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Showing results for tags 'Investigation'.
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News Article
Covid inquiry: Families unhappy with Welsh government
Patient Safety Learning posted a news article in News
Bereaved families of coronavirus victims feel the Welsh government has not adequately taken part in the Covid public inquiry, their solicitor says. Craig Court, who represents bereaved families, said the Welsh government had not participated "as well as they should have". He claimed the Welsh government failed to deliver crucial paperwork with just days to go before Tuesday's inquiry. The UK-wide inquiry could go on as long as three years, and will predominantly look at the UK government's approach to the pandemic. A Wales-specific inquiry was blocked by Labour members of the Senedd, with First Minster Mark Drakeford saying it should wait until after the UK-wide investigation had been completed. Mr Court told BBC Wales "there is a great concern over the duty of candour" displayed by the Welsh government. Read full story Source: BBC News, 9 June 2023 -
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Kettering General Hospital chief apologises over children's care
Patient Safety Learning posted a news article in News
A chief executive whose hospital has been accused of failing children has admitted it has not always "got it right" and apologised at a meeting. The care regulator has warned Kettering General Hospital (KGH) over its children's and young people's services and rated them inadequate. Dozens of parents with children who died or became seriously ill have contacted the BBC with concerns. Deborah Needham told a board meeting she was "here to listen" to worries. In April it was revealed inspectors from the Care Quality Commission (CQC) raised concerns over sepsis treatment, staff numbers, dirt levels and not having an "open culture" where concerns could be raised without fear, following an inspection in December. The CQC had inspected the Northamptonshire hospital's paediatric assessment unit, Skylark ward, and the neonatal unit after hearing concerns of safety. Read full story Source: BBC News, 9 June 2023- Posted
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News ArticleOne of the NHS’ largest hospital trusts is being investigated over “possible gross negligence manslaughter” after a baby died 24 hours after her birth. Polly Lindop died at St Mary’s Hospital on 13 March and Greater Manchester Police have now launched a probe into her death. Police said its major incident team launched the investigation into “possible Gross Negligence manslaughter” after concerns were raised to the force and local coroner. DCI Mark Davis of GMP’s major incident team said: “First, I want to express my condolences to the parents of Polly at what is an extremely difficult time for them. Our thoughts will remain with them as we carry out our investigation. “A number of hospital staff have been spoken to as witnesses by officers and no arrests have been made at this time. “The hospital trust has been fully cooperative with the police and all relevant authorities have been kept informed. The investigation into Polly’s death is on-going and her family will continue to be kept updated in relation to any significant developments.” Read full story Source: The Independent, 5 June 2023
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Doctor told cancer patient she had anorexia despite three ‘red flag’ signs
Patient Safety Learning posted a news article in News
A woman was “fobbed off” by her doctors who failed to diagnose her colon cancer for a year, an investigation revealed. In May 2019, Charlie Puplett, 45, expressed concern at her GP surgery in Yeovil, Somerset, about unexplained weight loss, lack of appetite and a change in bowel habits. But the surgery did not test her for colon cancer – with one doctor suggesting she had anorexia and was “in denial”, she said. She was not diagnosed until almost a year later when she was rushed to hospital after vomiting blood. Ms Puplett’s experience was detailed in an investigation by the Parliamentary and Health Service Ombudsman (PHSO), which found that her symptoms should have been “red flags” leading to urgent testing within two weeks, and said she had been “failed” by her doctors. Read full story Source: The Independent, 4 June 2023- Posted
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News ArticleWomen are waiting too long for abortions, according to a major review into a leading UK provider. The Care Quality Commission (CQC) review of the leadership at the abortion provider the British Pregnancy Advisory Service found there were “delays” in “investigating incidents”. The remains of some pregnancies were sometimes not stored properly and there were issues were record keeping, patient monitoring and safe care, the review found. The watchdog also noted “women did not always receive care in a timely way to meet their needs”. The health watchdog said: “In August 2021 we found significant concerns in we found that safe care was not being provided; ineffective safeguarding processes; incomplete risk assessments were not fully completed; observations were not monitored or recorded; records were not fully completed, clear or up to date.” Read full story Source: The Independent, 2 June 2023
