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Found 1,529 results
  1. News Article
    A man who murdered two women 34 years ago went on to sexually abuse 100 female corpses in hospital mortuaries, taking videos and images of his crimes, HSJ can reveal. David Fuller was employed as an electrician and later a maintenance supervisor at the now closed Kent and Sussex Hospital, in Tunbridge Wells, and later the Tunbridge Wells hospital in Kent. Over a period of 12 years from 2008 to 2020 he used his access to the hospital mortuaries to sexually abuse the bodies of women and girls. HSJ first learned of David Fuller’s crimes in June this year, but agreed to a request by Kent police not to publish before his trial concluded. They can now reveal all that they discovered. Police have identified 80 victims – from mortuary records and name tags visible in some of the photos and videos Mr Fuller took of the abuse – but 20 are currently unidentified. Mr Fuller’s mortuary offences – which he admitted at a court hearing last month – only came to light when he was arrested for the 1987 murders of Caroline Pierce and Wendy Knell. Police searching his home in Heathfield, East Sussex, discovered millions of videos and photographs, some clearly showing him abusing the bodies. To many of his colleagues at Tunbridge Wells Hospital, David Fuller was an affable and helpful maintenance supervisor who was always willing to carry out small tasks and was the “go to” man if a problem needed sorting. His arrest on murder charges last December was greeted with shock and disbelief by those who knew him. Both the families of the women violated by Mr Fuller and some staff at Maidstone and Tunbridge Wells are expected to need psychological help to deal with the enormity and nature of Fuller’s crimes. Families will be offered a range of support, including psychiatric counselling, and will also be given a letter from Mr Scott, with a personal apology and containing an invitation for them to contact the trust if they want to. Read full story (paywalled) Source: HSJ, 4 November 2021
  2. News Article
    A special Crown Office unit set up to probe Covid-linked deaths is considering 827 cases in Scotland's hospitals, latest figures show. The unit was set up to consider the circumstances of Covid-linked deaths such as those in care homes. But the prosecution service has also received reports of hundreds of hospital-related virus deaths. Prosecutors will eventually decide if these deaths should be the subject of a fatal accident inquiry or prosecution. As of 7 October, Crown Office figures show Scotland's biggest hospital, the Queen Elizabeth University Hospital in Glasgow, has the highest number of reported Covid-linked deaths at 113. This was followed by the Royal Alexandra Hospital in Paisley and Glasgow Royal Infirmary which both had 71 Covid-related deaths referred to the Crown Office. The figures do not include deaths at home addresses or hospices, or where a care home resident died in hospital after contracting COVID-19 in a home. Read full story Source: BBC News, 4 November 2021
  3. News Article
    Deborah Birx, who was the White House coronavirus response coordinator under President Donald Trump, has told a congressional inquiry that at least 129 000 lives could have been saved if his administration had provided adequate testing and properly communicated the gravity of the situation to the public. But the election year “just took people’s time away and distracted them from the pandemic,” she told the House Select Subcommittee on the Coronavirus Crisis. “I felt like the White House had gotten somewhat complacent through the campaign season.” Asked if Trump did everything he should have to counter the pandemic, she said, “No. And I’ve said that to the White House. I believe I was very clear to the president in specifics of what I needed him to do.” “If we had fully implemented the mask mandates, the reduction in indoor dining, the getting friends and family to understand the risk of gathering in private homes, and we had increased testing, then we probably could have decreased fatalities by 30-40%.” That would amount to at least 129 000 preventable covid deaths over the course of the Trump presidency, which saw roughly 429 000 reported deaths attributed to the coronavirus." Read full story Source: BMJ, 28 October 2021
  4. News Article
