happening it is best to get on top of them early." He also warned that it would be "confusing" to return to the NHS for treatment. But the parents spoke to an A&E doctor and an ultrasound scan revealed that the lumps were likely fat necrosis. Patient C later was discharged after her bloods tests came back as normal. The child’s mother told the tribunal that she and her husband had been "very upset" at Chowdhury’s diagnosis. She was also left "angry" after she later read Dr Chowdhury’s consultation notes and realised they were a "total falsification" of what was discussed. Read full story Source: Medscape, 18 July 2022
  8. News Article
    Catherine O’Connor, who was born with spina bifida and used a wheelchair all her life, was looking forward to the surgery to fix her twisted spine. Tragically, after a catastrophic loss of blood, she died on the operating table at Salford Royal Hospital in Manchester. She died in February 2007 but only now has an NHS-commissioned report concluded the “unacceptable and unjustifiable” actions of her surgeon, John Bradley Williamson, “directly contributed” to her death. Williamson pressed on with the surgery despite being explicitly told he needed a second consultant surgeon. Her case is one of more than a hundred of Williamson’s being reviewed by Salford Royal Hospital amid allegations by whistleblowers of a cover-up by managers and a “toxic culture” within his surgery team. An internal list produced by concerned clinicians as long ago as 2014 describes some of Williamson’s patients being left paralysed or in severe pain as a result of misplaced spinal screws and others being rushed back to theatre for life-saving surgery. Separately, leaked minutes of a meeting between staff and the hospital’s new chief executive in December 2021 described a “snapshot” of five of Williamson’s patients which “clearly identified significant areas of clinical care, avoidable harm and avoidable death”. They added: “Concerns around Mr Williamson continue to be raised and remain unaddressed.” Read full story (paywalled) Source: The Times, 17 July 2022
  9. News Article
    A couple whose baby died in Nottingham say they are "furious" at a memo to hospital staff criticising media coverage of the city's maternity units. Jack and Sarah Hawkins, whose daughter Harriet died in 2016, have led calls for an inquiry into failings. Nottingham University Hospitals NHS Trust (NUH) is at the centre of a review into failings at the city's maternity units. After years of campaigning and an earlier review which was abandoned, experienced midwife Ms Ockenden was appointed in May. On Tuesday it emerged Ms Wallis had sent a memo to NUH maternity staff which read: "Yesterday, (Monday 11th) Donna Ockenden met with families as part of the new independent review process. "Some of you will no doubt have seen some of the media fall out." "Yet again they painted a damning picture of our maternity services, leaving out of their reports the great work that has been done, the improvements that have been introduced and the passion and commitment of all of the staff." Mr and Mrs Hawkins told the Local Democracy Reporting Service: "It's not just the families and the press ganging up - there is very real concern about safety. For senior leadership to not be saying that they have a problem is beyond us." Hospital bosses have "wholeheartedly apologised" for offence caused. Read full story Source: BBC News, 13 July 2022
  10. News Article
    When Susan Sullivan died from Covid-19, her parents’ world fell quiet. But as John and Ida Sullivan battled the pain of losing their eldest, they were comforted by doctors’ assurance that they had done all they could. It was not until more than a year later, when they received her medical records, that the family made a crushing discovery. These suggested that, despite Susan being in good health and responding well to initial treatments, doctors at Barnet hospital had concluded she wouldn’t pull through. When Susan was first admitted on 27 March 2020, a doctor had written in her treatment plan: “ITU (Intensive therapy unit) review if not improving”, indicating he believed she might benefit from a higher level of care. But as her oxygen levels fell and her condition deteriorated, the 56-year-old was not admitted to the intensive unit. Instead she died in her bed on the ward without access to potentially life-saving treatment others received. In the hospital records, seen by the Observer, the reason Susan was excluded is spelled out: “ITU declined in view of Down’s syndrome and cardiac comorbidities.” A treatment plan stating she was not to be resuscitated also cites her disability. For John, 79, a retired builder, that realisation was “like Susan dying all over again”. “The reality is that doctors gave her a bed to die in because she had Down’s syndrome,” he said. “To me it couldn’t be clearer: they didn’t even try.” Susan is one of thousands of disabled people in Britain killed by Covid-19. Last year, a report by the Learning Disabilities Mortality Review Programme found that almost half those who died from Covid-19 did not receive good enough treatment, including problems accessing care. Of those who died from Covid-19, 81% had a do-not-resuscitate decision, compared with 72% of those who died from other causes. Read full story Source: The Guardian, 10 July 2022
