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Found 570 results
  1. News Article
    A string of failings may have contributed to the death of a “deeply vulnerable” law student who killed herself while being treated in a psychiatric hospital in Bristol, an inquest jury has said. Zoë Wilson, 22, had informed staff she was hearing voices in her head telling her to kill herself and 30 minutes before she died was seen by a nurse through an observation hatch looking frightened and behaving oddly but nobody went into her room to check her. Speaking after the jury’s conclusions, Wilson’s family said that Avon and Wiltshire mental health partnership NHS trust (AWP) should face criminal charges over the case. AWP said it accepted it had fallen short in its care of Wilson. Zoë on the 17 June 2019 she told staff she was hearing voices telling her to kill herself and handed over an item that she could have used to harm herself with. She was not moved to an acute ward and other items that she could have used were not removed. At 1am on 19 June she was observed standing beside her bathroom door looking frightened but staff did not go to her. Thirty minutes later she was checked again and had harmed herself. Emergency services were called but she was pronounced dead. Giving evidence to Avon coroner’s court, the nurse who saw Wilson at 1am said he had only worked in the unit a handful of times and had not met Wilson before that night. The jury concluded that steps taken to keep her safe that night had been inadequate and also criticised communication and information sharing. In a statement, her family, said: “Zoë was a wonderful, bright, and deeply vulnerable young woman. She was on a low-risk ward even when she told staff that voices in her head were telling her to kill herself.” They called for AWP to face a criminal prosecution by the Care Quality Commission (CQC). “We will continue to fight for justice in her name,” they said. “She will never be forgotten.” Read full story Source: The Guardian, 27 January 2022
  2. News Article
    Injured NHS patients have spoken out about the human cost of clinical negligence in a new report published as MPs examine how to cut the health service’s bill for causing harm. The House of Commons Health and Social Care Select Committee is gathering evidence for its inquiry on NHS litigation reform. “There is a fixation on the financial cost of clinical negligence, rather than on the human cost and the reasons why injured patients have to make a claim for compensation at all,” said Guy Forster of the Association of Personal Injury Lawyers (APIL) a not-for-profit group which campaigns on behalf of injured patients and their families. “There are a lot of voices and opinions in any debate which concerns the NHS and patient safety, but they are almost never the voices and opinions of the patients. This is why APIL has commissioned The Value of Compensation report,” said Mr Forster. Patients who took part in the research cite mounting debt; uncertainty about their future health; isolation; abandoned careers; relationship breakdowns; and loss of independence, as some of the many far-reaching side effects of injuries sustained through failures in care. “Patients are devastated to have trusted the NHS with their health and then have to live with the pain and suffering of an injury which should have been avoided,” said Mr Forster. “This report provides new insight on how compensation can help rebuild their lives.” “None of them relish having to make a claim for compensation. I cannot stress enough that the money is never, ever a ‘windfall’ for an injured patient,” he went on. “It is obvious that full and fair compensation is critical for injured patients. It should go without saying that the cost of compensation would be cut if the harm were not caused in the first place. But it is critical that when things go wrong, injured people are cared for properly and have the chance to get back on track.” Read press release Source: APIL, 12 January 2022
  3. News Article
    The Irish Cabinet has approved general indemnity cover and product liability cover for claims to two public sector bodies relating to transvaginal mesh products and the Gardasil HPV vaccine. The Health Minister Stephen Donnelly brought forward a proposal to Cabinet Wednesday for the provision of this cover to the Irish Blood Transfusion Service (IBTS) and the Mental Health Commission (MHC) for claims relating to the mesh products or Gardasil. Gardasil is a type of vaccine used to protect against HPV. Vaginal mesh devices have been used in operations to treat stress urinary incontinence and pelvic organ prolapse; two conditions that can impact women after natural childbirth or in their later years. Including the bodies in the State’s general indemnity scheme for these claims will eliminate the requirement for them to carry private insurance. The State Claims Agency was consulted and indicated that it supports the inclusion of both bodies under the scheme. The clinical indemnity scheme indemnifies hospitals but is confined to clinical acts and/or omissions and doesn’t cover product liability matters. Current legal cases around transvaginal mesh products involve allegations in relation to the product itself and allegations of clinical negligence. It has now been proposed to delegate the product liability claims for mesh products to the State Claims Agency to ensure hospitals aren’t exposed to uninsured liability. Thousands of women across the world have suffered complications after having a vaginal mesh device implanted. These complications include chronic pain and recurrent urinary tract infections and have been life-changing in many cases. Read full story Source: thejournal.ie, 19 January 2022