    The NHS and private hospitals need to improve how they work together after the death of an NHS patient treated privately during the pandemic, a watchdog has warned. An investigation by the Healthcare Safety Investigation Branch (HSIB) found some private hospitals took on more complex patients than they were used to, while problems with communication and confusion over responsibilities created safety risks. It has called on the Care Quality Commission to do more to inspect how the two sectors work together and how patients are transferred between hospitals safely. It launched an inquiry after the death of a patient, known as Rodney, aged 58, who was due to have keyhole surgery to remove part of his bowel due to cancer. His NHS operation was cancelled and rebooked at a nearby private hospital after cancer services were transferred to the independent hospital due to COVID-19. Rodney was asked to sign a consent form for open bowel surgery, rather than the less invasive keyhole procedure, due to guidance at the time around a "potentially increased risk of COVID-19 transmission with laparoscopic surgery", the HSIB said. The cancerous part of his bowel was removed but eight days later his condition he deteriorated rapidly and was transferred to the local hospital so he could receive intensive care - which was not available at the private hospital. When he arrived at the NHS hospital, a scan and more surgery showed a leak in his bowel which led to sepsis and organ failure. He died later that day. As a result of the case, the HSIB launched a wider investigation into NHS surgical services being carried out in independent hospitals. Read full story Source: The Independent, 28 October 2021
  5. News Article
    A nurse from scandal-hit Shrewsbury and Telford Hospital ordered a pregnant woman to take medication she was allergic to. Christine Speake, who had worked in the NHS for almost 40 years as a midwife and nurse, has been struck-off the Nursing and Midwifery Council (NMC) register after a tribunal heard she told the mother to “just take it” and then tried to cover-up her mistake after the woman suffered a reaction. The NMC hearing was told the 11-week pregnant patient and her unborn child could have died after being prescribed the Buscopan by a junior doctor to treat severe nausea and vomiting in January 2019. The woman – named only as 'Patient A' – was given the drug by Speake despite her allergy being included in her medical records. Speake was employed as a sister on the gynaecology ward at the Princess Royal Hospital. When the mother questioned what she was being given, Speake, who has worked as a midwife and nurse since 1985, snapped "just take it". The panel heard Patient A then had a violent reaction and broke out in a rash and started vomiting. But Speake, who realised her mistake, then failed to tell her colleagues in a bid to “cover up” what she had done and later resigned, the NMC tribunal heard. Read full story Source: The Independent, 26 October 2021
  6. News Article
    Five serious incidents, including the deaths of two children, spark “urgent” investigations at specialist trust Great Ormond Street Hospital FT has linked the incidents partly to what it described as a “faulty” batch of a type of glue used to close wounds during surgery Supplier says it followed the correct recall processes for the product Five serious incidents, including the deaths of two children, have sparked ‘urgent’ investigations into the processes through which clinicians are alerted to potential safety concerns over medical products used on patients. Great Ormond Street Hospital Foundation Trust has been investigating the incidents which happened between December 2020 and April 2021. The trust has linked the incidents partly to what it described as a “faulty” batch of a type of glue used to close wounds during surgery. The glue, called Histoacryl, is produced by B. Braun Medical Ltd, and the company issued three separate “field safety notices”, relating to different batches of the product, in March and April this year. The company has stressed that it followed the correct recall processes throughout. According to a report to GOSH’s public board meeting on 29 September, Histoacryl has been used for the endovascular treatment of brain arteriovenous malformations for more than 30 years, but earlier this year batches of the product were identified as hardening less rapidly than expected. The trust told HSJ in a statement: “A comprehensive serious incident investigation has been carried out to determine the impact of the faulty glue on all patients treated with it. “The investigation found that whilst the passage of glue through the intended vessel may have been contributory in some instances of harm, it was unlikely to be the sole or main factor. “Both patients who died had serious and complex medical conditions and the procedure to correct these always carries a high degree of risk which is discussed extensively with the families before any treatment takes place.” Read full article here (paywalled) Original source: Health Service Journal
  7. News Article
    The private laboratory that is under investigation for potentially issuing more than 40,000 false negative Covid tests was not fully accredited to perform the work, contrary to assurances made by health officials. The UK’s independent accreditation service, Ukas, told the Guardian on Monday that neither Immensa Health Clinics Ltd nor its sister company, Dante Labs, had ever been accredited by the service, and that it had informed the Department of Health that statements suggesting otherwise were incorrect. The UK Health Security Agency announced on Friday that it was suspending operations at Immensa’s laboratory in Wolverhampton pending an investigation into concerns that at least 43,000 people with coronavirus had been wrongly told their swabs tested negative for the virus. Because many of the individuals would have believed the typically more accurate PCR tests performed by Immensa over simpler lateral flow tests, there is a substantial risk they unwittingly spread the virus on to thousands more people. Read more Source: The Guardian, 18 October 2021
