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Found 1,550 results
  1. News Article
    Doctors at a hospital accused of bullying its staff have told the NHS care regulator that they are too scared to report lapses in patient safety in case they end up facing disciplinary action. The Guardian revealed earlier this week that West Suffolk hospital stands accused by its own medics of secrecy, bullying and intimidation after it demanded they take fingerprint tests in its effort to identify a whistleblower. Senior staff have privately passed on serious concerns to the Care Quality Commission (CQC) about the behaviour of the trust’s leadership. They used confidential meetings with CQC inspectors, who visited twice in the autumn, to explain why they lack confidence in Steve Dunn, the trust’s chief executive, Dr Nick Jenkins, its medical director, and Sheila Childerhouse, who chairs the hospital’s board. The CQC is due to publish its report into the trust, including the performance of its leadership, in January. “Staff are scared that they’ll face disciplinary action [if they raise concerns about patient safety],” said one doctor, who declined to be named. “As a result of recent events I can’t imagine that anyone at the trust will feel comfortable to speak out or whistleblow in the future. I fear that any future patient safety concerns will not be expressed and will simply be brushed under the carpet.” The trust demanded fingerprints and handwriting samples after a staff member wrote anonymously to the family of Susan Warby, who died in August 2018 after undergoing treatment at the hospital, which was investigated as a “serious incident”. Read full story Source: The Guardian, 11 December 2019
  2. News Article
    The Care Quality Commission (CQC) has rated six mental health hospitals “inadequate”, just months after describing them as either “good” or “outstanding”, since the Whorlton Hall scandal was revealed. HSJ analysis shows that of the 13 mental health hospitals admitting people with learning disabilities or autism which have been rated “inadequate” by the CQC since May this year, six of them dropped at least two ratings in a short space of time. The six hospitals which dropped at least two ratings include Whorlton Hall — the County Durham hospital closed following a BBC Panorama report in May showing residents being mistreated — which the CQC rated as “good” in December 2017 before revising this to “inadequate” in May. The BBC investigation prompted the CQC to investigate all similar mental health hospitals run by Cygnet, which took over the running of Whorlton Hall in January 2019. Cygnet Newbus Grange in Darlington — which was rated “outstanding” in a report published in February 2019 – was judged “inadequate” by September, while Cygnet Acer Clinic in Chesterfield fell from “good” in November 2018 to “inadequate’ in a report published 12 months later. The other three hospitals were the Breightmet Centre for Autism in Bolton, Kneesworth House in Hertfordshire and The Woodhouse Independent Hospital in Staffordshire. It comes as the CQC prepares to publish independent reports on its role in relation to the Whorlton Hall scandal. NHS England — one of the commissioners, along with local authorities and clinical commissioning groups, of learning disability inpatient care — also last month initiated a “taskforce” on the issue. The CQC has acknowledged it needed to “strengthen” its assessments of this type of care and said it had begun to do so, and was reviewing them further “from a human rights perspective”. Read full story (paywalled) Source: HSJ, 2 December 2019
  3. News Article
    More than 200 new families have contacted an inquiry into mother and baby deaths at a hospital trust in Shropshire. Investigators were already looking at more than 600 cases where newborns and mothers died or were left injured while in the care of the Shrewsbury and Telford Hospital Trust. One expert says the scandal, spanning decades, may be the tip of the iceberg. Dr Bill Kirkup says it suggests failure might be more widespread in the NHS. The surge in new cases follows the leak of an interim report last week. Read full story Source: BBC News, 27 November 2019
  4. News Article
    A GP who gave wrongly dated and misleading medical notes to police inquiring into the death of a 12 year old boy from undiagnosed Addison’s disease has been suspended from the UK medical register for nine months. Ryan Morse died in the early hours of 8 December 2012, hours after his mother rang the local Blaenau Gwent surgery twice in a day, reporting high temperature, extreme drowsiness, and involuntary bowel movement. The second time, she spoke to GP Joanne Rudling, telling her that the boy’s genitals had turned black. But Rudling failed to check the notes of the first call or give adequate weight to the fact that the mother was calling again, the tribunal found. She failed to obtain an adequate history or reach an appropriate conclusion about the change in genital colour. Read full story (paywalled) Source: BMJ, 25 November 2019