  4. News Article
    NHS England has encouraged trusts to consider taking legal action against patients who refuse to leave hospital beds when step-down care is made available. NHSE guidance sent to trusts late last year, seen by HSJ, advised clinicians that where people “with mental capacity” refuse to vacate a bed because they do not accept NHS-funded short-term care offers, the “local discharge choice policy” should be followed, which could involve legal action. The guidance said the process “may include seeking an order for possession of the hospital bed” under civil law, and that “appropriate formal notification of the process must be given to the person and their representatives/carers”. These legal powers were open to trusts prior to covid, but the memo from NHSE comes amid increasing pressure on trusts to improve discharge rates, as waits for emergency and elective care continue to soar. Helen Hughes, chief executive of Patient Safety Learning, said: “Given the current pressures posed by covid, it is understandable that the NHS is seeking to ensure that the hospital discharge process is as swift and effective as possible. “However, hospital discharges are complex processes and can potentially result in avoidable harm if patients are discharged before they are clinically ready. It only takes one element of this complex process failing to put a patient’s safety at risk. “We would be particularly concerned if patients and their carers were put under pressure to accept potentially unsafe discharge options due to the threat of possible legal action by an NHS trust.” Read full story (paywalled) Source: HSJ, 14 January 2022
  5. News Article
    A Christian nurse who claimed she was discriminated against for wearing a cross at work has won her case for unfair dismissal. Mary Onuoha, a theatre practitioner at Croydon University Hospital in London, said she was bullied and harassed for refusing to remove her necklace in 2018. But an employment tribunal has ruled Croydon Health Services NHS Trust discriminated against and harassed Ms Onuoha over her refusal to remove the jewellery. The trust told her the necklace was a safety risk and must not be outwardly visible. Ms Onuoha, supported by Christian Legal Centre, said she had worked at the hospital for 13 years before being asked to remove the symbol. The tribunal found the employer’s uniform policy arbitrary, with many staff allowed to wear necklaces and other religious symbols were permitted. Following the ruling, Christian Legal Centre chief executive Andrea Williams said the trust’s interpretation of uniform guidance had led to a campaign of harassment against a devoted, experienced, and highly professional nurse, who was in effect hounded out of the NHS. Ms Onuoha said she was investigated and suspended from clinical duties when she refused to remove the item and she was demoted to receptionist duties. In June 2020, she went off work with stress and said she felt she had no alternative but to resign. Read full story Source: Nursing Standard, 6 January 2022
  6. News Article
    The government has rejected advice from an independent inquiry into the actions of disgraced surgeon Ian Paterson to suspend all healthcare professionals who are suspected of posing a risk to patient safety. The Department of Health and Social Care today published its response to 15 recommendations from the inquiry, which found Mr Paterson, jailed for 20 years in 2017 for 17 offences of wounding with intent, may have conducted up to 1,000 botched and unnecessary operations over a 14-year period. Of its 15 recommendations, the DHSC accepts nine in full, five in principle, rejects one entirely and there is another further point which it is keeping under review. In particular, the inquiry panel members recommended that when a hospital investigates a healthcare professional’s behaviour, including the use of an HR process, any perceived risk to patient safety should result in the suspension of that healthcare professional. DHSC chiefs said they agree practice exclusions and restriction can be necessary, and in some cases immediate exclusion is an appropriate response while an investigation is ongoing. But they added: “However, we do not believe it would be fair or proportionate to impose a blanket rule to exclude practitioners in such cases. “Such a step may inadvertently cause a chilling effect, dissuading healthcare professionals from raising concerns and negatively impacting patient safety.” Read full story (paywalled) Source: HSJ, 16 December 2021
