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Content ArticleThe important issue of a patient’s right to a second medical opinion has recently hit the headlines with Martha’s Rule, which relates to the tragic death of 13-year-old Martha Mills in NHS care and the circumstances surrounding this. There is a groundswell of support for Martha’s Rule, with Health and Social Care Secretary Steve Barclay committed to introducing the rule in England. This is excellent news, but development and implementation must not be rushed writes John Tingle, Dr Dita Wickins-Drazilova and Steve Gulati from the University of Birmingham.
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Content ArticleIn this webinar recording, Alex RK, a barrister, writer and educator, takes stock of the mental capacity and mental health law and policy landscape as at August 2023. It primarily focuses on England & Wales, but also includes developments in the UK and further afield, including thinking about the implications of the French language version of Article 19 CRPD providing not for ‘living independently’, but ‘autonomie de vie’.
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News ArticleA not-for-profit health system in Maine has threatened legal action against a 15-year-old boy for shedding light on alleged patient safety issues in the paediatric ward of one of its hospitals. Samson Cournane, a student at the University of Maine, started a petition (Patient Safety in Maine Matters) advocating for an investigation into Northern Light Eastern Maine Medical Center last year, claiming conditions at the hospital were unsafe. Mr Cournane’s mother, Dr Anne Yered, had previously been fired from the hospital after reportedly voicing safety concerns to the hospital’s CEO and president in 2020. In the petition, Mr Cournane said his mother was threatened by hospital staff after raising concerns, with one hospital manager going so far as to show up in her backyard to confront her. Dr Yered subsequently claimed she was wrongfully terminated. Mr Cournane then began pushing for an investigation into the hospital, outlining problems in the petition, which was addressed to US Representative Jared Golden. He alleged that the medical director of the paediatric intensive care unit (ICU) — a former colleague of his mother’s — finished just one year of a three-year critical care fellowship, and implied other hospital employees may be scared to come forward with safety concerns. Read full story Source: The Independent, 4 September 2023
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Content ArticleMost US healthcare organisations use staffing guidelines to decide a nurse's patient load on a given shift, but current staffing shortages are pushing nurse-to-patient ratios to the limit. In this article for Nurse Journal, registered nurse Alexa Davidson asks whether laws and regulations could prevent nursing workloads from getting out of control. She argues that mandated staffing ratios are a proven way to ensure patient safety. She describes the situation in Massachusetts and California, the two US states where laws have been passed mandating nurse-to-patient ratios, and outlines the implications of introducing ratios for nurses and patients.
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News Article
Nine out of 10 beauty clinics breaking the law by advertising Botox
Patient Safety Learning posted a news article in News
Nine in 10 beauty clinics are breaking the law by advertising Botox, new research reveals, sparking fresh concern that Britain’s booming £3.6bn cosmetic treatments industry is like the “wild west”. Academics at University College London (UCL) found 88% clinics in London are flouting regulations intended to protect public health banning the advertising of Botox and other forms of botulinum toxin. The disclosure prompted warnings the illegal advertisements could help persuade vulnerable people to undergo injections that could leave them feeling traumatised. Promotion of the anti-ageing substance is illegal because it is a prescription-only medicine, which cannot be advertised under the Human Medicines Regulations 2012. A group of beauty professionals who are seeking to rid the industry of its reputation for dubious practices said the findings showed consumers were being subjected to “a tsunami of untamed and unrestricted promotional activity that presents a threat to public protection and patient safety”. Read full story Source: The Guardian, 14 April 2023 -
Content ArticleIn rare cases, healthcare providers who have contributed to accidental patient harm may be criminally prosecuted to obtain justice for the patient and family or to set an example, which theoretically prevents other providers from making similar mistakes due to fear of punishment. This strategy was chosen in the recent case of RaDonda Vaught, who was convicted of criminally negligent homicide and impaired adult abuse after a medication error killed a patient in 2017. This article in the journal Human Factors in Healthcare discusses the case and its ramifications for healthcare staff and systems. The authors provide recommendations for actions that healthcare organisations should take to foster a safer and more resilient healthcare system, including: placing an emphasis on just culture. ensuring timely, systems-level investigations of all incidents. refining and bolstering participation in national reporting systems. incorporating Human Factors professionals at multiple levels of organisations. establishing a national safety board for medicine in the US.