  11. News Article
    Health Minister Robin Swann has announced plans to improve the review process for serious adverse incidents (SAI) in Northern Ireland's health and social care system. The reviews take place after unintended incidents of harm and ensure improvements are made. The Regulation and Quality Improvement Authority (RQIA) was commissioned to examine the system's effectiveness. It found the process was not "sufficiently robust". In the RQIA report, the independent body found that "neither the SAI review process nor its implementation is sufficiently robust to consistently enable an understanding of what factors, both systems and people, have led to a patient or service user coming to harm". It added: "The reality is that similar situations, where events leading to harm have been inadequately investigated and examples of recognised good practice have not been followed, have been and are likely to be repeated in current practice." It identified failures in the SAI procedure, including failures to: Answer patient and family questions. Determine where safety breaches have occurred. Achieve a systemic understanding of those safety breaches. Design recommendations and action plans to reduce the opportunity for the same or similar safety breaches in future. Read full story Source: BBC News, 7 July 2022
  12. News Article
    A world-famous hospital has a culture where some staff may put research interests above patient safety, according to an external investigation. A report published yesterday cited some employees at Great Ormond Street Hospital for Children Foundation Trust as saying “they feel that the hospital sometimes put too much emphasis on pushing the boundaries of science” and “are concerned [this] may lead to a culture where some prioritise innovation over safety in their practice”. The trust’s medical director Sanjiv Sharma commissioned the report into the effectiveness of its safety procedures, from consultancy Verita, in 2020, after families of several patients who died at the hospital raised concerns in the media about how it responded to safety incidents. The report said: “We believe that it is sometimes culturally difficult within Great Ormond Street to accept that things can go wrong and to respond appropriately. We were told that some see the organisation as ‘bullet-proof’ in the face of criticism." “There is also a view outside the trust that some clinicians at Great Ormond Street can find it difficult to accept that something had gone wrong. Some believe that this reflex is deeply ingrained. This is potentially indicative of a culture of defensiveness. Acknowledging this trait is the first step on the road to changing it.” Dr Sharma said in a statement yesterday that GOSH had already taken steps to improve its culture and systems, appointing patient safety educators and patient safety leads in each directorate. Read full story (paywalled) Source: HSJ, 7 July 2022
  13. News Article
    A two-day old baby died just days after his mother begged doctors to assess her ahead of a c-section despite her pregnancy being deemed high risk. Davi Heer-Do Naschimento was born via emergency caesarean section during the early hours of 29 September 2021, after doctors at Royal London Hospital failed to communicate crucial details during handover meetings. An inquest at Poplar Coroners Court heard that his parents, Ruth Heer and Tiago Do Naschimento, had asked numerous times for assistance and were not seen by the obstetrics team the day before her planned caesarean. Tragically, after becoming "feverish" during the night, she was rushed into theatre with Devi sadly dying two days later. Speaking on behalf of the family, Francesca Kohler said that there had been “multiple occasions” throughout the day when Ms Heer and her partner had called for assistance and had raised concerns, but were not attended. She had also not been seen by the obstetrics team and had not been spoken to about the upcoming caesarean section. Read full story Source: My London, 4 July 2022
  14. News Article