  8. News Article
    The trust at the centre of a maternity scandal does not have enough midwifery staff to keep women and babies safe, a Care Quality Commission (CQC)inspection has revealed. East Kent Hospitals University Foundation Trust relied on community midwives to fill slots at its acute unit, with some of them working 20-hour days after being called in to help cover and feeling outside of their competence. The trust had suspended a midwife-led unit and diverted women in labour to other hospitals – and when the CQC raised the understaffing issue at its inspection in July, it suspended its home birth service. But the CQC found that the number of midwives and maternity workers on duty rarely matched planned numbers and managers rarely calculated staffing numbers accurately, with some elements of the workload not being factored in. Lack of staff meant there was a risk to the safe assessment and monitoring of women and babies at the trust’s William Harvey Hospital in Ashford. Unqualified staff were having to deal with telephone queries from women who needed advice and support. Read full story (paywalled) Source: HSJ, 15 October 2021
  9. News Article
    NHS guidance ‘too long to read,’ say hospital staff as safety watchdog exposes systemic risks to patients. The Healthcare Safety Investigation Branch (HSIB) revealed some NHS staff had admitted not reading official guidance on how to avoid the ‘never event’ error as part of a new report identifying deeper systemic problems that it said left patients at an increased risk. The independent body warned patients across the NHS remained vulnerable to being injured or even killed by the error that keeps happening in hospitals despite warnings and safety alerts over the last 15 years. HSIB launched a national investigation into the problem of misplaced nasogastric (NG) tubes after a 26-year-old man had 1,450ml of liquid feed fed into his lungs in December 2018 after a bike accident. The patient recovered but the error was not spotted, even after an X-ray. Read full story Source: The Independent, 17 December 2020
  10. News Article
    All NHS trusts in England have been given a deadline of Monday to enact safety improvements in maternity care amid Shropshire's baby deaths scandal. Heath chiefs have told hospitals they must have the 12 "urgent clinical priorities" in place by 17:00 GMT. The move is to address "too much variation" in outcomes for families. It comes during a probe into the maternity care of more than 1,800 families in Shropshire. The inquiry, launched amid concerns of repeated failings at Shrewsbury and Telford Hospital NHS Trust (SaTH), focuses on the experience of 1,862 in total, and includes instances of infant fatality. An interim report published last week found poor care over nearly two decades had harmed dozens of women and their babies. The report called for seven "essential actions" to be implemented at maternity units across England. But that has since been transformed into 12 clinical tasks, including giving women with complex pregnancies a named consultant, ensuring regular training of fetal heart rate monitoring, and developing a proper process to gather the views of families. The directions are revealed in a letter in which NHS England says there is "too much variation in experience and outcomes for women and their families". Read full story Source: BBC News, 15 December 2020
  11. News Article
    The number of women involved in an investigation into a consultant gynaecologist who "unnecessarily harmed" patients has risen to 382. University Hospitals of Derby and Burton NHS Foundation Trust has written to another 110 women who were treated by Daniel Hay. Mr Hay is under investigation after eight women treated by him were found to have been "unnecessarily harmed". The latest women have been told there are "no concerns" for their health. Staff at the Royal Derby Hospital raised concerns about the consultant's care in late 2018. An initial review of 58 cases involving Mr Hay identified the eight lapses of care for which he and the trust have apologised. A broader investigation was launched and another 135 women, who had undergone surgery, were contacted to say their care was being reviewed. In September the trust wrote to a further 79 women who had received intermediate care. It has now said 110 more women, all outpatients at Ripley Hospital between April 2017 and July 2018, have now been contacted. Dr Magnus Harrison, executive medical director, said: "We have widened the review to a specific outpatient clinic... to understand the care being provided there. We are doing this proactively, rather than in response to any specific concerns, so that the review is as thorough as possible." "Each of the women have been informed that there are no concerns regarding their current health." Read full story Source: BBC News, 11 December 2020