  5. News Article
    Shrewsbury and Telford hospital NHS trust has uncovered dozens of avoidable deaths and more than 50 babies suffering permanent brain damage over the past 40 years. But how many more babies must die before NHS leaders finally tackle unsafe, disrespectful, life-wrecking services? The NHS’s worst maternity scandal raises fundamental questions about the culture and safety of our health service. Too many hospital boards complacently believe “it couldn’t happen here”. Instead of constantly testing the quality and reliability of their services, they look for evidence of success while explaining away signs of danger. Across the NHS there are passionate clinicians and managers dedicated to building a culture that delivers consistently high quality care. But they are undermined by a pervasive willingness to tolerate and excuse poor care and silence dissent. Until that changes, the scandals will keep coming. Read full story Source: The Guardian, 2 November 2019
  6. News Article
    As many as one in three women in the UK are traumatised by their birth experiences, and one in 25 of those will go on to develop full-blown PTSD. Following the most recent scandal at Shrewsbury, Milli Hill, the founder of the Positive Birth Movement, talks to The Independent about why we need to bring human connection back into maternity services, as well as continuing to invest in the research and technology that can save the lives of those most at risk and, why, above all, we need to start listening to women. If we don’t do these things, history will only repeat itself. Milli says: "We cannot continue to see scandals like Shrewsbury and Morecambe Bay as isolated, instead we must be brave enough to view them as symptomatic of a wider problem of a maternity system that has become completely dehumanised and unable to listen to women." Read full story Source: The Independent, 20 November 2019
  7. News Article
    Babies and mothers died amid a "toxic" culture at a hospital trust stretching back 40 years, a report has said. The catalogue of maternity care failings at Shrewsbury and Telford Hospital NHS Trust are contained in a report leaked to The Independent. It reveals that some children were left disabled, staff got the names of some dead babies wrong and, in one case, referred to a child as "it". The trust apologised and said "a lot" had been done to address concerns. In 2017, then Health Secretary Jeremy Hunt announced an investigation into avoidable baby deaths at the trust, which runs Royal Shrewsbury Hospital and Telford's Princess Royal. It is being led by maternity expert Donna Ockenden, who authored the report for NHS Improvement. Its initial scope was to examine 23 cases but this has now grown to more than 270 , covering the period from 1979 to the present day. The cases include 22 stillbirths, three deaths during pregnancy, 17 deaths of babies after birth, three deaths of mothers, 47 cases of substandard care and 51 cases of cerebral palsy or brain damage. The interim report said the number of cases it is now being asked to review "seems to represent a longstanding culture at this trust that is toxic to improvement effort". Read full story Source: BBC News, 20 November 2019
  8. Content Article
    This Healthcare Safety Investigation Branch (HSIB) investigation aims to improve patient safety in relation to the use of oral morphine sulfate solution (a strong pain-relieving medication taken by mouth). As its ‘reference case’, the investigation used the case of Len, an 89 year-old man who took an accidental overdose of morphine sulfate oral liquid. Patient Safety Learning has published a blog reflecting on the key patient safety issues highlighted in this report.
  9. Content Article
    In a wide-ranging Report on NHS litigation reform, the Health and Social Care Committee finds the current system for compensating injured patients in England ‘not fit for purpose’ and urges a radically different system to be adopted. Reforms would introduce an administrative scheme which would establish entitlement to compensation on the basis that correct procedures were not followed and the system failed to perform rather than clinical negligence which relies on proving individual fault. The new system would prioritise learning from mistakes and would reduce costs. Currently, litigation offers the only route by which those harmed can access compensation. MPs say in addition to being grossly expensive and adversarial, the existing system encourages individual blame instead of collective learning. This is a House of Commons Committee report, with recommendations to government. The Government has two months to respond.