    A doctor who killed a mother-of-three when he botched a procedure during a routine appointment has been jailed. Dr Isyaka Mamman, now thought to be 85, admitted gross negligence manslaughter over the death of Shahida Parveen, 48, at the Royal Oldham Hospital in 2018. He used the wrong needle and inserted it in the wrong place, piercing the sac holding Mrs Parveen's heart. Mrs Justice Yip at Manchester Crown Court said Mrs Parveen's death was his fault and sentenced him to three years. She also criticised the NHS trust, pointing to the fact that Mamman had both lied about his age and had been involved in two critical incidents similar to that which led to Mrs Parveen's death. The court heard Mrs Parveen attended Royal Oldham Hospital on 3 September, 2018, to give a bone marrow sample. This is usually taken from the hip bone but, after failing in his first attempt, Mamman tried to instead take it from her sternum. This was a "highly dangerous" procedure, the court was told, and one which had led to another of Mamman's patients being permanently disabled three years earlier. Read full story Source: BBC News, 5 July 2022
  15. News Article
    A mother was killed at her hospital appointment by a doctor who botched a routine procedure, a court has heard. Dr Isyaka Mamman, 85, was responsible for a series of critical incidents before the fatal appointment, Manchester Crown Court heard. Mamman, who admitted gross negligence manslaughter, had already been sacked by medical watchdogs for lying about his age but was re-employed by the Royal Oldham Hospital. He is due to be sentenced on Tuesday. Mother-of-three Shahida Parveen, 48, had gone to hospital with her husband for investigations into possible myeloproliferative disorder on 3 September 2018 and a bone marrow biopsy had been advised, Andrew Thomas QC, prosecuting, told the hearing. Normally, bone marrow samples are taken from the hip bone but Mamman, of Cumberland Drive, Royton, Oldham, failed to obtain a sample at the first attempt, he said. Instead, he attempted a rare and "highly dangerous" procedure of getting a sample from Ms Parveen's sternum - despite objections from the patient and her husband, the court heard. Mamman, using the wrong biopsy needle, missed the bone and pierced her pericardium, the sac containing the heart, causing massive internal bleeding. Ms Parveen lost consciousness as soon as the needle was inserted. She died later that day. Read full story Source: BBC News, 4 July 2022
  16. News Article
    A baby suffered brain damage and died due to failings at a hospital where her mother spent hours alone in pain and suffered crucial delays, according to her family. Dominic and Ewelina Clyde-Smith told The Independent their daughter, Amelia, was otherwise healthy and poor care led to her being starved of oxygen at birth. The couple said they experienced a series of failings at Jersey General Hospital in 2018, including a lack of a doctor during a difficult labour and staff taking “too long” to resuscitate their child. They believe Amelia suffered further harm when a ventilator was not plugged in properly during a transfer. Amelia was left with brain damage and died aged one month after being put into palliative care. Her parents said they have spent years trying to get justice through official channels but are now speaking out for the first time as they believe the standard of care received should be public knowledge. “It happened nearly four years ago,” Ms Clyde-Smith says, adding: “But the whole maternity unit just failed us completely.” Read full story Source: BBC News, 1 July 2022
  17. News Article
    A struggling mental health trust is being prosecuted over accusations it failed to protect a teenager at a children’s inpatient unit. Tees, Esk and Wear Valleys Foundation Trust ran the former West Lane Hospital in Middlesbrough until the Care Quality Commission (CQC) closed it in 2019. The CQC is now prosecuting the trust, alleging it breached the Health and Social Care Act 2008 in relation to the death of Christie Harnett, who took her own life at the facility in June 2019. In a statement, the regulator claimed TEWV “failed to provide safe care and treatment” by exposing the patient to a “significant risk of avoidable harm”. A CQC spokeswoman added: “Our main priority is always the safety of people using health and social care services, and if we have concerns we will not hesitate to take action in line with our regulatory powers. We will report further as soon as we are able to do so.” Read full story (paywalled) Source: HSJ, 30 June 2022
  18. News Article
    The outgoing chief investigator of the national safety watchdog has described his frustration with the organisation’s ‘ambivalent’ relationship with NHS England. Keith Conradi, who is due to retire from the Health Safety Investigation Branch in July, said he did not think he had “ever really spoken to any of the hierarchy in NHS England”. He added “their priorities are elsewhere”. In an interview with health commentator Roy Lilley for the Institute for Health and Social Care Management, Mr Conradi also described HSIB’s relationship with NHSE as “ambivalent”. “It wobbled along that sort of line and got worse as time has gone on,” he said. “At the very start I had a chat with the permanent secretary of the Department of Health and said we would be better off in the department than NHS England. He disagreed and felt that we’d be too close to [then health secretary] Jeremy Hunt, and particularly at that time that would have a negative effect.” Mr Conradi was also critical of the decision to ask HSIB to take on investigations into maternity care early in its life. He said he was “shocked” that it happened so quickly “when we hadn’t really got going”. He continued: “We hadn’t developed a method of doing normal national investigations and suddenly we were being asked to do maternity ones. There was a huge amount of pressure to do this.” Read full story (paywalled) Source: HSJ, 28 June 2022