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News Article
NHS ombudsman calls for Martha's rule to give power to patients
Patient Safety Learning posted a news article in News
Top boss of NHS complaints in England has told the BBC he wants Martha's rule to be introduced to give patients the power to get an automatic second medical opinion about hospital care, when they think things are going wrong. Rob Behrens said he had been moved by the plea of Merope Mills, who shared the story of her daughter's death. Martha was 13 when she died from sepsis. Merope Mills wants hospitals around the country to bring in Martha's rule, which would give parents, carers and patients the right to call for an urgent second clinical opinion from other experts at the same hospital, if they have concerns about their current care. It is something that Parliamentary and Health Service Ombudsman Rob Behrens fully supports. He told BBC Radio 4's Today programme: "Along with many others, I was moved and in great admiration for what Merope has said and done and I give unambiguous support. "Unfortunately, as tragic as this case is, it's not the first and there have been many cases where patients have been failed by their doctors because they haven't been listened to." Read full story Source: BBC News, 5 September 2023 -
News Article
Hundreds of UK women can now take legal action over Essure device
Patient Safety Learning posted a news article in News
Two hundred women in the UK who claim they were left in pain after having a permanent contraception device fitted, can now take group legal action through the courts, against its manufacturer. The Essure coil "has caused irreparable damage physically and mentally", the women's lawyers say. German maker Bayer says it will defend itself vigorously against the claims. When Essure was withdrawn from sale, in 2017, the UK medicines regulator said there was no risk to safety. Lawyers in England began legal action in 2020 and now have permission to bring a group claim on behalf of 200 women. Other women wishing to join the group action have until 2024 to do so. The Essure device is a small metal coil inserted into a woman's fallopian tubes. Scar tissue forms around the coil, creating a barrier that keeps sperm from reaching the eggs. Launched in 2002, the device was marketed as a simpler alternative to sterilisation by surgery. But some women say they suffered constant pain and complications, including heavy bleeding, with some ending up having hysterectomies or the device removed altogether. Read full story Source: BBC News, 5 September 2023 -
News ArticleA Bristol woman says her life has 'never been the same' since receiving unnecessary operations on her bowel more than ten years ago. Following a recent review, Mandy Giltrow is one of more than 200 patients who received a mesh bowel procedure - which she says may not have been needed. The operations were all conducted by surgeon Tony Dixon who has been sacked by the North Bristol NHS Trust. Mandy Giltrow underwent a mesh bowel procedure which was performed by Mr Dixon at Frenchay Hospital in April 2011. Following the surgery her symptoms continued. Following follow up appointments Mandy, a mum-of-four, underwent a further procedure in April 2013. Mr Dixon carried out a further operation in October 2014 at Spire Bristol to replace mesh. However Mandy, who is 49 and lives in Staple Hill, continues to suffer issues including stomach and bowel pain as well as recurrent water infections. She also has a hernia near her surgery scars. North Bristol NHS Trust has since admitted liability. Mandy told ITV West Country: "I got anxiety for all the different operations I had and then I physically could not do anything. I was stuck for three months in a bubble." "I couldn't go out, I couldn't do anything with my children not even take them to school." Mandy says her mental health was badly affected by the operations leading to a nervous breakdown and agoraphobia, meaning she could not lead the house. "You have an operation. It doesn't resolve the original problem and now you have another problem which is twice as bad." Read full story Source: ITV, 30 May 2022
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News Article
'I will never be the same': RaDonda Vaught speaks out after sentencing
Patient Safety Learning posted a news article in News
RaDonda Vaught has spoken out about her criminal case for the first time last week in an exclusive interview with ABC News. Ms. Vaught, 38, was sentenced to three years of supervised probation on 13 May. She was convicted of criminally negligent homicide and abuse of an impaired adult for a fatal medication error she made in December 2017 after overriding an electronic medical cabinet as a nurse at Vanderbilt University Medical Center in Nashville, Tenn. The error, in which vecuronium, a powerful paralyser, was administered instead of the sedative Versed, led to the death of 75-year-old Charlene Murphey. "I will never be the same person," Ms. Vaught told ABC News, "It's really hard to be happy about something without immediately feeling guilty. She could still be alive, with her