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Found 575 results
  1. News Article
    There is a "moral case" for compensation to be paid to people affected by the contaminated blood scandal, the government has said. But Paymaster General Jeremy Quin told MPs he could not commit to a timetable. In August, the government announced that 4,000 UK victims would receive interim payments of £100,000. Tens of thousands of people contracted HIV or hepatitis C in the 1970s and 80s after being given infected blood. In September, modelling by a group of academics commissioned by the public inquiry estimated that 26,800 people were infected after being given contaminated transfusions between 1970 and 1991. The study calculated that 1,820 of those died as a result, but that the number could be as high as 3,320. The inquiry, chaired by retired High Court judge Sir Brian Langstaff, began taking evidence in 2018. The interim compensation announcement in August came after Sir Brian argued there was a compelling case to make payments quickly - saying victims were on borrowed time because of their failing health. Payments have been made to those whose health is failing after developing hepatitis C and HIV, and partners of people who have died. But families have complained that many people affected, such as bereaved parents, missed out. Read full story Source: BBC News, 15 December 2022
  2. Content Article
    In this editorial. Peter Walsh reflects on 20 years as Chief Executive of Action against Medical Accidents (AVMA) as he retires from the role. AvMA also marks its 40th anniversary this year, and Peter examines the organisation's unique role in focusing on patient safety and justice for patients. He highlights that healthcare systems and patient safety practice still have a long way to go in offering fairness and support to families affected by avoidable harm in healthcare, and argues that focusing on patients and their families must be a top priority when looking at system safety. He highlights the vital role that AvMA has played in bringing Duty of Candour into law in the countries of the UK, and argues that legal action is an important right that must be retained for patients and families who have come to harm as a result of medical error. He also talks about AvMA's recent development of a Harmed Care Pathway in collaboration with the Harmed Patients Alliance, which outlines the specific set of needs that should form part of a package of care for harmed patients and families.
  3. Content Article
    This editorial in the Journal of Patient Safety and Risk Management reflects on the achievements of the organisation Action Against Medical Accidents (AvMA) over the past 40 years and looks at the emerging role of Patient Safety Learning amongst organisations working for patient safety. Helen Hughes, Chief Executive of Patient Safety Learning, and Albert Wu, Editor-in-chief of the journal, reflect on the purpose and value of patient safety charities and not-for-profit organisations, highlighting the ways in which they channel and champion the patient voice and campaign to address specific areas of recurrent harm. They discuss the vital nature of the patient perspective in driving safety improvements in healthcare, and look at how these organisations amplify this. They also talk about the role of Patient Safety Learning and what it is doing to both drive system change at policy level, and share widely the knowledge of risk and good practice for safer care. They discuss the ways in which Patient Safety Learning delivers its aim to "listen to and promote the voice of the patient safety front line - patients, families and staff.”
  4. News Article
    Lucy Letby used a plunger to force milk and air into one of the babies she is accused of attempting to murder, a medical expert has told a court. The alleged attack caused the infant’s stomach to distend to such a degree that she then projectile vomited a “massive” amount of milk so violently that the material left her cot and splashed over a chair several feet away. Staff at the Countess of Chester Hospital managed to save Baby G’s life but the incident was so catastrophic that it caused the child severe brain damage. Seven years later she still suffers from quadriplegic cerebral palsy. Dr Dewi Evans, a consultant paediatrician called in by the prosecution, said the use of a plunger on the end of a syringe was the only explanation for the baby’s sudden collapse in the early hours of 7 September 7 2015. Letby, 32, of Hereford, is accused of murdering seven children in the neonatal unit of the hospital in Cheshire, and of ten attempted murders, between June 2015 and June 2016. She denies all the charges. Read full story (paywalled) Source: The Times, 13 December 2022
  5. News Article