  19. News Article
    Former prime minister Sir John Major has described the contaminated blood scandal as "incredibly bad luck", drawing gasps from families watching him give evidence under oath to the public inquiry into the disaster. Up to 30,000 people contracted HIV and hepatitis C in the 1970s and 80s after being given blood treatments or transfusions on the NHS. Thousands have since died. Sir John later apologised for his choice of language. He said: "I obviously caused offence inadvertently this morning when I referred to the fact that it was awful that people had been fed infected blood and I referred to it as sheer bad luck. "I can only say to people it wasn't intended to be offensive. I was seeking to express the fact that I was concerned about what happened. "It was intended simply to say that it was a random matter and I perhaps expressed it injudiciously." The UK-wide inquiry was launched after years of campaigning by victims, who claim the risks were never explained and that the scandal was covered up. Campaigners say those infected decades ago are now dying at the rate of one every four days as a result. Read full story Source: BBC News, 27 June 2022
  20. News Article
    A doctor who attempted to cover up the true circumstances of the death in 1995 of a four-year-old patient has been struck off. Consultant paediatric anaesthetist Dr Robert Taylor dishonestly misled police and a public inquiry about his treatment of Adam Strain, who died at the Royal Belfast Hospital for Sick Children, a medical tribunal found. The youngster was admitted for a kidney transplant at the hospital following renal failure but did not survive surgery in November 1995. Six months later an inquest ruled Adam died from cerebral oedema – brain swelling – partly due to the onset of dilutional hyponatraemia, which occurs when there is a shortage of sodium in the bloodstream. Two expert anaesthetists told the coroner that the administration of an excess volume of fluids containing small amounts of sodium caused the hyponatraemia. But Dr Taylor resisted any criticism of his fluid management and refused to accept the condition had been caused by his administration of too much of the wrong type of fluid. In 2004 a UTV documentary When Hospitals Kill raised concerns about the treatment of a number of children, including Adam, and led to the launch of the Hyponatraemia Inquiry. The tribunal found Dr Taylor acted dishonestly on four occasions in his dealings with the the public inquiry, including failing to disclose to the inquiry a number of clinical errors he made and falsely claiming to detectives he spoke to Adam’s mother before surgery. Read full story Source: The Independent, 22 June 2022
  21. News Article
    A hospital and one of its managers are facing a criminal investigation into the death of a vulnerable man who absconded by climbing a fence. An inquest concluded failings amounting to neglect contributed to the death of Matthew Caseby in 2020, after he fled from Birmingham's Priory Hospital Woodbourne and was hit by a train. The investigation will be carried out by the Care Quality Commission (CQC). Priory said it would co-operate fully "if enquiries are raised by the CQC". Mr Caseby, 23, climbed over a 2.3m-high (7ft 6in) courtyard fence on 7 September 2020. He was found dead the following day after being hit by a train near Birmingham's University station. The inquest in April heard other patients had previously climbed the fence and, despite concerns by members of staff, no action was taken to improve security in and around the courtyard until another patient absconded two months after Mr Caseby's death. Following the inquest, coroner Louise Hunt said she was concerned the fence and courtyard area may still not be safe and urged health chiefs to consider imposing minimum standards for perimeter fences at mental health units. She also criticised record-keeping and how risk assessments were carried out. Read full story Source: BBC News, 23 June 2022
  22. News Article