family. Even with all the system errors, the nurse is the last to check." Ms. Vaught immediately took responsibility for the medication error after it occurred but contends that her actions alone did not cause the error. Her case has spurred an outcry from nurses across the country, many of whom have expressed concerns about the likelihood of similar mistakes under increasingly difficult working conditions. "So many things had to line up incorrectly for this error to have happened, and my actions were not alone in that," Ms. Vaught said. When Ms. Pilgrim asked her if she felt like a scapegoat, Ms. Vaught said, "I think the whole world feels like I was a scapegoat." "There's a fine line between blame and responsibility, and in healthcare, we don't blame," she said. "I'm responsible for what I failed to do. Vanderbilt is responsible for what they failed to do." Read full story Source: Becker's Hospital Review, 23 May 2022 -
News Article
NHS ambulance service doctored documents to cover up truth about deaths
Patient Safety Learning posted a news article in News
Quinn Evie Beadle died in 2018. Her parents later found out that the “kind, caring” 17-year-old had been failed by a paramedic at the scene of her death — and that the ambulance service altered documents to try to stop them finding out the truth. The teenager, who dreamt of becoming a medic but suffered poor mental health, was found after she hanged herself near her home in Shildon, Co Durham, on the evening of 9 December 2018. The paramedic who attended the scene made basic mistakes, and made no effort to clear her airway or continue with basic life support — despite the fact her heart was still active. But instead of attempting to learn lessons, bosses at the North East Ambulance Trust (NEAS) set out to prevent the family learning what happened. They changed a key witness statement given to the coroner at her first inquest, removing references to mistakes the paramedic had made and inserting the claim that any life support offered would “not have had a positive outcome”. They also withheld from the coroner a key piece of evidence — a reading from a heart monitor — which demonstrated Quinn’s heart activity. It is thought Quinn’s death could be one of more than 90 cases in the past three years in which the NEAS failed to provide families with the whole truth about how their relatives died. Senior managers repeatedly withheld key evidence from coroners about deaths linked to service failures, an internal report shows. In some cases, bosses doctored or suppressed evidence to cover up failures by staff. An independent report into a small number of the cases, including Quinn’s, raised by whistleblowers found that, as in her case, statements were changed or suppressed and pieces of key evidence not disclosed. Read full story (paywalled) Source: The Sunday Times, 22 May 2022 -
News Article
Shrewsbury and Telford NHS Trust admits failures after two patients die
Patient Safety Learning posted a news article in News
A hospital trust has pleaded guilty to failures in care that contributed to the deaths of two patients. One of the charges related to the death of patient Mohammed Ismael Zaman in 2019 at the Royal Shrewsbury Hospital. The 31-year-old died of severe blood loss while undergoing dialysis, Telford Magistrates' Court heard. Max Dingle, in his 80s, died after his head became trapped between a mattress and bed rail while he was being treated at the Royal Shrewsbury Hospital. Shrewsbury and Telford Hospital NHS Trust (SaTH) admitted three counts of failing to provide treatment and care in a safe way, resulting in harm or loss, between October 2019 and May 2020. Representing the CQC, Ryan Donoghue said the failures in Mr Zaman's care "were the legal cause of his death, for which the trust is responsible". He said Mr Dingle, who had been admitted with chronic lung disease, died from a cardiac arrest after he was freed. "The basis [of the guilty plea] is that the failures exposed him to a significant risk of avoidable harm," Mr Donoghue said. As well as the two deaths, the CQC accused the trust of exposing other patients to significant risk of avoidable harm. Read full story Source: BBC News, 18 May 2022 -
News ArticleRaDonda Vaught was sentenced to three years of supervised probation on the 13 May for a fatal medication error she made in 2017 while working as a nurse at the Vanderbilt University Medical Center in the USA. In remarks made during the sentencing hearing, Ms. Vaught expressed concerns over what her case means for clinicians and patient safety reporting. "This sentencing is bound to have an effect on how [nurses] proceed both in reporting medical errors, medication errors, raising concerns if they see something they feel needs to be brought to someone's attention," she said. "I worry this is going to have a deep impact on patient safety." Numerous medical organisations expressed similar concerns in statements circulated after Ms. Vaught's sentencing. "To achieve our goal of zero patient harm and death from preventable medical errors, we need to foster a culture where leadership of hospitals and healthcare organizations support healthcare workers and encourage them to share near misses," the Patient Safety Movement Foundation said in a statement. "Healthcare workers are human and healthcare systems need to ensure there are appropriate processes in place to provide their staff with a safe and reliable working environment so they can provide their patients with the best care. Only by identifying potential problems and learning from them can change occur." Read full story Source: Becker's Hospital Review, 16 May 2022