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East Kent: A decade of failure in maternity care
Patient Safety Learning posted a news article in News
After health inspectors considered closing a maternity unit over safety fears, the BBC's Michael Buchanan looks at a near-decade of poor care at East Kent Hospitals NHS Trust. "I've been telling you for months. The place is getting worse." The message in February, which Michael received from a member of the maternity team, was stark but unsurprising. In a series of texts over the previous few months, the person had been getting increasingly concerned about what was happening at the East Kent trust. The leadership is "totally ineffective" read one message. "How long do we have to keep hearing this narrative - we accept bad things happened, we have learned and are putting it right. Nothing changes." Friday's report from the Care Quality Commission (CQC) is unfortunately just the latest marker in a near-decade of failure to improve maternity care at the trust. The revelation that inspectors considered closing the unit at the William Harvey Hospital in Ashford comes nine years after the trust's head of midwifery made a similar recommendation for the same reasons - that it was a danger to women and babies. The failure to act decisively then allowed many poor practices to continue. Read full story Source: BBC News, 28 May 2023- Posted
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Child died at mental health hospital ‘while staff were meant to be watching her’
Patient Safety Learning posted a news article in News
A 14-year-old girl who should have been under constant supervision at a mental health hospital died after a member of staff on his first shift left her unattended, an inquest has heard. Ruth Szymankiewicz died at Taplow Manor Hospital in Maidenhead on 12 February 2022 after a care worker responsible for her one-to-one supervision “sporadically” left his post, the hearing was told. It also emerged at the hearing that the care worker, who is now abroad, was allegedly using a fake name. Detectives are investigating him as part of a fraud investigation although he has not yet been interviewed by police. After Ruth’s death, the Care Quality Commission launched a criminal investigation. In an update to the coroner, it said that the investigation was looking at whether the provider had “brought about avoidable harm or exposure to risk” in relation to the young girl’s death. Read full story Source: The Independent, 26 May 2023- Posted
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Closing baby unit considered over safety concerns
Patient Safety Learning posted a news article in News
Health inspectors considered shutting down a maternity unit earlier this year over safety concerns. The Care Quality Commission (CQC) instead called for "immediate improvements" following a visit to the William Harvey hospital in Ashford, Kent. Helen Gittos, whose newborn daughter died in the care of the East Kent Hospitals Trust, said there were "fundamental" problems at the trust. The inspection of East Kent's William Harvey hospital laid bare multiple instances of inadequate practices at the unit, including staff failing to wash their hands after each patient, and life-saving equipment not being in the right place. Days after the visit, the watchdog raised safety concerns and threatened the trust with enforcement action to ensure patients are protected. Ms Gittos, whose baby Harriet was born at the East Kent trust's Queen Elizabeth the Queen Mother Hospital (QEQM) in 2014 and died eight days later, said: "When my daughter Harriet was born, the then head of midwifery was so concerned about safety that she thought that the William Harvey in particular should be closed down." She told BBC Radio 4's Today programme: "Here we are, almost nine years later, in a similar kind of situation. What has been happening has not worked. "I keep being surprised at how possible it is to keep being shocked about all of this, but I am shocked, that under so much scrutiny, and with so much external help, it's still the case that so much is not right. "The problems that are revealed are so fundamental that we have to do things differently." Read full story Source: BBC News, 26 May 2023- Posted
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Top doctor questions need for change at gender clinic
Patient Safety Learning posted a news article in News