  7. News Article
    A nurse who was sacked by a private hospital provider treating NHS patients which believed she had deliberately tried to sabotage its Care Quality Commission inspection has won a tribunal. An employment tribunal found Care UK’s dismissal of Lorna Jarrett carried “the taint of race discrimination” and said the company had provided no evidence of any malice on her part. Ms Jarret worked at the North East London Treatment Centre. The judgment said management at the facility were convinced Ms Jarrett had deliberately faxed confidential patient identifiable data to the inspectorate instead of the GP surgery they were supposed to be sent to. This incident occurred in the week of the centre’s CQC inspection. However, the tribunal ruled Care UK “did not explore any evidence that might support the claimant’s account and disbelieved her explanation”. It added: “Finding that she sent the fax deliberately and maliciously demands an explanation.” The tribunal judgment said it was Ms Jarrett’s case that “subconscious bias was in play” and found Care UK had not explained the “lack of any motive”. Employment judge Lewis said: “Whilst we accept that Mr O’Brien did not consciously discriminate against the claimant because of her race we find that the factors relied on, her demeanour, attitude, her supposed lack of remorse, are matters that demonstrate subconscious bias and are not free from the taint of race discrimination. We find that the respondent has failed to discharge the burden on it to explain the difference in treatment.” Read full story (paywalled) Source: HSJ, 15 December 2021
  8. News Article
    A trust will not face a second prosecution over the death of a baby seven days after a chaotic birth at one of its hospitals, unless new evidence emerges. Kent police had been looking into incidents at the maternity services department of East Kent Hospitals University Foundation Trust. These incidents include the death of Harry Richford, who was born at Queen Elizabeth, the Queen Mother, Hospital in November 2017. A coroner found a string of failures in his care amounted to neglect. The trust pleaded guilty to failing to meet fundamental standards of care and was fined £733,000 in a case brought by the Care Quality Commission earlier this year. But detective chief superintendent Paul Fotheringham, head of major crime at Kent Police, said: “After careful consideration and following consultation with the Crown Prosecution Service, we took the decision that a criminal investigation would not be undertaken at this time as there is no realistic prospect of conviction against any individual or organisation based on the evidence currently available." In a statement, Harry’s family said: “We are disappointed that Kent Police, in collaboration with the CPS special crime unit in London, have not been able to take forward a charge of corporate manslaughter for Harry at this time. They have assured us that they will keep an open mind on this matter, and any other appropriate charges as and when new evidence is brought before them. “We believe that the Kirkup inquiry and investigation may allow them to revisit a raft of charges on behalf of harmed babies in east Kent in due course. Only when senior leaders are properly held to account, will there be lasting change.” Read full story (paywalled) Source: HSJ, 9 December 2021
  9. News Article
    "You hear his heartbeat and the next thing you know, you've got nothing." A woman whose son was stillborn has said she wants to change the law to enable an inquest to investigate the circumstances surrounding his death. Katie Wood's son Oscar was stillborn on 29 March 2015, but under law in England and Wales, inquests for stillborn babies cannot take place. A consultation was put out by the UK government in March 2019, but the findings have yet to be published. The UK government said it would set out its response in due course, but this delay was criticised by the House of Commons justice committee in September. Katie and her family said they have never received satisfactory answers about why Oscar died. Her pregnancy, while challenging, had not given any serious cause for concern. An investigation by the Aneurin Bevan health board found a number of failings in Katie's care. A post-mortem examination suggested a condition known as shoulder dystocia, where the baby's shoulder becomes stuck during birth, may have contributed, but this is rarely fatal. The health board said it conducted a serious incident investigation into Oscar's death and added: "Whilst we seek to find answers during any investigation, in some cases, a full understanding around the cause of death may not always be achieved and we accept the unavoidable distress this may pose for families." Clinical negligence and medical law specialist, Mari Rosser, says allowing coroners to look into the reasons for a baby's death is long overdue. "Currently parents who suffer a still birth can have the circumstances investigated, but the circumstances are investigated by the health board and of course that's less independent," she said. Read full story Source: BBC News, 9 December 2021