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News Article
Nurses take to streets ahead of RaDonda Vaught sentencing
Patient Safety Learning posted a news article in News
Nurses from across the country are heading to Washington, D.C., and Nashville, Tenn., this week to march for better working conditions and to show support for nurse RaDonda Vaught. Ms. Vaught, 38, was convicted of criminally negligent homicide and abuse of an impaired adult for a fatal medication error she made in December 2017 after overriding an electronic medical cabinet as a nurse at Vanderbilt University Medical Center in Nashville. Her case has spurred a national outcry from nurses who argue the ruling sets a dangerous precedent for the profession and will discourage nurses from speaking up about errors. Ms. Vaught's sentencing is scheduled for 13 May in Nashville, and she faces up to eight years in prison. Hundreds of nurses are planning to march in Nashville the day of the hearing to show their support for Ms. Vaught and to fight for better protection for nurses against criminal prosecution of errors. "We expect a large number of people to show up … just to show our strength in numbers and hope that the judge takes this into consideration and makes it slightly better by not sentencing her to any prison time," said Erica, a Las Vegas-based hospice nurse who is attending the sentencing. Read full story Source: Becker's Hospital Review, 13 May 2022 -
News Article
Medical director wins 'whistle blowing' unfair dismissal case
Patient Safety Learning posted a news article in News
A former medical director on the Isle of Man, who lost her job when she questioned decisions made on the island during the COVID-19 pandemic, has won her case for unfair dismissal at an employment tribunal. The hearing, which began in January, heard how Dr Rosalind Ranson was victimised and dismissed from her role after making 'protected disclosures' as part of her efforts to persuade the Manx Government to deviate from Public Health England (PHE) advice in the early stages of the pandemic. Dr Ranson, who had extensive experience as a GP and as a senior medical leader in the NHS in England, was appointed to her post as the island's most senior doctor in January 2020 with the aim of tackling what she identified as a disillusioned medical workforce, failings in management, and a bullying culture. She was soon called on to provide expert medical advice and guidance on how the Isle of Man’s health system should respond to the spread of COVID-19. In March, Dr Ranson channelled concerns from the island's doctors that the advice from PHE was flawed, and that a more robust approach should be taken to stem the spread of SARS-CoV-2. That included closing the island’s borders – a move that was initially ignored. Dr Ranson became concerned that her medical advice was not being heeded and that it might not be being passed on to ministers by the then Chief Executive of the Isle of Man’s Department of Health and Social Care (DHSC), Kathryn Magson, who was not medically qualified. The tribunal heard that because Dr Ranson had "blown the whistle" when she spoke out, she was sidelined and eventually dismissed unfairly. Read full story Source: Medscape, 11 May 2022 -
News Article
Covid inquiry broadens scope to include children
Patient Safety Learning posted a news article in News
The scope of the UK public inquiry into the handling of the Covid pandemic has widened to include a focus on children. When the draft terms were published in March, there was criticism that they failed to even mention the impact on children and young people. But after a public consultation, the final terms have been published and now incorporate the effect on the health, wellbeing and education of children. The final terms of reference were decided following a four-week public consultation on the draft terms. As well as expanding the terms to include the impact on the health, wellbeing and education of children and young people, the inquiry will also look at the wider mental health impact across the population. The focus on inequalities will also be strengthened, the inquiry said, so that the unequal impact on different sections of society will be considered at all stages. Alongside these issues, the UK-wide inquiry will also look at the following issues which were included originally: the UK's preparedness for the pandemic the use of lockdowns and other "non-pharmaceutical" interventions, such as social distancing and the use of face coverings the management of the pandemic in hospitals and care homes the procurement and provision of equipment like personal protective equipment and ventilators support for businesses and jobs, including the furlough scheme, as well as benefits and sick pay. Read full story Source: BBC News, 12 May 2022 -
