Search the hub
Showing results for tags 'Investigation'.
Found 1,558 results
-
News Article
NHS board named in Glasgow hospital corporate homicide probe
Patient Safety Learning posted a news article in News
Scotland's largest health board has been named as a suspect in a corporate homicide investigation following the deaths of four patients at a Glasgow hospital campus. NHS Greater Glasgow and Clyde (NHSGGC) informed families of the development via a closed Facebook group set up during a water contamination crisis. The board confirmed it had received an update from the Crown Office. But it added there was no indication prosecutors had "formed a final view". Police Scotland launched a criminal investigation in 2021 into a number of deaths at the Queen Elizabeth University Hospital (QEUH) campus, including that of 10-year-old Milly Main. The Crown Office and Procurator Fiscal Service (COPFS) instructed officers to investigate the deaths of Milly, two other children and 73-year-old Gail Armstrong. Milly's mother previously told a separate public inquiry into the building of several Scottish hospitals that her child's death was "murder". A review earlier found an infection which contributed to Milly's death was probably caused by the QEUH environment. Read full story Source: BBC News, 13 November 2023 -
News Article
Two-thirds of homecare patient safety incidents linked to major provider
Patient Safety Learning posted a news article in News
Two-thirds of patient safety incidents recorded during hospital trusts’ monthly reporting period for homecare medicine provision were for services provided by the company Sciensus, an investigation by The Pharmaceutical Journal has revealed. In response to a freedom of information request sent to 131 hospital trusts in England in August 2023, 32 trusts recorded 417 patient safety incidents during their most recent monthly reporting period, which ranged from May to July 2023. Some 66% of these incidents (277) related to services delivered by homecare provider Sciensus, despite providing medicines to fewer than half (44%) of the 96,849 patients covered in the data. The findings come after the House of Lords Public Services Committee opened an inquiry into homecare medicines services in May 2023 following press reports of complaints from patient organisations and others about the service provided. The inquiry heard evidence from patient groups, regulators, homecare companies and the government during the summer and the committee will publish its report on 16 November 2023. Sciensus was previously known as Healthcare at Home and is one of the UK’s largest homecare companies. The data also uncovered that Sciensus was a poor performer on “failed” deliveries, defined as those that did not arrive on the scheduled day. Read full story Source: The Pharmaceutical Journal, 9 November 2023 -
Content ArticleA pulmonary embolism happens when a blood clot breaks off and travels to the lungs where it blocks the flow of blood. Although life-threatening, when diagnosed promptly survival rates are good. This report from the Parliamentary and Health Service Ombudsman (PHSO) looks at the case of a man who died of a pulmonary embolism after doctors failed to test for deep vein thrombosis.
-
Content Article
NHS Providers: UK Covid-19 public inquiry briefings
Patient Safety Learning posted an article in Covid-19 Inquiry
Weekly briefings on the UK Covid-19 Inquiry summarising the proceedings most relevant to NHS trusts. -
News Article
Consultant carried out 'unnecessary' surgery for financial gain, tribunal hears
Patient Safety Learning posted a news article in News
A doctor who worked for the same private healthcare company as rogue surgeon Ian Paterson performed unnecessary shoulder operations for financial gain, a medical tribunal has heard. Orthopaedic consultant Michael Walsh worked at a Spire Healthcare hospital in Leeds from 1993 until 2018, when he was suspended after concerns were raised about his work. Spire, which runs 38 hospitals around the UK, reported him to the General Medical Council (GMC) after an investigation found he carried out operations unnecessarily or badly, with many patients left suffering pain or trauma. Mr Walsh, who also worked at another private hospital in Leeds run by Nuffield Health but is now retired, is facing dozens of medical negligence claims from patients, with some already having received payouts. Read full story Source: Medscape, 8 November 2023 -
Content ArticleThe Department of Health and Social Care has published a letter, final report with recommendations, and a proposed code of practice framework from Baroness Hollins on the use of long-term segregation for people with a learning disability and/or autistic people. In her scathing report, Baroness Shelia Hollins said: “My heart breaks that after such a long period of work, the care and outcomes for people with a learning disability and autistic people are still so poor, and the very initiatives which are improving their situations are yet to secure the essential funding required to continue this important work."