  10. News Article
    A couple whose child died in the womb after mistakes by maternity staff have received a £2.8m settlement. Sarah Hawkins was in labour for six days before Harriet was stillborn at Nottingham City Hospital in April 2016. Hospital bosses initially found "no obvious fault", but an external inquiry identified 13 failings in care. Solicitors representing Mrs Hawkins and husband Jack said it was believed to be the largest payout for a stillbirth clinical negligence case. Mrs Hawkins was nearly 41 weeks' pregnant when Harriet was delivered, almost nine hours after dying. The couple were first told their child had died of an infection but refused to accept this and launched their own investigation. A Root Cause Analysis Investigation Report published in 2018 concluded the death was "almost certainly preventable". The report said errors included a delay in applying appropriate foetal monitoring, the important omission of information on an antenatal advice sheet and a failure to follow the Risk Management Policy for maternity. It also found failures to record or pass on information correctly, failure to follow correct guidelines and delays in administering the correct treatment. Following the report's publication, the hospital trust apologised and said major changes would be made. Read full story Source: BBC News, 6 December 2021
  11. News Article
    A doctor has accused England's health and care regulator of "moral corruption". Consultant orthopaedic surgeon Shyam Kumar says the Care Quality Commission misled the public over patient safety. Mr Kumar alleges he was unfairly dismissed from his role as a special adviser to the CQC because he acted as a whistleblower. His claims were made during an employment tribunal hearing in Manchester. Seconded by his employer, University Hospitals of Morecambe Bay NHS Foundation Trust, Mr Kumar had been giving the CQC expert advice on surgical departments during hospital inspections. But he was dismissed from this role, in early 2019. The CQC said a letter he had written to a colleague he had been in dispute with at his trust was incompatible with the standards expected of its special advisers. But Mr Kumar claims he was dismissed because, in 2018, he raised concerns with senior CQC figures that he was expected to simply rubber-stamp the final report following an under-resourced inspection. And he accused the regulator of sweeping his concerns under the carpet and providing false assurances on patient safety. Read full story Source: BBC News, 25 November 2021
  12. News Article
    One hundred people with learning disabilities and autism in England have been held in specialist hospitals for at least 20 years, the BBC has learned. The finding was made during an investigation into the case of an autistic man detained since 2001. Tony Hickmott's parents are fighting to get him housed in the community near them. Mr Hickmott's case is being heard at the Court of Protection - which makes decisions on financial or welfare matters for people who "lack mental capacity". Senior Judge Carolyn Hilder has described "egregious" delays and "glacial" progress in finding him the right care package which would enable him to live in the community. He lives in a secure Assessment and Treatment Unit (ATU) - designed to be a short-term safe space used in a crisis. It is a two-hours' drive from his family. This week, Judge Hilder lifted the anonymity order on Mr Hickmott's case - ruling it was in the public interest to let details be reported. She said he had been "detained for so long" partly down to a "lack of resources". Like many young autistic people with a learning disability, Mr Hickmott struggled as he grew into an adult. In 2001, he was sectioned under the Mental Health Act. He is now 44. In addition to the 100 patients, including Mr Hickmott, who have been held for more than 20 years - there are currently nearly 2,000 other people with learning difficulties and/or autism detained in specialist hospitals across England. In 2015, the Government promised "homes not hospitals" when it launched its Transforming Care programme in the wake of the abuse and neglect scandal uncovered by the BBC at Winterbourne View specialist hospital near Bristol. But data shows the programme has had minimal impact. Read full story Source: BBC News, 24 November 2021
  13. News Article