News Article
Senegal midwives convicted over mother's death
Patient Safety Learning posted a news article in News
Three Senegalese midwives involved in the death of a woman in labour have been found guilty of not assisting someone in danger. They received six-month suspended sentences, after Astou Sokhna died while reportedly begging for a Caesarean. Her unborn child also died. Three other midwives who were also on trial were not found guilty The case caused a national outcry with President Macky Sall ordering an investigation. Mrs Sokhna was in her 30s when she passed away at a hospital in the northern town of Louga. During her reported 20-hour labour ordeal, her pleas to doctors to carry out a Caesarean were ignored because it had not been planned in advance, local media reported. The hospital even threatened to send her away if she kept insisting on the procedure, according to the press reports. Her husband, Modou Mboup, who was in court, told the AFP news agency that bringing the case to light was necessary. "We highlighted something that all Senegalese deplore about their hospitals," "If we stand idly by, there could be other Astou Sokhnas. We have to stand up so that something like this doesn't happen again." Read full story Source: BBC News, 11 May 2022 -
News Article
When the NHS spends billions on personal injury cases, it’s the public that loses
Patient Safety Learning posted a news article in News
Hunt’s radical plan to reform compensation for clinical negligence is “completely unacceptable” says the Association of Personal Injury Lawyers, which includes some of the kinds of firms that urge people to sue the NHS, soliciting online, in TV ads or posters in waiting rooms. Damages paid by the NHS as a result of medical negligence claims have soared exponentially over the last decade, up from £900m to £2.2bn now. Yet despite horror stories of deaths and life-changing damage in badly run maternity wards, the National Audit Office (NAO) finds no evidence of more injuries, only that the number of claims and sums awarded by courts are shooting up. The NAO found that “the claimant’s legal costs exceeded the damages awarded in 61% of claims settled”. Though the lawyers in the clinical compensation business protest vigorously that they defend patients’ rights, the Hunt committee demolishes any justification for the present system. The report quotes Sir Ian Kennedy QC, the chair of many inquiries and emeritus professor of health law and ethics at University College London, who wrote in 2021 that clinical negligence was an “outdated, arbitrary and scandalously expensive system” with a “stranglehold that lawyers exert over a system that should be putting the interests and needs of patients first”. What injured patients need is an independent authority to conduct a speedy and transparent investigation of what went wrong, with everyone free to speak openly, ending in reasonable compensation and a pledge to prevent anyone else being put at risk by the same error. Peter Walsh, the chief executive of Action Against Medical Accidents, told the committee that litigation was often “a last-gasp attempt to get a sense of justice and to get to the bottom of what has actually happened after people have experienced denial after denial”. Instead of a system of delays and denials that frustrates grieving families and terrorises doctors as lawyers seek to pin personal blame on someone, the committee proposes a system closer to those used in New Zealand and Scandinavia. An independent administrative body would investigate a patient’s case to see if the harm done was avoidable and if so, to fix fair compensation briskly within six months. The priority would be openness and learning from mistakes to protect future patients. Not needing to find a person to blame makes it easier for patients to get compensation – but the payout would be far lower. Some warn this lower burden of proof would encourage a flood of claims, but New Zealand found a similar system ended up halving the sums paid out. Read full story Source: The Guardian, 3 May 2022 -
News Article
US Supreme Court may overturn abortion law, leak suggests
Patient Safety Learning posted a news article in News
The US Supreme Court could be about to overturn the nationwide legal right to abortion, according to an unprecedented leaked draft of a court document. In a 98-page draft opinion, Justice Samuel Alito writes that the 1973 Roe v Wade decision legalising abortion across the US is "egregiously wrong". If the top US court strikes down the ruling, "trigger laws" could instantly make abortion illegal in 22 US states. The justices are not expected to issue a ruling until early July. It sparked immediate outcry from Democrats, and protests - by both pro and anti-abortion supporters - outside the Supreme Court on Monday night. Speaker of the House of Representatives Nancy Pelosi and Senate Majority Leader Chuck Schumer - both Democrats - issued a joint statement saying that if the report was accurate, the "Supreme Court is poised to inflict the greatest restriction of rights in the past 50 years". News outlet Politico published the leaked document in full, quoting Justice Alito as saying: "Roe was egregiously wrong from the start. Its reasoning was exceptionally weak, and the decision has had damaging consequences. "And far from bringing about a national settlement of the abortion issue, Roe and Casey have enflamed debate and deepened division." Read full story Source: BBC News, 3 May 2022 -