  12. News Article
    Strong leadership, challenging poor workplace culture, and ringfencing maternity funding are key to improving safety. That’s the message from two leading Royal Colleges as they respond to the independent review of maternity services at Shrewsbury and Telford NHS Trust led by Donna Ockenden. The RCOG and the Royal College of Midwives (RCM) have today welcomed the Ockenden Review and its recognition of the need to challenge poor working relationships, improve funding and access to multidisciplinary training and crucially to listen to women and their families to improve learning and to ensure tragedies such as those that have happened at Shrewsbury and Telford NHS Trust never occur again. The Colleges have said that the local actions for learning and the immediate and essential actions laid out in this report must be read and acted upon immediately in all Trusts and Health Boards delivering maternity services across the UK. Commenting, Dr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, said: “This report makes difficult reading for all of us working in maternity services and should be a watershed moment for the system. Reducing risk needs a holistic approach that targets the specific challenges of fetal monitoring interpretation and strengthens organisational functioning, culture and behaviour." Read press release Source: RCOG, 10 December 2020
  13. News Article
    Patient Safety Learning Press Release 10th December 2020 Today the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust published its first report on its findings.[1] The report made recommendations for actions to be implemented by the Trust and “immediate and essential actions” for both the Trust and the wider NHS. The Review was formally commissioned in 2017 to assess “the quality of investigations relating to new-born, infant and maternal harm at The Shrewsbury and Telford Hospital NHS Trust”.[2] Initially it was focused on 23 cases but has been significantly expanded as families have subsequently contacted the review team with their concerns about maternity care and treatment at the Trust. The total number of families to be included in the final report is 1,862. These initial findings are drawn from 250 cases reviewed to date. This is another shocking report into avoidable harm. We welcome the publication of these interim findings and the sharing of early actions that have been identified to make improvements to patient safety in NHS maternity services. We commend the ambition for immediate responses and action. Reflecting on the report, there are a number of broad patient safety themes, many of which have been made time and time again in other reports and inquiries. A failure to listen to patients The report outlines serious concerns about how the Trust engaged and involved women both in their care and after harm had occurred. This was particularly notable in the example of the option of having a caesarean section, where there was an impression that the Trust had a culture of wanting to keep the numbers of these low, regardless of patients’ wishes. They commented: “The Review Team observed that women who accessed the Trust’s maternity service appeared to have little or no freedom to express a preference for caesarean section or exercise any choice on their mode of deliver.” It also noted a theme in common with both Paterson Inquiry and Cumberlege Review relating to the Trusts’ poor response to patients raising concerns.[3] The report noted that “there have also been cases where women and their families raised concerns about their care and were dismissed or not listened to at all”. The need for better investigations Concerns about the quality of investigations into patient safety incidents at the Trust is another theme that emerges. The review reflected that in some cases no investigation happened at all, while in others these did take place but “no learning appears to have been identified and the cases were subsequently closed with it deemed that no further action was required”. One of the most valuable sources for learning is the investigation of serious incidents and near misses. If these processes are absent or inadequate, then organisations will be unable to learn lessons and prevent future harm reoccurring. Patient Safety Learning believes it is vital that Trusts have the commitment, resources, and frameworks in place to support investigations and that the investigators themselves have the right skills and training so that these are done well and to a consistently high standard. This has not formed part of the Report’s recommendations and we hope that this is included in their final report. Lack of leadership for patient safety Another key issue highlighted by the report is the failure at a leadership level to identify and tackle the patient safety issues. Related to this one