-
News Article
Private health firm Sciensus fails to fix defects that led to UK patient’s death
Patient Safety Learning posted a news article in News
A private health company paid millions by the NHS has failed to fix safety defects that led to the death of a cancer patient, the Guardian can reveal. Three patients were hospitalised and a fourth died when they were given the wrong doses of a powerful chemotherapy drug after a catastrophic IT failure at the medicine manufacturing unit of Sciensus in April this year. The incident, first revealed by the Guardian in July, prompted an investigation by the Medicines and Healthcare products Regulatory Agency (MHRA). Its inspectors found “significant deficiencies” at the Sciensus manufacturing facilities and ordered the partial suspension of its manufacturing licence. However, six months after the IT blunder, Sciensus has not fixed the problems identified by the regulator, according to people familiar with the matter. As a result, the suspension of its licence – originally due to be lifted last month – has been extended until July next year. Sciensus is the UK’s biggest provider of medicines services to NHS and private patients at home. It is contracted by the NHS and other organisations to deliver and administer medicines to more than 200,000 people with conditions such as heart disease, diabetes, dementia, HIV and cancer. Read full story Source: The Guardian, 5 November 2023 -
News Article
Patient left permanently blind after hospital failure
Patient Safety Learning posted a news article in News
A patient was left with permanent sight loss after a hospital failed to spot the signs of a blood vessel blockage for several months. The person referred to only as Mr L, visited the emergency department at one of Wales' hospitals in January, 2018, but medics failed to consider the possibility he had suffered a watershed stroke. Details of how it took nine months before Mr L was offered a scan to consider this diagnosis have been described in a report from the Public Service Ombudsman detailing the care under Betsi Cadwaldr University Health Board. The Ombudsman, Michelle Morris, also slammed the health board for its failure to act promptly with the complaints process. She said she "cannot fail to be shocked by the fact that, although Mr L first complained to the health board in June, 2019, it took until February, 2023 for it to recognise any failings." The report details how between January and September, 2018, the health board failed to promptly and appropriately identify, investigate and treat a blockage of blood vessels in his neck (a condition called carotid artery stenosis, where the blockage restricts the blood flow to the middle of the brain, face and head). Mr L also complained that when the issue was eventually identified in September, there was a delay in getting the treatment (surgery) until November. Read full story Source: Wales Online, 2 November 2023 -
Content ArticleSussex Community NHS Foundation Trust share their patient safety newsletters with the hub.
-
Content Article
.thumb.thumb.thumb.thumb.thumb.png.7662e0a9bfba7f48330bfeaab4235486.png.c571d068b7814a95ecfa77b8e2689468.png)
This blog provides an overview of a Patient Safety Management Network (PSMN) meeting discussion on 27 October 2023. At this meeting, members of the network were joined by Dr Ted Baker, Chair of the Health Services Safety Investigations Body (HSSIB). The PSMN, created in June 2021, is an innovative voluntary network for patient safety managers and everyone working in patient safety. It provides a weekly drop-in session with guests to talk through issues of importance to patient safety managers, providing information, peer support and safe space for discussion. Find out more about the Network. -
News ArticleA public inquiry into the deaths of at least 2,000 mental health inpatients has been relaunched with new powers. The Essex Mental Health Independent Inquiry was established in 2021 to investigate the deaths of people on mental health wards in the county. The number of initial responses to the inquiry from current and former staff was described as "disappointing". The inquiry has converted to a statutory inquiry meaning witnesses can be forced to give evidence. It is understood the new chairwoman is considering extending the inquiry's timeframe to include deaths from the start of 2000 until the end of 2023. Baroness Kate Lampard, leading the inquiry, said: "I am determined to conduct this inquiry in a fair, thorough and balanced manner. "I am also concerned to ensure that I do not take any longer than necessary - the recommendations from this inquiry are urgent and cannot be delayed." She added: "To be clear from the outset, I will not be compelling families to give evidence. "Evidence from staff, management and organisations will be gathered in a proportionate, fair and appropriate manner." Read full story Source: BBC News, 1 November 2023
-
Content ArticleThe aim of this investigation and report is to help improve the inpatient care of adults with a known learning disability in acute hospital settings. It focuses on people referred urgently for hospital admission from a community setting, such as a person’s home or residential home. In undertaking this investigation, the Health Services Safety Investigations Body (HSSIB) looked to explore the factors affecting: The sharing of information about people with a learning disability and their reasonable adjustment needs following admission to an acute hospital. How ward-base staff are supported to delivery person-centred care to people with a learning disability.