A doctor with a key role in reforming a controversial gender identity clinic for children has been recorded questioning the need for change. Prof Gary Butler, clinical lead for the children's gender clinic in England and Wales, also appeared to accuse the author of a report, which will underpin the new service, of "nepotism". He was recorded making the comments in a keynote speech at a major conference. The Gender Identity Development Service (Gids), based at London's Tavistock and Portman NHS Foundation Trust, was rated as "inadequate" by inspectors, who visited in late 2020. It was earmarked for closure in July 2022. An independent review, led by Dr Hilary Cass, also called for a "fundamentally different" model of care for children with gender dysphoria. Prof Butler has been awarded a key role in shaping the new service, as one of several people tasked with implementing a new training programme, underpinned by Dr Cass's recommendations. However, BBC Newsnight has learned Prof Butler has publicly questioned the need for change and described Dr Cass's recommendations as "slightly unusual". In the 14-minute speech at the conference, he talked about current services across the UK, the legal challenges to the situation in England, and how he felt Gids has been the subject of "lies" in the media. Read full story Source: BBC News, 24 May 2023- Posted
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Trust execs accused of creating a ‘cult of the individual’
Patient Safety Learning posted a news article in News
Regulators are probing a series of whistleblowing claims about the leadership culture of a trust which is rated ‘outstanding’ for its management, HSJ has learned. It is understood multiple current and former staff members at Bolton Foundation Trust, including people in senior positions, have been in contact with NHS England and the Care Quality Commission in recent months. The claims include a dramatic worsening in leadership culture at the trust, particularly around the FTSU process and people who speak up being bullied, side-lined and silenced. And investigations and meetings are stage-managed and tightly controlled by executives, with constant “sugar-coating” and positive spin on board reports, and intolerance of people who disagree. Read full story (paywalled) Source: HSJ, 22 May 2023- Posted
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Warning as baby dies and seven more fall critically ill with ‘usually mild virus’
Patient Safety Learning posted a news article in News
A baby has died and seven others were left requiring intensive care after a “usually mild” virus appeared to trigger a serious heart condition, health officials have said. The World Health Organization (WHO) said it had been notified of an “unusual” increase in myocarditis –inflammation of the heart – among newborns in south Wales infected with an enterovirus over the past year. While enteroviruses are common and often asymptomatic, they are known to cause “occasional outbreaks in which an unusually high proportion of patients develop clinical disease, sometimes with serious and fatal consequences – in this instance myocarditis”, the UN health agency said. While prior to the recent cluster of cases, south Wales had experienced only two similar cases in six years, the 10 months to April saw 10 cases of myocarditis in babies under the age of 28 days who tested positive for enterovirus, according to WHO. Read full story Source: The Independent, 19 May 2023- Posted
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News ArticleAn inquiry into maternity care failings at an NHS trust that left dozens of babies dead or brain-damaged is “wholly insufficient” because only a fraction of Black and Asian women have come forward, its chair has warned. Donna Ockenden, who is leading a review into Nottingham University Hospitals NHS Trust, suggested the health service must do more to increase the number of responses from ethnic minorities if the trust is to learn from the scandal. Less than 20 families from Black and Asian communities are currently involved in the inquiry, compared to more than 250 white families, The Independent understands. It is understood letters have only been sent out in English, while Ms Ockenden pointed to examples of women being unable to access translation services and expectant Muslim mothers being turned away if they objected to male sonographers. She said the communities’ “mistrust” towards the trust had “deepened”, leaving the review team “climbing a mountain” to engage with them. Read full story Source: The Independent, 18 May 2023
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Gosport hospital drug deaths: Police identify 19 suspects
Patient Safety Learning posted a news article in News
Nineteen suspects have been identified by police as part of a new inquiry into hundreds of deaths at a hospital. An independent panel found 456 patients died after being given opiates inappropriately at Gosport War Memorial Hospital between 1987 and 2001. The new criminal investigation is being led by Kent Police after three previous ones by Hampshire Constabulary resulted in no prosecutions. Police said interviews with the suspects under caution were ongoing. Detectives are examining more than 750 patient records as part of Operation Magenta after families, who have also campaigned for judge-led "Hillsborough-style" inquests, repeatedly called for justice. Read full story Source: BBC, 17 May 2023- Posted