issue it notes is high levels of turnover in the roles of Chief Executive, executive directors and non-executive directors. As part of its wider recommendations, the Report suggests trust boards should identify a non-executive director who has oversight of maternity services. Good leadership plays a key role in shaping an organisations culture. Patient Safety Leadership believes that leaders need to drive patient safety performance, support learning from unsafe care and put in place clear governance processes to enable this. Leaders need to be accountable for patient safety. There are questions we hope will be answered in the final report that relate to whether leaders knew about patients’ safety concerns and the avoidable harm to women and their babies. If they did not know, why not? If they did know but did not act, why not? Informed Consent and shared decision-making The NHS defines informed consent as “the person must be given all of the information about what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment does not go ahead”.[4] The report highlights concerns around the absence of this, particularly on the issue of where women choose as a place of birth, noting: “In many cases reviewed there appears to have been little or no discussion and limited evidence of joint decision making and informed consent concerning place of birth. There is evidence from interviews with women and their families, that it was not explained to them in case of a complication during childbirth, what the anticipated transfer time to the obstetric-led unit might be.” Again this is another area of common ground with other recent patient safety reports such as the Cumberlege Review.[5] Patient Safety Learning believes it is important that patients are not simply treated as passive participants in the process of their care. Informed consent and shared decision making are vital to respecting the rights of patients, maintaining trust in the patient-clinician relationship, and ensuring safe care. Implementation for action and improved patient safety In its introduction, the report states: “Having listened to families we state that there must be an end to investigations, reviews and reports that do not lead to lasting meaningful change. This is our call to action.” Responding with an official statement in the House of Commons today, Nadine Dorries MP, Minister for Mental Health, Suicide Prevention and Patient Safety, did not outline a timetable for the implementation of this report’s recommendations. In 2020 we have seen significant patient safety reports whose findings have been welcomed by the Department of Health and Social Care but where there has subsequently been no formal response nor clear timetable for the implementation of recommendations, most notably the Paterson Inquiry and Cumberlege Review. Patient Safety Learning believes there is an urgent need to set out a plan for implementing the recommendations of the Ockenden Report and these other patient safety reports. Patients must be listened to and action taken to ensure patient safety. [1] Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Emerging findings and recommendations form the independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, 10 December 2020. https://www.ockendenmaternityreview.org.uk/wp-content/uploads/2020/12/ockenden-report.pdf [2] Ibid. [3] The Right Reverend Graham Jones, Report of the Independent Inquiry into the Issues raised by Paterson, 2020. https://assets.publishing.serv...; The Independent Medicines and Medical Devices Safety Review, First Do No Harm, 8 July 2020. https://www.immdsreview.org.uk/downloads/IMMDSReview_Web.pdf [4] NHS England, Consent to treatment, Last Accessed 16 July 2020. https://www.nhs.uk/conditions/consent-to-treatment/ [5] Patient Safety Learning, Findings of the Cumberlege Review: informed consent, Patient Safety Learning’s the hub, 24 July 2020. https://www.pslhub.org/learn/patient-engagement/consent-and-privacy/consent-issues/findings-of-the-cumberlege-review-informed-consent-july-2020-r2683/
  14. News Article
    Great Ormond Street Hospital may have broken the law by failing to share information with parents that showed its errors had contributed to their son’s death, The Independent understands. The care watchdog is speaking to Great Ormond Street about its handling of an expert report into five-year-old Walif Yafi in 2017. It showed that the hospital’s failure to share results that showed a deadly infection had played a role in Walif’s death. But the boy’s parents were only told about the findings after inquiries by The Independent – months after settling a lawsuit with Great Ormond Street in which the trust denied responsibility. The Care Quality Commission is looking at concerns relating to duty of candour regulations, which require hospitals to be open and honest with families about mistakes made that result in serious harm to patients. Breaching the regulations is a criminal offence and can lead to prosecution. Read full story Source: The Independent, 7 December 2020
  15. News Article