    An acute trust has been fined £2.5m after pleading guilty to charges of failing to provide safe care after the deaths of two patients. The Care Quality Commission brought charges against The Dudley Group Foundation Trust earlier this year over care failings in two separate cases which the regulator said exposed two patients to “significant risk of avoidable harm”. The trust pleaded guilty to the charges in July and was fined during a sentencing hearing today. The cases, involving 33-year-old mother of six Natalie Billingham, and 14-year-old Kaysie-Jane Bland [also known as Kaysie-Jayne Robinson], were both in 2018 and related to care at the trust’s Russells Hall Hospital in Dudley. Ms Billingham was admitted to Dudley’s Russells Hall Hospital with numbness in her right foot on 28 February 2018 and died on 2 March of organ failure caused by a “time critical” infection. The court was told she was initially thought to have a deep vein thrombosis after a three-minute triage that failed to identify "disordered" observations. The hospital then had multiple reasons to reconsider the initial diagnosis, but opportunities for review were "missed or ignored". In the case of Kaysie-Jane, who had cerebral palsy, an "early warning score" was inaccurate, meaning a sepsis screening tool was not triggered. The CQC said the care both patients received at Russells Hall Hospital was undermined by the Dudley Group’s failure to address known safety failings which the regulator repeatedly raised with the trust in the months before their deaths. The CQC said the trust did not take all reasonable steps to make improvements, despite its intervention. The trust has denied it did not react to the concerns raised. Failings included errors in the hospital’s initial assessments and monitoring of both patients, which hindered the timely escalation of concerns. A lawyer acting on behalf of the Dudley Group NHS Foundation Trust had admitted the trust failed to provide treatment in a safe way, resulting in harm, in February and March 2018. Read full story (paywalled) Source: HSJ, 19 November 2021
  14. News Article
    A boy who suffered "catastrophic brain injuries" when doctors failed to see he had a virus and sent him home after he had a seizure has been awarded £27m. The boy, who cannot be identified but is now 13, suffered seizures as a toddler more than a decade ago. Details of the settlement between the boy's father and Liverpool's Alder Hey Children's NHS Foundation Trust were published in a written ruling. High Court judge Mr Justice Fordham said it was a "sensible settlement". Trust bosses admitted "breach of duty" and "causation of loss and damage", the judge said. The judgment, from the hearing in Manchester, said the boy had suffered a seizure at 17 months old on 19 September 2009 and was taken to Alder Hey Children's Hospital. He suffered a second seizure in the accident and emergency department which was seen by medical staff. The boy was sent home and, despite going back to hospital, was not diagnosed with a virus until 24 September. Read full story Source: BBC News, 12 November 2021
  15. News Article
    There have been more than 30 serious security breaches at NHS hospital mortuaries in the past five years, The Independent can reveal. The figures come as local MPs demand a public inquiry into the crimes of NHS electrician David Fuller who sexually abused 100 corpses, including three children, over a period of 12 years. The calls for a full inquiry have also been backed by Labour’s shadow health secretary Jonathan Ashworth who said on Friday: “It is important the secretary of state listens to the concerns of the local MP and the families of those who have been involved, and establishes a full, swift public inquiry, so that lessons can be learned from this appalling incident and ensure this is never repeated.” Fuller, aged 67, pleaded guilty on Thursday to the murders of two women, Wendy Knell, 25, and Caroline Pierce, 20, in two separate attacks in Tunbridge Wells, Kent, in 1987. Detectives searching Fuller’s home found four million images of sexual abuse he had downloaded from the internet on computer hard drives. They also found footage he had filmed of himself carrying out attacks on the bodies of women at the now-closed Kent and Sussex Hospital and the Tunbridge Wells Hospital, where he had worked since 1989. Read full story Source: The Independent, 5 November 2021
  16. News Article
    The High Court in Canberra, Australia, has ruled against big pharma giants Johnson and Johnson's application to appeal the Federal Court’s decision in favour of the survivors of their defective medical devices in November 2019. This means the decision of the Full Federal Court, in favour of the Lead Applicant and group members, will stand. Shine Lawyers', which has led the class action, has launched further actions against American Medical Systems (AMS), another manufacturer of mesh and tape implants supplied in Australia. The AMS implants, which are used to treat pelvic organ prolapse and stress urinary incontinence, have left many Australian women with severe complications. The legal group has also moved against Boston Scientific for defective vaginal mesh and sling implants received by women in Australia and opened a second Ethicon / Johnson & Johnson’s on behalf of women implanted with a defective mesh product on or after 4 July 2017. The class actions were filed in the Federal court and MIA believe other class actions, including hernia mesh, are underway. Kath Sansom, founder of the Sling the Mesh campaign, said "Brilliant news from Australia! Johnson & Johnson Loses High Court Appeal against the pelvic mesh verdict of 2019. This means J&J can no longer appeal the verdict! I realise compensation may still take time to be awarded to the 10,000+ mesh injured but at least the appeals are over! Congratulations to all the Australian mesh campaigners!" Read press release