-
Content ArticleIn this video, the Long Covid Groups' KC Anthony Metzer questions Professor Kamlesh Khunti to find out if he agrees that Long Covid should be cited as a reason not to allow Covid-19 to spread unchecked via non-pharmaceutical interventions (NPIs). Professor Khunti is a member of SAGE and former Chair of the National Long Covid Research Working Group.
-
News Article
Parents of babies who died or were harmed in NHS care demand inquiry
Patient Safety Learning posted a news article in News
Parents of babies who have died or been harmed as a result of poor care are demanding that ministers order a public inquiry into repeated failings in NHS maternity units. They want Steve Barclay, the health secretary, to set up a judge-led statutory inquiry to investigate recurring problems in maternity services, which cost the NHS in England £2.6bn a year in damages. Babies are still being damaged and dying, despite previous inquiries into maternity scandals at the Morecambe Bay, Shrewsbury and Telford, and East Kent NHS trusts recommending changes. The NHS’s failure to improve maternity safety is so alarming that a public inquiry is needed to finally ensure that women and babies no longer come to harm, the families say. The Maternity Safety Alliance, a group of relatives of newborns who have died due to lapses in NHS childbirth, warned that scandals will continue unless such an inquiry is held. “Our babies are too precious to keep on ignoring the reality that despite a raft of national initiatives and policies implemented in the wake of investigations and reports, systemic issues continue to adversely impact on the care of women and babies. “Far too much avoidable harm continues to devastate lives in circumstances that could and should be avoided. Fundamental reform is needed,” they said in a letter urging Barclay to intervene. Read full story Source: The Guardian, 31 October 2023 -
Content Article"With every patient safety inquiry the lessons are the same. We owe the families affected by these repeated failures meaningful organisational change." Says Juliet Dobson, in this Editorial for the BMJ.
-
News ArticleRecord numbers of patients are complaining to the NHS Ombudsman about poor care, exorbitant fees and difficulty getting treatment from NHS dental services in England. Mistakes by dentists mean some patients are being left in agony – in some cases unable to eat – while others are being landed with huge bills for work on their teeth. “Poor dental care leaves patients frustrated, in pain and out of pocket,” said Rob Behrens, the parliamentary and health service ombudsman. The number of complaints he receives every year about NHS dental services has jumped from 1,193 in 2017-18 to 1,982 in 2022-23 – a rise of 66%. Behrens also disclosed that the proportion of complaints he upholds about NHS dentistry after an investigation has increased from 42% to 78% over the same period. That 78% figure for upheld complaints about dental services is “significantly more” than for any other area of NHS care, such as GP, hospital or mental health care, where the overall average is 60%, he said. Dentistry has become one of the public’s main concerns about the NHS, especially the obstacles many people face when trying to access NHS care. A BBC survey last year found that 90% of surgeries across the UK were not accepting new adult patients and 80% were not taking on children as new patients. Read full story Source: The Guardian, 30 October 2023 Related reading on the hub: “I’ve been mocked, scolded and gaslighted”: a harmed patient’s experience of orthodontic treatment A patient harmed by orthodontic treatment shares their story We want to hear from patients with experience of NHS and/or private orthodontists and dentists in any healthcare setting, including community practices and hospitals. Did the orthodontist/dentist give you the treatment and support you needed? If you had ongoing problems, how did the orthodontist/dentist and other healthcare professionals respond? Have you tried to make a complaint? Share your experience of orthodontist and dentistry services
-
News Article
Michael Watt hearing: Lawyers withdraw over mental health concerns
Patient Safety Learning posted a news article in News
Lawyers for a doctor at the centre of Northern Ireland's biggest patient recall have withdrawn from his new fitness to practise hearing. Legal representatives for Michael Watt said they are "concerned about his serious mental health condition". They told the Medical Practice Tribunal Service that the continuation of the hearing in public "presents a real risk to his mental health". A new fitness to practise hearing began in September. The legal team has also formally withdrawn an application to the tribunal for Michael Watt to remove himself from the medical register. It followed a ruling by the High Court earlier this year to quash a decision where he previously was voluntary erased from the medical register. The tribunal is inquiring into the allegation that, between 7 and 22 of October 2018, Michael Watt underwent a General Medical Council assessment of the standard of his professional performance. It is alleged that that performance was unacceptable in the areas of maintaining professional performance, assessment, clinical management, record keeping and relationship with patients. Read full story Source: BBC News, 27 October 2023 -
Content ArticleIn this article Sir Bernard Jenkin, Member of Parliament for Harwich and North Essex, considers the role of new statutory body to investigate patient safety concerns across England to improve NHS care at a national level, the Health Services Safety Investigations Body (HSSIB). He talks about the new “safe space” powers of the organisation and its intended role in the healthcare system.