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Allegations of bullying within maternity programme of HSIB
Patient Safety Learning posted a news article in News
It was created with the very best of intentions – to help hospitals learn lessons when a baby or mother is harmed or dies. But a Channel 4 News investigation has been hearing that the maternity programme of the Healthcare Safety Investigation Branch – or HSIB – was riddled with flaws. One former senior staff member spoke to Channel 4 about bullying within the organisation and failings which could have led to harm. In a previous report, Channel 4 heard from the mothers of Beatrice and Marnie, who were stillborn and other parents have come forward with their experience. Watch the story Source: Channel 4 News, 16 May 2023 -
News Article
GMC to investigate ‘stalker’ doctor who shared patient’s records
Patient Safety Learning posted a news article in News
The UK medical regulator has launched an investigation into a “stalker” doctor who accessed intimate details of the health history of a woman who had begun dating the doctor’s ex-boyfriend. The General Medical Council (GMC) is investigating whether the doctor – a consultant at Addenbrooke’s hospital in Cambridge – breached their professional, ethical and legal duties to protect the woman’s personal information. The victim has given the watchdog a statement detailing the consultant’s repeated violations of her medical records and documentation that shows what she did. The GMC declined to comment because it has not yet decided to open a formal disciplinary case against the consultant, who could face serious sanctions including a ban on working as a doctor. One of the GMC’s investigative officers is examining the victim’s claims and collecting evidence. The Guardian revealed how the doctor had looked at the victim’s hospital and GP records seven times last August and September, in the early stages of the woman’s relationship with a man the consultant had been involved with for several years. Read full story Source: The Guardian, 15 May 2023- Posted
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Baby heart death parents left waiting 14 months for answers
Patient Safety Learning posted a news article in News
Grieving parents have been left waiting more than 14 months for answers about why their 12-day-old son died. Elijah was born at Merthyr Tydfil's Prince Charles Hospital on 25 February 2022 and died after being diagnosed with enterovirus and myocarditis. Joann and Christian Edwards said they were told they would have a report by the end of 2022, but are still waiting. Joann and Christian, from Mountain Ash, Rhondda Cynon Taf, said they were told Elijah's myocarditis was a "one off" but subsequently read about 10 babies, including one who died, getting severe enterovirus with myocarditis across south Wales. Public Health Wales (PHW) said Elijah's death was not being looked into as part of an investigation into this cluster of cases, as the dates were set at June 2022 to April 2023 to coincide with the enterovirus season. But it said it would look to include Elijah's death as part of a "wider clinical investigation" of the cases. Read full story Source: BBC News, 15 May 2023- Posted
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ADHD: Private clinics exposed by BBC undercover investigation
Patient Safety Learning posted a news article in News
Patients are being offered powerful drugs and told they have attention deficit hyperactivity disorder (ADHD) after unreliable online assessments, a BBC investigation has discovered. Three private clinics diagnosed an undercover reporter via video calls. But a more detailed, in-person NHS assessment showed he didn't have the condition. Panorama spoke to dozens of patients and whistleblowers after receiving tip-offs about rushed and poor-quality assessments at some private clinics, including Harley Psychiatrists, ADHD Direct and ADHD 360. The investigation found that: Clinics carried out only limited mental health assessments of patients. Powerful drugs were prescribed for long-term use, without advice on possible serious side effects or proper consideration of patients' medical history. Patients posting negative reviews were threatened with legal action. The NHS is paying for thousands of patients to go to private clinics for assessments. Commenting on Panorama's findings, Dr Mike Smith - an NHS consultant psychiatrist - said he was seriously concerned about the number of people who might "potentially have received an incorrect diagnosis and been started on medications inappropriately". "The scale is massive." Read full story Source: BBC News, -
News Article
Sick and tired: Australia's Long Covid inquiry report released
Patient Safety Learning posted a news article in News