  17. News Article
    Trusts are still spending at least £1m a year on settlement agreements with staff containing ‘gagging clauses’ despite a crackdown on these conditions in recent years, HSJ research reveals. Freedom of information responses reveal 214 settlement agreements with confidentiality conditions worth £4.6m across three years NDAs — which are also known as “confidentiality clauses” or “gagging clauses” and prevent parties to a settlement agreement from disclosing its details — also seem to be becoming less popular. HSJ’s FOIs revealed 119 settlement agreements with an NDA with a total value of £2.16m, in 2018-19. In 2019-20, this fell to 87 such agreements with a total value of £1.5m. In 2020-21, there were 41 settlement agreements with such a clause, with a total value of £1.04m. A source with knowledge of confidentiality agreements in the NHS said: “Following some high-profile whistleblowing cases a few years ago… NHS organisations have been far more cautious in imposing confidentiality obligations in settlement agreements.” Numerous health secretaries have issued warnings about NDAs potentially being used to silence staff. In 2019, former health and social care secretary Matt Hancock said: “Settlement agreements that infringe on an individual’s right to speak out for the benefit of patients are completely inappropriate.” In 2013, then health secretary Jeremy Hunt said he would ban clauses in compromise agreements — as settlement agreements were then known — preventing NHS staff from raising patient safety concerns. After the Mid Staffordshire report was published, he wrote to all trust chairs, asking them to review the confidentiality clauses they were using. Read full story (paywalled) Source: HSJ, 1 November 2021
  18. News Article
    A mental health trust ‘scapegoated’ a psychiatrist over the death of a patient amid systemic issues, an employment tribunal has found. Judges called the conduct of two senior directors — one of whom is a current NHS trust medical director — into question after ruling they had colluded to scapegoat Bernadette McInerney for issues that would have damaged the trust’s reputation. Nottinghamshire Healthcare Foundation Trust was found unanimously to have unfairly sacked and victimised Dr McInerney, a former consultant forensic psychiatrist at Rampton secure hospital, in a decision published last week. The judgement was critical of both Chris Packham, a GP at Rampton hospital, and NHFT’s then-executive medical director Julie Hankin, but it also strongly condemned the trust’s former executive director for forensic services Peter Wright. Dr Hankin is now medical director at Cambridgeshire and Peterborough FT. Read full article here (paywalled) Original source: Health Service Journal
  19. News Article
    A hospital for men with learning disabilities has been placed in special measures after the Care Quality Commission (CQC) identified “serious risks to patient safety”. The CQC said it had also suspended its current rating of “good” for caring for Cygnet Woodside, Bradford, West Yorkshire, following an inspection in September. The commission said it carried out the unannounced inspection following allegations of abuse by staff towards a patient, which are subject to an ongoing police investigation. The hospital said it was “disappointed” with the CQC’s assessment, stressing that the inspection was triggered by its own management notifying the commission of a concern it had identified. It said the report “does not provide an entirely accurate representation” of the hospital. Dr Kevin Cleary, the CQC deputy chief inspector of hospitals and lead for mental health, said: “Our latest inspection of Cygnet Woodside found that the hospital was not ensuring its patients’ safety.” Cleary added: “The service showed warning signs that increased the likelihood of a closed culture developing. This would have put people at serious risk of coming to harm if we didn’t take action.” He said care was compromised because there was not always the right number or skill level of staff looking after patients. Read full story Source: Guardian, 23 December 2020
  20. 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
  21. News Article