    Healthcare practitioners who committed child sexual abuse commonly did so under the guise of medical treatment, which went unchallenged by other staff even when unnecessary or inappropriate because of their position of trust, research has found. An independent inquiry into child sexual abuse report into abuse in healthcare settings between the 1960s and 2000s found that perpetrators were most commonly male GPs or healthcare practitioners with routine clinical access to children. As a result their behaviour was not questioned by colleagues, the children or their parents. In many cases patients’ healthcare needs related to physical, psychological and sexual abuse they suffered at home. They spoke of attending health institutions seeking treatment, care and recovery, but were instead subjected to sexual abuse. This included fondling, exposing children to adult sexuality, and violations of privacy. More than half who shared their experiences described suffering sexual abuse by penetration. Read full story Source: The Guardian, 4 December 2020
  16. News Article
    Trusts have been urged to reflect on their disciplinary procedures, and review them annually where required, following the death of a senior nurse who took his own life after being dismissed. NHS England’s chief people officer Prerana Issar has written to trust leaders to highlight Imperial College Healthcare Trust’s new disciplinary procedures, which were put in place following Amin Abdullah’s suicide. Mr Abdullah, a senior nurse at Charing Cross Hospital in west London, was suspended in September 2015 before being let go from his job that December. He died in February 2016 after setting himself on fire. An independent investigation criticised both the trust and its staff and concluded he had been “treated unfairly”. The summary report produced by the trust was labelled a “whitewash”, which “served to reassure the trust that it had handled the case with due care and attention”, and the delay of three months between the events and hearing were “troubling”. The report, which also criticised the delays as “excessive” and “weak” in their justification, said Mr Abdullah found the delay “stressful” and caused him to become “distressed”. In the letter sent on Tuesday, seen by HSJ, Ms Issar said: “The shared learning from Amin’s experience has demonstrated the need for us to work continuously and collaboratively, to ensure that our people practices are inclusive, compassionate and person-centred, with an overriding objective as to the safety and wellbeing of our people… our collective goal is to ensure we enable a fair and compassionate culture in our NHS. I urge you to honestly reflect on your organisation’s disciplinary procedure…" Read full story (paywalled) Source: HSJ, 3 December 2020
  17. News Article
    Regulators have apologised to a health manager who went through “five years of hell” while being investigated for misconduct, before being told there was no case to answer. Debbie Moore was a senior manager at the former Liverpool Community Health Trust, where there was a major care scandal in the early 2010s. As head of healthcare at HMP Liverpool, where many of the most serious failings were identified, Ms Moore was suspended in 2014 and referred to the Nursing and Midwifery Council. She was accused of multiple failures to take action or escalate concerns, of failing to investigate deaths, and discouraging staff from reporting incidents. However, in a first public interview about her experience, she told HSJ she was “scapegoated” for the problems at the prison, where she says she worked tirelessly to address the issues and had repeatedly flagged concerns to the LCH management team. External inquiries have found the trust would routinely downgrade risks escalated by divisional managers, as it sought to make drastic cost savings in pursuit of foundation trust status. Read full story (paywalled) Source: HSJ, 30 November 2020
  18. News Article
    The safety of maternity services at a major north London hospital has been criticised by the care watchdog after an inspection prompted by the death of a woman. The Care Quality Commission (CQC) has issued the Royal Free Hospital, in Hampstead with a warning notice after inspectors identified serious safety failings in its maternity unit. An unannounced inspection of the hospital’s maternity service took place in October, following the death of Malyun Karama, in February this year. The 34-year-old died while giving birth to her stillborn baby. She suffered a ruptured uterus after being given an overdose of misoprostol to induce her labour. In a report following an inquest into her death Coroner Mary Hassell said: “Abnormal observations were relayed by a midwife to a senior registrar, but the doctor failed to attend Ms Karama and instead ordered fluids. The uterine rupture would have been life threatening whatever the care rendered to Ms Karama, but if the doctor had attended immediately and had reviewed and treated appropriately, the likelihood is that Ms Karama’s life would have been saved.” The CQC has yet to publish a full report on its inspection of the hospital but confirmed it had taken enforcement action and issued the trust with a warning notice. The concerns relate to the trust being too slow to investigate and make changes after incidents of harm. It’s understood a panel to investigate Ms Karama’s death did not meet until June this year. Read full story Source: The Independent, 1 December 2020