A national Long Covid and Covid-19 database is among the key recommendations of a unanimous report released by an Australian parliamentary Committee for its inquiry into Long Covid and repeated Covid infections. The House of Representative’s Standing Committee on Health, Aged Care and Sport’s report aims to improve Australia’s response to Long Covid, an often-debilitating condition possibly affecting hundreds of thousands of Australians. The Chair of the Committee, Dr Mike Freelander MP said: ‘It is clear that the emergence of Long Covid has created challenges for patients and health care professionals alike. People with Long Covid suffer from a lack of information and treatment options. Health care professionals, who worked tirelessly over the acute phase of the pandemic, are now in a difficult situation trying to support patients with this new and poorly understood condition.’ The Committee made nine unanimous recommendations aimed at strengthening the Australian Government’s management of Long Covid, including regarding: A definition of long COVID for use in Australia Evidence-based living guidelines for long COVID, co-designed with patients with lived experience A nationally coordinated research program for long COVID and COVID-19 The COVID-19 vaccination communication strategy Access to antiviral treatments for COVID-19 Support for primary healthcare providers Indoor air quality and ventilation. Read full story Source: Parliament of Australia, 24 April 2023- Posted
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Senedd could investigate Wales' Covid response in Labour-Tory deal
Patient Safety Learning posted a news article in News
Wales' response to the pandemic could be investigated by a new Senedd committee under a deal between Welsh Labour and the Welsh Conservatives. A special committee will see if there are any gaps in what the UK Covid-19 inquiry says about Wales. It follows a long-running row over whether Wales needs its own probe into the pandemic. The Welsh Conservatives welcomed the "halfway-house" compromise. The Welsh government has continued to resist calls for a Wales-specific public inquiry into Covid, supporting instead the UK-wide effort chaired by Baroness Hallett. The inquiry has a sub-module specific to Wales and will hold public hearings in the country this autumn. Campaigners fear the UK inquiry will not be comprehensive enough. Read full story Source: BBC News, 4 May 2023- Posted
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Hyponatraemia inquest an opportunity for the truth, mother says
Patient Safety Learning posted a news article in News
The mother of a nine-year-old girl who died from hyponatraemia has said a new inquest that started today is "an opportunity for truth". Raychel Ferguson, from Londonderry, died at the Royal Belfast Hospital for Sick Children in June 2001. Her parents, Ray and Marie Ferguson, have long campaigned to find out the truth about their daughter's death. Hyponatraemia is an abnormally low level of sodium in blood and can occur when fluids are incorrectly administered. Mrs Ferguson said the fact there was a second inquest "speaks to the culture of cover up that has plagued her death, involving the medical and legal professions". An inquiry in 2018 into the deaths of five children in Northern Ireland hospitals, including Raychel, found her death was avoidable. The 14-year-long inquiry into hyponatraemia-related deaths was heavily critical of the "self-regulating and unmonitored" health service. In January 2022, a new inquest opened but was postponed in October after new evidence came to light. Read full story Source: BBC News, 2 May 2023- Posted
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Watchdog repeatedly told about private NHS medicines courier
Patient Safety Learning posted a news article in News
The watchdog responsible for investigating unresolved healthcare complaints has been warned repeatedly for nine months about problems with Sciensus, a private company paid millions to deliver vital medicines to NHS patients, the Guardian can reveal. The Parliamentary and Health Service Ombudsman (PHSO) has received 18 official requests to examine grievances against Sciensus since August last year, but has not begun any investigations, according to a person familiar with the matter. The revelation comes after a Guardian investigation exposed serious and significant concerns raised by patients, clinicians and health groups about Sciensus. The investigation revealed that the company has struggled to provide a safe or reliable service. Patients persistently complain about delayed or missed home deliveries of medication, the Guardian found, with clinicians warning that the health of some has deteriorated as a result. The investigation also uncovered how some NHS staff experience “daily issues” with Sciensus. Others reported an increase in patients “flaring” as a result of missed or delayed medication. Some have seen a rise in hospital admissions. In the wake of the investigation, the Care Quality Commission, the care regulator, said it was “aware of concerns raised” about Sciensus, and was reviewing them. Read full story Source: The Guardian, 1 May 2023- Posted
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Almost one in three doctors investigated by GMC ‘have suicidal thoughts’
Patient Safety Learning posted a news article in News