News Article
Covid: Discharging hospital patients to care homes 'unlawful'
Patient Safety Learning posted a news article in News
Government policies on discharging untested patients from hospital to care homes in England at the start of the Covid pandemic have been ruled unlawful by the High Court. The ruling comes after two women took former Health Secretary Matt Hancock and Public Health England to court. Dr Cathy Gardner and Fay Harris said it had caused a "shocking death toll". Prime Minister Boris Johnson renewed his apologies for all those who lost loved ones during the pandemic. Dr Gardner and Ms Harris partially succeeded in claims against Mr Hancock and Public Health England. The women claimed key policies of discharging patients from hospitals into care homes were implemented with no testing and no suitable isolation arrangements in the homes. A barrister representing Dr Gardner and Ms Harris told the court at a hearing in March that more than 20,000 elderly or disabled care home residents died from Covid between March and June 2020 in England and Wales. Jason Coppel QC also said in a written case outline for the judicial review that the care home population was known to be "uniquely vulnerable" to Covid. "The government's failure to protect it, and positive steps taken by the government which introduced Covid-19 infection into care homes, represent one of the most egregious and devastating policy failures in the modern era," he added. Read full story Source: BBC News, 27 April 2022 -
News Article
US doctor accused of killing 14 patients found not guilty
Patient Safety Learning posted a news article in News
In an unprecedented murder case in the United States about end-of-life care, a physician accused of killing 14 critically ill patients with opioid overdoses in a Columbus, Ohio hospital ICU over a period of 4 years was found not guilty by a jury Wednesday. The jury, after a 7-week trial featuring more than 50 witnesses in the Franklin County Court of Common Pleas, declared William Huse not guilty on 14 counts of murder and attempted murder. In a news conference after the verdict was announced, lead defense attorney Jose Baez said Husel, whom he called a "great doctor," hopes to practice medicine again in the future. The verdict, he argued, offers an encouraging sign that physicians and other providers won't face prosecution for providing "comfort care" to patients suffering pain. "They don't need to be looking over their shoulders worrying about whether they'll get charged with crimes," he said. The trial raised the specific issue of what constitutes a medically justifiable dose of opioid painkillers during the end-of-life procedure known as palliative extubation, in which critically ill patients are withdrawn from the ventilator when they are expected to die. Under medicine's so-called double-effect principle, physicians must weigh the benefits and risks of ordering potentially lethal doses of painkillers and sedatives to provide comfort care for critically ill patients. To many observers, however, the case really centered on the largely hidden debate over whether it's acceptable to hasten the deaths of dying patients who haven't chosen that path. That's called euthanasia, which is illegal in the United States. In contrast, 10 states plus the District of Columbia allow physicians to prescribe lethal drugs to terminally ill, mentally competent adults who can self-administer them. That's called medical aid in dying, or physician-assisted dying or suicide. Read full story Source: Medscape, 27 April 2022 -
News Article
Johnson & Johnson ordered to pay $302M in pelvic mesh case
Patient Safety Learning posted a news article in News
A California appeals court has upheld a lower court ruling that Johnson & Johnson must pay penalties to the state for deceptively marketing pelvic mesh implants for women, but reduced the amount by $42 million to $302 million. Johnson & Johnson had appealed in 2020 after Superior Court Judge Eddie Sturgeon assessed the $344 million in penalties against Johnson & Johnson subsidiary Ethicon. Sturgeon found after a non-jury trial that the company made misleading and potentially harmful statements in hundreds of thousands of advertisements and instructional brochures for nearly two decades. The instructions for use in all of the company’s pelvic mesh implant packages "falsified or omitted the full range, severity, duration, and cause of complications associated with Ethicon’s pelvic mesh products, as well as the potential irreversibility and catastrophic consequences," Presiding Justice Judith McConnell of the appeals court said in a 3-0 ruling upholding the $302 million in penalties. The products, also called transvaginal mesh, are synthetic and surgically implanted through the vagina of women whose pelvic organs have sagged or who suffered from stress urinary incontinence when they cough, sneeze or lift heavy objects. Many women have sued the New Jersey-based company alleging that the mesh caused severe pain, bleeding, infections, discomfort during intercourse and the need for removal surgery. Read full story Source: Fox News, 12 April 2022 -