  19. News Article
    A mother fighting for a public inquiry into the death of her son and more than 20 other patients at an NHS mental health hospital in Essex has won a debate in parliament after more than 100,000 people backed her campaign. On Monday, MPs in the House of Commons will debate Melanie Leahy’s petition calling for a public inquiry into the death of her son Matthew in 2012, as well as 24 other patients who died at The Linden Centre, a secure mental health unit in Chelmsford, Essex, since 2000. The centre is run by Essex Partnership University NHS Trust which has been heavily criticised by regulators over the case. A review by the health service ombudsman found 19 serious failings in his care and the NHS response to his mother’s concerns. This included staff changing records after his death to suggest he had a full care plan in place when he didn’t. Matthew was detained under the Mental Health Act but was found hanged in his room seven days later. He had made allegations of being raped at the centre, but this was not taken seriously by staff nor properly investigated by the NHS. The trust has admitted Matthew’s care fell below acceptable standards. In November, it pleaded guilty to health and safety failings linked to 11 deaths of patients in 11 years. Read full story Source: The Independent, 29 November 2020
  20. News Article
    The chairman of an inquiry that has confirmed a 20-year cover-up over the avoidable death of a baby has warned there are other families who may have suffered a similar ordeal. Publishing the findings of his investigation into the 2001 death of Elizabeth Dixon, Dr Bill Kirkup said he wanted to see action taken to prevent harmed families having to battle for years to get answers. Dr Kirkup, who has been involved in multiple high-profile investigations of NHS failures in recent years, said: “There has been considerable difficulty in establishing investigations, where events are regarded as historic. I don't like the term historic investigations. I think that these things remain current for the people who've suffered harm, until they're resolved, it’s not historic for them. “There has been significant reluctance to look at a variety of cases. Mr and Mrs Dixon were courageous and very persistent and they were given help by others and were successful in securing the investigation and it worries me that other people haven't been. “I do think we should look at how we can establish a proper mechanism that will make sure that such cases are heard." “It's impossible to rule out there being other people who are in a similar position. In fact, I know of some who are. I think it's as important for them that they get heard, and that they get things that should have been looked at from the start looked at now, if that's the best that we can do.” Read full story Source: The Independent, 27 November 2020
  21. News Article
    The death of a premature baby in 2001 led to a "20-year cover-up" of mistakes by health workers, an independent inquiry has found. Elizabeth Dixon, from Hampshire, died due to a blocked breathing tube shortly before her first birthday. The government, which ordered the inquiry in 2017, said the mistakes in her care were "shocking and harrowing". The inquiry report by Dr Bill Kirkup said some of those involved had been "persistently dishonest". Elizabeth, known as Lizzie, died from asphyxiation after suffering a blockage in her tracheostomy tube while under the care of a private nursing agency at home. Dr Bill Kirkup, who was appointed by the government to review the case, said her "profound disability and death could have been avoided". He said: "There were failures of care by every organisation that looked after her, none of which was admitted at the time, nor properly investigated then or later." "Instead, a cover-up began on the day that she died, propped up by denial and deception." Read full story Source: BBC News, 26 November 2020 Patient Safety Learning's statement on the Dixon Inquiry report
  22. News Article