  10. Content Article
    Yakob Seman Ahmed, former Director General for Medical services in Ethiopia and the chair of national patient safety task force, and a recent Humphrey fellow, Public Health Policy, at the Virginia Commonwealth University, reflects on Patient Safety Learning's recent report 'Mind the implementation gap: The persistence of avoidable harm in the NHS' and the similar challenges Ethiopia faces in implementing its own standards and policies.
  11. Content Article
    The Ockenden review of maternity services at Shrewsbury and Telford NHS Trust uncovered the biggest maternity scandal in the NHS’s history. The report concludes that 201 babies and nine mothers might have survived if they had received better care and raises serious questions about how avoidable deaths and injury to so many mothers and babies could have happened  Staffing pressures, training gaps, and overstretched rotas all contributed. But so did a failure to follow clinical guidelines or to investigate and learn from mistakes. Staff did not listen to patient experience, women were blamed or held responsible for poor outcomes—even their own deaths—and there was a lack of compassion in how patients were treated and responded to. Inadequate leadership and a bullying culture left staff feeling unable to raise concerns or escalate problems Is there a failure to listen to women across the NHS? Why are women’s voices ignored and their health concerns brushed aside?
  12. Content Article
    The UK Government has announce a statutory public inquiry into the handling of the Covid-19 pandemic - the Hallett inquiry. However, in light of the wide-ranging impact of the pandemic, the inquiry faces a huge task to decide on the highest priority areas for investigation. This long read by Tim Gardner, Senior Policy Fellow at The Health Foundation, aims to examine what the parameters and structure of the UK Covid-19 Inquiry could be, and set out what it might realistically cover.
  13. Content Article
    The newly released Ockenden report into maternity services at Shrewsbury and Telford NHS trust is at least the fourth similar report in recent years, with two more in progress. Many messages are not new, and these are not isolated findings. Women and families accessing care throughout the UK continue to feel ignored. Many families remain concerned that they are not receiving full and frank investigations and explanations after the death or injury of a mother or baby. Repeated headlines understandably undermine women’s confidence in services when they should be able to trust that they will receive safe, high quality care writes Marian Knight and Susanna Stanford in this BMJ Editorial.
  14. Content Article
    This Healthcare Safety Investigation Branch (HSIB) investigation explores the care of patients who present to child and adolescent mental health services (CAMHS) with questions about their gender identity and are referred to specialised gender dysphoria services. Gender dysphoria is a sense of unease, distress or discomfort that a person may have because of a mismatch between their biological sex and their gender identity. For example, a child who is registered as male at birth might feel or say that they are a girl, or feel that neither ‘boy’ nor ‘girl’ are the right word to describe how they feel about themselves. Gender dysphoria is not identified as a mental illness by the NHS, but some people may develop mental health problems because of gender dysphoria.
  15. Content Article
    This analysis by Paul Gallagher, Health Correspondent at i News discusses the prevalence of maternity scandals in the NHS, in light of the publication of the Ockenden Review into failings in maternity services at Shrewsbury and Telford NHS Trust. He highlights the importance of implementing the findings of the review, particularly focusing on the need for a comprehensive plan to tackle workforce shortages. He also highlights the continued existence in some trusts of a culture of covering up harm, evidenced by staff at Shrewsbury being pressured not to talk to investigators, right up until the report's publication.