Almost one in three UK doctors investigated by the General Medical Council (GMC) think about taking their own life, a survey has found. Many doctors under investigation feel they are treated as “guilty until proven innocent” and face “devastating” consequences, the Medical Protection Society (MPS) said. Its survey of 197 doctors investigated by the GMC over the last five years found: 31% said they had suicidal thoughts. 8% had quit medicine and another 29% had thought about doing so. 78% said the investigation damaged their mental health. 91% said it triggered stress and anxiety. The MPS, which represents doctors accused of wrongdoing, accused the GMC of lacking compassion, being heavy-handed and failing to appreciate its impact on doctors. Read full story Source: The Guardian, 27 April 2023- Posted
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NHS warned over writing to patients in English after child dies
Patient Safety Learning posted a news article in News
Patient safety investigators have issued a warning to the NHS over writing to patients only in English after a Romanian child died following missed cancer scans. The three-year-old, of Romanian ethnicity, had an MRI scan delayed after they were found to have eaten food beforehand. When the appointment for the child’s MRI scan was made by the radiology booking team, a standard letter was produced by the NHS booking system in English asking the child not to eat before the scan, despite the family’s first language being Romanian. Staff at the trust had hand-written on the patient’s MRI request sheet that an interpreter was required. “The family recognised key details in the written information, including the time, date and location of the scan,” the report said. “However, they were not able to understand the instructions about the child not eating or drinking (fasting) for a certain amount of time before the scan.” The Healthcare Safety Investigation Branch (HSIB) has urged NHS England to develop and implement new rules on supplying written appointment information in languages other than English. Read full story Source: The Independent, 27 April 2023- Posted
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Cover-ups and lies in maternity care keep happening, says Donna Ockenden
Patient Safety Learning posted a news article in News
A week after Donna Ockenden published her damning report on the catastrophic failures in maternity services at Shrewsbury and Telford Hospital NHS Trust in March last year, she was contacted by families in Nottingham asking her to investigate how dozens of babies had died or been injured in their city hospitals. Six months later, Ockenden — herself a senior midwife — was put in charge of another inquiry by the government and yet again she is finding a culture of cover-ups and lies in maternity care. “Of the families that I have met in Nottingham to date, some of them have expressed concerns to me that the trust were not truthful in discussions around their cases,” she tells the Times Health Commission. “We have all the systems and structures in place that should be able to spot maternity services in difficulty and here we are again. Families are having to fight to get answers.” The woman who has done more than anyone to highlight the problems with maternity care is reluctant to use the word “crisis” but she warns: “I think that without urgent and rapid action, from central government downwards — on funding and workforce and training — mothers and their babies are not going to be able to receive the safe, personalised maternity care that they deserve and should expect". Read full story (paywalled) Source: The Times, 21 April 2023- Posted
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News ArticleUnannounced and out-of-hours spot-checks on mental health services are set to ramp up following a string of abuse scandals, The Independent can reveal. The Care Quality Commission’s new mental health chief Chris Dzikiti said he was “saddened” by “unacceptable” scandals in the last six months, warning the regulator “will use the powers [it has] to hold people to account.” He said the organisation will be carrying out more unannounced inspections of providers, including inspections launched out of normal hours, with the aim to have the “majority” of spot-checks carried out this way. In his first interview since joining the regulator in November Mr Dzikiti, who is mental health nurse by background, said: “I talk to chief execs of mental health services, I talk about [how] as a regulator, we will use the power we have, when [we] see poor practice, we will definitely hold people to account. “In our inspection programmes, we are also increasing the unannounced inspections out of hours inspections, because we need to try and get really deep into the culture of mental health services, especially those areas where we think there’s a higher risk of poor practice. “I will not rest until we get people safe.” Read full story Source: The Independent, 24 April 2023
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