    A world-leading children’s hospital has been accused of a “concerted effort” to cover up the mistakes that led to the death of a toddler. Jasmine Hughes died at London’s Great Ormond Street Hospital aged 20 months after suffering acute disseminated encephalomyelitis (ADEM), a condition in which the brain and spinal cord are inflamed following a viral infection. Doctors said that her death in February 2011 had been caused by complications of ADEM. But an analysis of detailed hospital computer records shows the toddler died after her blood pressure was mismanaged – spiking when she was treated with steroids then allowed to fall too fast. Experts say this led to catastrophic brain damage. Although the detailed computer records were supplied to the coroner who carried out Jasmine’s inquest, crucial information concerning her blood pressure was not included in official medical records that should hold the patient’s entire clinical history. Dr Malcolm Coulthard, who specialises in child blood pressure and medical records examination, carried out the analysis of the files, comprising more than 350 pages of spreadsheets. Dr Stephen Playfor, a paediatric intensive care consultant, examined the computer records and came to the same conclusion as Dr Coulthard, that mismanagement of Jasmine’s blood pressure by Great Ormond Street and Lister Hospital, in Stevenage, was responsible for her death. Dr Coulthard told The Independent: “As a specialist paediatrician, it is with great regret and disappointment that I have concluded that the doctors' records in Jasmine Hughes’ medical notes fail to reflect the truth about her diagnosis and treatment.” Read full story Source: The Independent, 20 November 2020
  23. News Article
    Several patients were harmed after leaders at an acute trust failed to act on multiple concerns being raised about a surgeon, documents obtained by HSJ suggest. The documents reveal a catalogue of governance and safety concerns over the trauma and orthopaedics department at University Hospitals of Morecambe Bay Foundation Trust in the last three years. They include an external review which described the process for investigating clinical incidents as akin to “marking your own homework” and found the T&O department at Royal Lancaster Infirmary driven by “internecine squabbles”. It comes as the trust, which is widely known for a patient safety scandal within its maternity department, also faces a major investigation into whistleblowing concerns over its urology services. Read full story (paywalled) Source: HSJ, 17 November 2020
  24. News Article
    The Department of Health and Social Care (DHSC) has been criticised by the national health ombudsman for the ‘maladministration’ of a 2018 review into the death of a teenage girl under the care of one of England’s top specialist hospitals, HSJ can reveal. The Parliamentary and Health Service Ombudsman (PHSO) came to the conclusion after investigating a DHSC review into the 1996 death of 17-year-old Krista Ocloo which had been requested by her mother. Krista died at home of acute heart failure in December 1996. She had been admitted to the Royal Brompton Hospital with chest pains in January of that year. The PHSO report states her mother was told “there was no cause for concern” and that another appointment would be scheduled in six months. This follow-up appointment did not happen. The young woman’s death was considered by the hospital’s complaints process, an independent panel review and an inquiry into the hospital’s paediatric cardiac services. They concluded the doctor involved was not responsible for Krista’s death – though the paediatric services inquiry criticised the hospital for poor communication. A coroner declined to open an inquest into the case. Civil action against the hospital, brought by Ms Ocloo, found Krista’s death could not have been prevented. However, a High Court judge found that the failure to arrange appropriate follow-up by the RBH was “negligent”. A spokeswoman for PHSO said: “Our investigation found maladministration by the Department for Health and Social Care, which should have been more transparent in its communication. The department’s failure to be open and clear compounded the suffering of a parent who was already grieving the loss of her child.” A DHSC spokeswoman said: “We profoundly regret any distress caused to Ms Ocloo. “[The PHSO] report found that in communicating with Ms Ocloo the department’s actions were – in places – not consistent with relevant guidance. The department has writen to Ms Ocloo to apologise for this and provide further information about the review.” Read full story (paywalled) Source: HSJ, 12 November 2020
  25. News Article
    A nurse is due in court charged with eight counts of murder following an investigation into baby deaths at the Countess of Chester hospital neonatal unit in Cheshire. Lucy Letby, 30, is due to appear at Warrington magistrates court on Thursday. She was arrested for a third time on Tuesday as part of the investigation into the hospital, which began in 2017. A force spokesman said: “The Crown Prosecution Service has authorised Cheshire police to charge a healthcare professional with murder in connection with an ongoing investigation into a number of baby deaths at the Countess of Chester hospital.” He said Letby was facing eight charges of murder and 10 charges of attempted murder relating to the period from June 2015 to June 2016. On Tuesday, police said parents of all the babies involved were being kept fully updated on developments and were being supported by officers. Read full story Source: The Guardian, 11 November 2020
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