  16. Content Article
    In March 2015, Bill Kirkup published his report on avoidable harm in maternity services at the Morecambe Bay NHS Trust. His introduction carried a warning: “It is vital that the lessons, now plain to see, are learnt... by other Trusts, which must not believe that ‘it could not happen here.’” With the publication of the Ockenden report, we now know that one of those other Trusts was the Shrewsbury and Telford NHS Hospital Trust.  “For more than two decades,” Donna Ockenden wrote, “they [famiies] have tried to raise concerns but were brushed aside, ignored and not listened to.” But why should patients and families have had to show that kind of courage in the first place? Instead of seeing patient feedback as a foundation stone of high quality, evidence based care, healthcare providers too often see it as a threat writes Miles Sibley in this BMJ Editorial.
  17. Content Article
    This duty of candour animation offers guidance on the importance of being open and honest. Being open and honest with patients and those close to them is always the right thing to do and is often referred to as the duty of candour. NHS Resolution have produced a short animation to help those working in health and social care to better understand the similarities and differences that exist between the professional and statutory duties of candour. The 8-minute animation also offers guidance on how they can be fulfilled effectively.
  18. Content Article
    This is the transcript of a statement given in the House of Commons by the Secretary of State for Health and Social Care, Sajid Javid MP, in response to the publication of the final report of the Ockenden Review. In the statement he makes a commitment that the local trust, NHS England and the Department of Health and Social Care will accept all 84 recommendations made by the Review. This is followed by questions from MPs in the Chamber and Mr Javid's responses.
  19. Content Article
    In this blog Patient Safety Learning sets out its initial response to the report of the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust (also known as the Ockenden Maternity Review).
  20. Content Article
    Two professionals who treated Jack Adcock before his death were convicted of gross negligence manslaughter, receiving 24-month suspended sentences. His nurse, Isabel Amaro, was erased from the nursing register; but after reviews in the High Court and Court of Appeal, his doctor, Hadiza Bawa-Garba, was merely suspended. Nathan Hodson explores the proposition that nurses are at greater risk of erasure than doctors after gross negligence manslaughter through a close reading of the guidance for medical and nursing tribunals informed by analysis from the High Court and Court of Appeal in the Bawa-Garba cases. 
  21. Content Article
    The Independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust was commissioned in 2017 to assess the quality of investigations relating to newborn, infant and maternal harm at the Trust. When it commenced this review was of 23 families’ cases, but it has subsequently grown to cover cases of maternity care relating to 1,486 families, the majority of which were patients at the Trust between the years 2000 and 2019. Some families had multiple clinical incidents therefore a total of 1,592 clinical incidents involving mothers and babies have been reviewed with the earliest case from 1973 and the latest from 2020.
  22. Content Article
    In this article in the journal Health Expectations, the authors explore how current investigative responses can increase the harm for all those affected by failing to acknowledge and respond to the human impacts. They argue that when investigations respond to the need for healing alongside learning, it can reduce the level of harm for everyone involved, including including patients, families, health professionals and organisations.
  23. Content Article
    At the moment, we’ve got maternity scandals day in, day out, which are pure evidence of the fact that our maternity units are just not up to scratch. They’re unsafe for mothers, unsafe for babies, and that is not acceptable.  Suzanne White, a former radiographer and a clinical negligence lawyer for the past 25 years, looks at the maternity safety scandals across the NHS and considers if any lessons have been learnt.
  24. Content Article
    The Preventable Deaths Tracker was set up to explore concerns raised by coroners to prevent future deaths. The tracker aims to collate data, information and analysis arising from coroners reports and other investigations and make it accessible for all. It hopes to warn against repeat hazards and highlight important lessons, to improve public safety, reduce avoidable harms and prevent premature deaths. The tracker was originally developed with funding from the National Institute for Health Research (NIHR) School for Primary Care Research.
  25. Content Article
    This investigation by the Healthcare Safety Investigation Branch (HSIB) explores the timely recognition and treatment of suspected pulmonary embolism in emergency departments. Pulmonary embolisms can form when clots from the deep veins of the body, usually originating in the legs, travel through the venous system and become lodged in the lungs. A person suffering from a pulmonary embolism requires urgent treatment to reduce the chance of significant harm or death.
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