News Article
Trust board backs medical director who wrongly dismissed whistleblower
Patient Safety Learning posted a news article in News
A trust board has backed the medical director who oversaw the dismissal of a whistleblower in a case linked to patient deaths. Portsmouth Hospitals University Trust told HSJ John Knighton had the full support of the organisation when asked if he faced any censure over the wrongful dismissal of a consultant who raised the alarm about a surgical technique. Jasna Macanovic last month won her employment tribunal against the trust with the judge calling its conduct “very one-sided, reflecting a determination to remove [her] as the source of the problem”. The judgment found that the disciplinary process Dr Knighton oversaw was “a foregone conclusion” and as such had broken employment rules. The nephrologist was twice offered the opportunity to resign with a good reference, once during her disciplinary hearing and again on the day the outcome of that hearing was delivered. The trust told HSJ nothing in the judgment suggested Dr Knighton should face any action about his conduct and none had been taken. It said there were no reasons to doubt his credibility or probity. The trust did not respond when asked if any apology had been offered to Dr Macanovic. A spokesperson said: “We are committed to supporting colleagues raising concerns, so they are treated fairly with compassion and respect.” Read full story (paywalled) Source: HSJ, 13 April 2022 -
News Article
NHS whistleblowers still face consequences
Patient Safety Learning posted a news article in News
Criticism of NHS managers over the treatment of whistleblowers has been reignited by Donna Ockenden’s damning review of maternity services at Shrewsbury and Telford Hospital Trust. Her findings come seven years after the “Freedom to speak up?” report from Sir Robert Francis QC, which found that NHS staff feared repercussions if they blew the whistle on poor practice. He recommended reforms to change the culture and support whistleblowers. The Public Interest Disclosure Act 1998 makes it unlawful to subject workers to negative treatment or dismiss them because they have raised a whistleblowing concern, known as a “protected disclosure”. But critics say little has changed since the Francis review. According to Protect, a whistleblowing charity, 64% of those contacting it for advice said that they had been victimised, dismissed or forced to resign. Shazia Khan, founding partner at Cole Khan Solicitors, says that instead of being afforded protection, whistleblowers are “targeted as a form of retaliation by trust senior management and disciplined on trumped up charges to shut them down”. Those seeking to vindicate their rights before an employment tribunal, Khan adds, will often be “priced out of justice” by well-resourced NHS trust lawyers who at public expense “deploy a menu of tactics” to defend cases. When Peter Duffy, a consultant urologist at University Hospitals of Morecambe Bay Foundation NHS Trust, reported on allegedly unsafe practices by colleagues in 2016, he was demoted, falsely accused of financial irregularities, and threatened with a six-figure adverse costs order by Capsticks, the hospital’s law firm. “All my witnesses dropped out after the medical hierarchy told them that the department might be dissolved if the case went badly,” Duffy says, which meant there was no one to rebut the trust’s evidence. Read full story (paywalled) Source: The Times, 7 April 2022 -
News ArticleOn 25 March2022, a Tennessee jury convicted RaDonda Vaught, a nurse at Vanderbilt University Medical Center, of criminally negligent homicide and impaired adult abuse in a 2017 medication administration error that tragically resulted in a patient death. The Washington State Nurses Association have issued a joint statement adamantly opposed to criminalization of patient care errors. "Focusing on blame and punishment solves nothing. It can only discourage reporting and drive errors underground. It not only undermines patient safety; it fosters an environment of fear and lack of respect for health care workers." "The Vaught case has drawn intense national attention and concern. We join with health care workers and patient safety experts around the country and the world in rejecting the criminalization of medical errors. Further, we are committed to redoubling our efforts to achieve health care environments that are safe for patients and health care workers alike. This includes the ongoing, critical fight to achieve safe staffing standards in Washington state." Read full statement Source: Washington State Nurses Association, 8 April 2022