    Mistakes by Great Ormond Street contributed to the death of a five-year-old boy, the children’s hospital has admitted – just months after it concluded a legal case with his family in which it denied responsibility. The world-renowned children’s hospital failed to flag results of a crucial blood test, showing that Walif Yafi had a dangerous infection, to doctors at King’s College Hospital where he had been receiving treatment. He died a few weeks later, in September 2017. In September this year, Walif’s parents agreed an out-of-court settlement with Great Ormond Street, which admitted negligence but denied liability for the boy’s death. However, this week the hospital admitted an expert had reviewed the case ahead of the settlement and concluded its actions did contribute to Walif’s death. The hospital said it had been under no duty to share these results with Walif’s parents at the time. Walif had a liver transplant in 2012 after suffering cancer shortly after his birth, and was being overseen by Great Ormond Street as an outpatient, as well as by the transplant team at King’s College Hospital, in south London. On 24 August 2017, he had a routine blood test at Great Ormond Street, which showed he had an adenovirus infection – something that is common in children whose immune system is being suppressed by drugs, as Walif’s was because of his transplant. If untreated, the infection can be deadly. But the blood test result was not communicated to the team at King’s College Hospital. Shortly afterwards, Walif’s health deteriorated and he was admitted to hospital. He was transferred to King’s College Hospital a week later, and it was not until 7 September that the infection was confirmed. By this stage, he was severely unwell and, though he began anti-viral therapy, Walif suffered multiple organ failure from the spread of the infection. On 30 September, he suffered cardiac arrest and died. It was only when approached by The Independent this week that the trust revealed its expert had, in the course of negotiating the settlement with Walif’s parents, determined the hospital did materially contribute to the child’s death. Read full story Source: The Independent, 29 November 2020
  22. 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
  23. 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
  24. News Article
    A woman has been arrested after attempting to take her 97-year-old mother out of a care home for lockdown. Qualified nurse Ylenia Angeli, 73, wanted to care for her mother, who has dementia, at home. But when she told staff at the care home, they called the police who then briefly arrested Ms Angeli. The family have not been able to see their elderly relative for nine months, and decided to act ahead of the second national lockdown. Assistant Chief Constable Chris Noble, from Humberside Police, said: "These are incredibly difficult circumstances and we sympathise with all families who are in this position." "We responded to a report of an assault at the care home, who are legally responsible for the woman's care and were concerned for her wellbeing. We understand that this is an emotional and difficult situation for all those involved and will continue to provide whatever support we can to both parties." The incident came to light on the day the government announced new rules for families wishing to visit their loved ones in care homes. Under the guidance, issued hours before lockdown, families can meet relatives through a window or in a secure outdoor setting. Visits will need to be booked in advance, but the Department of Health and Social Care advice said care homes "will be encouraged and supported to provide safe visiting opportunities". All care home residents are allowed to receive visits from friends and family during the second national lockdown. Read full story Source: Sky News, 5 November 2020
  25. News Article
    A major acute trust has confirmed the health service inspectorate has begun a criminal investigation into three incidents at its hospitals. University Hospitals Birmingham FT told HSJ the Care Quality Commission (CQC) has started a criminal investigation into incidents involving potential errors around the provision of anti-coagulant medication. The trust received a letter from the CQC this month informing it that the regulator has begun the investigation under regulation 22 of the Health and Social Care Act 2008 (regulated activities) regulations 2014. The incidents happened at Queen Elizabeth Hospital in Birmingham and Good Hope Hospital — the trust’s two main sites. Regulation 22 says: “In order to safeguard the health, safety and welfare of service users, the registered person must take appropriate steps to ensure that, at all times, there are sufficient numbers of suitably qualified, skilled and experienced persons employed for the purposes of carrying on the regulated activity.” The CQC launched a prosecution into East Kent Hospitals University FT this month for failing to meet fundamental standards of care. The regulator also successfully prosecuted University Hospitals Plymouth Trust in September after it pleaded guilty to breaching the duty of candour. Read full story (paywalled) Source: HSJ, 23 October 2020
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