    Vulnerable patients cared for in secure mental health units across England could miss out on vital medications due to a shortage of learning disability nurses, the Healthcare Safety Investigation Branch (HSIB) has warned. The report into medication omissions in learning disability secure units across the country highlights problems with retaining learning disability nurses, with the number recruited each year matching those leaving. Figures quoted in the report suggest the number of learning disability nurses in the NHS nearly halved from 5,500 in 2016 to 3,000 in 2020. The HSIB launched a national investigation after being alerted to the case of Luke, who spent time in NHS secure learning disability units but was not administered prescribed medication for diabetes and high cholesterol on several occasions. At Luke’s facility, which included low and medium secure wards, HSIB investigators considered that the quality and style of care provided to patients had been directly impacted by a lack of nurses with required skill sets. Findings from HSIB’s wider national investigation link a shortfall of learning disability nurses to instances of patients missing their medication, with the report’s authors describing a “system in which medicines omissions were too common and prevention, identification and escalation processes were not robust”. Read full story (paywalled) Source: HSJ, 23 June 2022
  23. News Article
    A leading NHS hospital failed to publicly disclose that four very ill premature babies in its care were infected with a deadly bacterium, one of whom died soon after, the Guardian has revealed. St Thomas’ hospital did not admit publicly that it had suffered an outbreak of Bacillus cereus in the neonatal intensive care unit (NICU) of its Evelina children’s hospital in late 2013 and early 2014. It occurred six months before a well publicised similar incident in June 2014 in which 19 premature babies at nine hospitals in England became infected with it after receiving contaminated baby feed directly into their bloodstream. Three of them died, including two at St Thomas’. Leaked documents show that both the first outbreak and newborn baby’s death were investigated but never publicly acknowledged by the NHS trust that runs the hospital. GSTT insists that it did not acknowledge the baby’s death publicly in any reports because it believed the child had died of other medical conditions, not the bacteria. However, it declined to say if it had told the baby’s parents that it had become infected with Bacillus cereus. Read full story Source: The Guardian, 23 June 2022
  24. News Article
    Systems and processes in place around patient safety failed in terms of the work of a Belfast-based neurologist, an inquiry has found. Dr Michael Watt was at the centre of Northern Ireland’s largest ever recall of patients, which began in 2018, after concerns were raised about his clinical work. More than 4,000 of his former patients attended recall appointments. Almost a fifth of patients who attended recall appointments were found to have received an “insecure diagnosis”. The final report following the Independent Neurology Inquiry found that problems with Dr Watt’s practice were missed for years and opportunities to intervene were lost. It makes 76 recommendations to the Department of Health, healthcare organisations, General Medical Council and the independent sector. “While one process or system failure may not be critical, the synergistic effect of numerous failures ensured that a problem with an individual doctor’s practice was missed for many years and, as this inquiry finds, opportunities to intervene, particularly in 2006/2007, 2012/2013, and earlier in 2016 were lost,” the inquiry found. Read full story Source: The Independent, 21 June 2022
  25. News Article
    An epilepsy drug that caused disabilities in thousands of babies after being prescribed to pregnant women could be more dangerous than previously thought. Sodium valproate could be triggering genetic changes that mean disabilities are being passed on to second and even third generations, according to the UK’s medicines regulator. The Medicines and Healthcare Products Regulatory Agency (MHRA) has also raised concerns that the drug can affect male sperm and fertility, and may be linked to miscarriages and stillbirths. Ministers are already under pressure after it emerged in April that valproate was still being prescribed to women without the legally required warnings. Six babies a month are being born after having been exposed to the drug, the MHRA has said. It can cause deformities, autism and learning disabilities. Cat Smith, the Labour chairwoman of the all-party parliamentary group on sodium valproate, said: “This transgenerational risk is very concerning. There have been rumours that this was a possibility, but I had never heard it was accepted until last week by the MHRA." “The harm from sodium valproate was caused by successive failures of regulators and governments, and this news means it could be an order of magnitude worse than we first thought. It underlines the need for the Treasury to step up to their responsibilities around financial redress to those families.” Read full story (paywalled) Source: Sunday Times, 19 June 2022
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