-
News ArticleSome care home residents may have been "neglected and left to starve" during the pandemic, Scotland's Covid Inquiry is expected to hear. Lawyers representing bereaved relatives said they also anticipate the inquiry will hear some people were forced into agreeing to "do not resuscitate" plans. Shelagh McCall KC told the inquiry that evidence to be led would "point to a systemic failure of the model of care". The public inquiry is investigating Scotland's response to the pandemic. Ms McCall is representing Bereaved Relatives Group Skye, a group of bereaved relatives and care workers from Skye and five other health board areas of Scotland. In her opening statement, she told the public inquiry that families wanted to know why Covid was allowed to enter care homes and "spread like wildfire" during the pandemic. She added: "As well as revealing the suffering of individuals and their families, we anticipate the evidence in these hearings will point to a systemic failure of the model for the delivery of care in Scotland, for its regulation and inspection. "We anticipate the inquiry will hear that people were pressured to agree to do not resuscitate notices, that people were not resuscitated even though no such notice was in place, that residents may have been neglected and left to starve and that families are not sure they were told the truth about their relative's death." Read full story Source: BBC News, 25 October 2023
-
News Article
Muckamore inquiry: Staff accused of ignoring TB symptoms
Patient Safety Learning posted a news article in News
The mother of a patient at Muckamore Abbey Hospital has described how her son contracted tuberculosis (TB) while at the hospital. She said he had been left severely disabled after a series of associated strokes. Patient P116 is now 40 years old and has suffered from severe epilepsy since he was a baby. His mother told the inquiry into abuse at the hospital that her concerns over her son's health were ignored. She said that even after he began developing symptoms - including losing six stone (38kg) of weight - staff seemed "not to care". In the end, he was only diagnosed with TB after his mother took him to hospital herself. Due to the delay in the diagnosis and the way the family's complaint was handled, a serious adverse incident review was carried out and P116's mother received a letter of apology from the then permanent secretary at the Department of Health, Richard Pengelly, and Theresa Villiers, who was Northern Ireland secretary at the time. His mother told the inquiry her son's time in Muckamore remained a "major trauma" for the family and she still found it very difficult to talk about. She told the inquiry she felt strongly that "independent expert support" should be given to patients abused or neglected in Muckamore, including specialist counselling for the patients and their families. Read full story Source: BBC News, 12 October 2023 -
News Article
Three patients died after doctor failed to ensure bowel test follow-up treatment
Patient Safety Learning posted a news article in News
Three patients have died after being given a bowel test by a doctor who failed to ensure treatment needed was carried out, a health board has said. NHS Greater Glasgow and Clyde (NHSGGC) said three more patients suffered harm. The six patients were identified in a clinical review the health board carried out of 2,700 people the consultant carried out a colonoscopy on between 2020 and 2022. The consultant, who has not been named, was suspended in November 2022 and has since left the health board. NHSGGC deputy medical director Professor Colin McKay said: “We would like to offer our sincere apologies to patients who were not followed up appropriately and our condolences to the families of those patients who have died." “Our investigations found that the doctor did not consistently follow up the results of investigations that had been completed or requested and therefore missed the opportunity for patients to be treated, including a number of patients who went on to develop malignancy." Read full story Source: The Independent, 11 October 2023 -
News Article
Over 17 000 serious incidents reported in mental healthcare last year
Patient Safety Learning posted a news article in News
The UK’s largest mental health charity, Mind, has published previously unseen data laying bare the full scale of the emergency in mental healthcare, with staff reporting 17,340 serious incidents in 12 months. The Care Quality Commission (CQC) figures shows mental healthcare staff across England reported an incident two times every hour in the last year, where people are treated for issues including self-harm, eating disorders and psychosis. Incidents included: injuries to patients that caused likely long term sensory, movement or brain damage, or physically damaged their body prolonged physical pain or psychological harm, or shortened life expectancy cases of abuse, including those involving the police injuries for which the patient needed treatment to prevent them dying. All of these incidents involved care providers raising concerns with the CQC under their statutory duty under Regulation 18. Dr Sarah Hughes, Chief Executive of Mind, says: “It is deeply worrying that healthcare staff across the country are so concerned about the situation in mental health settings that they are reporting a serious incident once every half an hour. We knew this was a crisis – now we know the scale of this crisis. People seek mental healthcare to get well, not to endure harm. Families are being let down by a system that’s supposed to protect their loved ones when they are most sick. The consequences can be and have been fatal". Read full story Source: Mind, 10 October 2023 -
News Article
Hospital chief quits in protest at ‘cover-up’ over baby deaths
Patient Safety Learning posted a news article in News
An NHS hospital has been accused of posing a continuing risk to patients by “covering up” leadership failures, including not properly investigating the deaths of two babies. Dr Max Mclean, chairman of Bradford Teaching Hospitals trust, has quit in protest at the conduct of the trust’s chief executive, Professor Mel Pickup, after no action was taken over serious concerns about her performance. In a blistering resignation letter, Mclean said he “cannot, in good conscience, work with a CEO who has fallen so short of the standards expected of her role that there is a genuine safety risk to patients and colleagues”. He is calling for senior national NHS figures to establish new leadership at the trust, and has written to the head of NHS England to share his concerns about Pickup, who has been in post since 2019. Mclean told The Times there were parallels with the Lucy Letby scandal, when management ignored the concerns of whistleblowers. “Patients are at risk, babies are at risk, and there could be avoidable deaths unless there is a change of leadership,” he said. The former detective chief superintendent who has chaired the trust since 2019, raised nine serious issues about Pickup’s performance, which he said were confirmed by an independent investigation that concluded last month. However, the trust’s board met on October 2 and decided there would be no further action against Pickup, leaving Mclean with “no option” but to resign and speak publicly. Read full story (paywalled) Source: The Times, 10 October 2023 -
News Article
NHS ombudsman warns Sciensus that patients ‘should not be ignored’
Patient Safety Learning posted a news article in News
The boss of Britain’s biggest medicines courier has been told to urgently improve its complaints system by the NHS ombudsman amid concerns patients let down by missing deliveries are repeatedly ignored. In a highly unusual development, Darryn Gibson, the chief executive of Sciensus, has received a written warning from Rob Behrens, the parliamentary and health service ombudsman (PHSO). It says patients “should not be ignored” and must be “listened to and taken seriously” or he will consider taking further action. The PHSO investigates complaints that have not been resolved by the NHS or by private providers of NHS care. Sciensus is the single largest provider of homecare medicines services to the NHS and has contracts worth millions of pounds. In an email seen by the Guardian, Behrens told Gibson he had been unable to investigate most reports received about Sciensus because patients had not been able to complete the company’s complaints process. “That is not acceptable or fair to complainants,” Behrens wrote. In a statement, Sciensus said it worked “very hard” to ensure NHS patients received their medicines on time. Its services had “a 95% satisfaction rating”, it added. The move follows a Guardian investigation that exposed how Sciensus put NHS patients at risk of harm with delayed, missed or botched deliveries of medicines for conditions including cancer, heart disease, diabetes, dementia and HIV. It also uncovered how patients’ alarm at vital drugs and medical devices not arriving at their home was often compounded by a struggle to reach Sciensus to complain and fix the problems. Read full story Source: The Guardian, 19 October 2023 -
News ArticleFinancial directors need to take responsibility for safety, which should be at the core of how the NHS runs services, the leadership of the Health Services Safety Investigations Body (HSSIB) said at its launch Wednesday. The Healthcare Safety Investigation Branch is now an independent body – and has been renamed HSSIB – although maternity investigations are hosted by the Care Quality Commission. Questioning how many finance directors across the NHS take responsibility for safety, HSSIB’s interim chief investigator Rosie Benneyworth said: “We need a position where finance directors in every organisation are as responsible for safety as the person leading the safety agenda and vice versa, the safety person works with the finance agenda to support them. “Often you see the finance director and safety lead don’t work effectively together and we need to change that.” Dr Benneyworth said progress will not be made unless operational delivery, financial delivery and safety are tackled “in the same breath”. HSSIB’s new chair Ted Baker also called for safety to become a core part of running services “in the way running the accounts is”, as it is currently still seen “as an add-on”. He stressed that safety “drives efficiencies, enables innovation and saves costs”. Read full story (paywalled) Source: HSJ, 19 October 2023
.thumb.thumb.thumb.thumb.thumb.png.7662e0a9bfba7f48330bfeaab4235486.png.c571d068b7814a95ecfa77b8e2689468.png)