    Nanette Barragán, US representative for California’s 44th Congressional District, has announced the introduction of new legislation intended to establish a National Patient Safety Board (NPSB) as a non-punitive, collaborative, independent agency to address safety in healthcare. This landmark legislation is a critical step to improve safety for patients and healthcare providers by coordinating existing efforts within a single independent agency solely focused on addressing safety in health care through data-driven solutions. Prior to the COVID-19 pandemic, medical error was the third leading cause of death in the United States, with conservative estimates of more than 250,000 patients dying annually from preventable medical harm and costs of more than $17 billion to the U.S. healthcare system. Recent data from the Centers for Medicare and Medicaid Services and Centers for Disease Control and Prevention indicate that patient safety worsened during the pandemic. The NPSB’s solutions would focus on problems like medication errors, wrong-site surgeries, hospital-acquired infections, errors in pathology labs, and issues in transition from acute to long-term care. By leveraging interdisciplinary teams of researchers and new technology, including automated systems with AI algorithms, the NPSB’s solutions would help relieve the burden of data collection at the frontline, while also detecting precursors to harm. A coalition of leaders in health care, technology, business, academia, and other industries has united to call for the establishment of an NPSB. “We have seen many valiant efforts to reduce the problem of preventable medical error, but most of these have relied on the frontline workforce to do the work or take extraordinary precautions,” said Karen Wolk Feinstein, PhD, president and CEO of the Pittsburgh Regional Health Initiative and spokesperson for the NPSB Advocacy Coalition. “The pandemic has now made things worse as weary, frustrated, and stressed nurses, doctors, and technicians leave clinical care, resulting in a cycle where harm becomes more prevalent. Many organizations have united to advance a national home for patient safety to promote substantive solutions, including those that deploy modern technologies to make safety as autonomous as possible.” Read full story Source: Business Wire, 8 December 2022
  6. Content Article
    This article provides an overview of the National Patient Safety Board Act of 2022; legislation which has been introduced in the USA to establish an independent federal agency dedicated to preventing and reducing healthcare-related harms.
  7. News Article
    Two clinicians who say they lost their jobs at Berkshire Healthcare NHS Foundation Trust after raising patient safety concerns claim the trust’s legal team brought a five-figure costs threat against them to prevent witnesses from giving evidence in a tribunal. The threat of costs liability, intended to bring the case to a halt, was made halfway through the hearing – less than 48 hours before witnesses for the trust were due to give evidence. One of the claims put forward at the tribunal hearing was that the trust had destroyed crucial evidence by deleting the email account of a former staff member. The clinicians – Samir Lalitcumar and Ahmed Ghedri – brought allegations of poor practice against current and former staff at the trust. Berkshire NHS trust claimed their allegations, including claims that the trust had deleted email evidence, were “without merit”. A fortnight into the tribunal hearing, both out-of-work medics were threatened with costs liability, known as a “drop-hands offer”, totalling more than £300,000, had they opted to proceed with their case and lost. Lalitcumar and Ghedri had brought claims of whistleblowing detriment against their former employer, Berkshire Healthcare Trust. They say they were “victimised” and unfairly dismissed as a result of having blown the whistle on dangerous care within the trust’s geriatrics services – potentially affecting upwards of 2,000 patients. Read full story Source: Computer Weekly, 7 December 2022
  8. News Article
    In September, Shine Lawyers won a $300 million settlement in two class actions over the failed mesh products by Johnson & Johnson Medical and Ethicon. However, the law firm is proposing to take up to $99.5 million from the payout in costs, just under a third of the total sum. Of 11,000 women involved in the class action, Janelle Gale is one of 200 who is not happy with Shine Lawyers' compensation proposal. Representatives of the group said there was mass confusion over what compensation they might be eligible for and how many hoops they would have to jump through to receive a payment. Despite having barely any leakage before her 2014 surgery, afterwards Janelle became heavily incontinent. She was a drag-racing champion, but that came to a halt. She said it destroyed her marriage, she couldn't have sex and she still can't work. Read more Source: ABC News, 3 December 2022
  9. News Article
    NHS England has acted unlawfully by making thousands of patients with gender dysphoria wait “extreme” periods of time for treatment, the high court has heard. Transgender claimants, who have suffered distress as a result of delays, want the court to declare that NHSE broke the law by failing to meet a target for 92% of patients to commence treatment within 18 weeks. NHSE figures show there are 26,234 adults waiting for a first appointment with an adult gender dysphoria clinic, of whom 23,561 have been waiting more than 18 weeks. The number of children on the waiting list is approximately 7,600, of whom about 6,100 have been waiting more than 18 weeks. In a witness statement, one of the claimants, Eva Echo, said she received a referral in October 2017 but had still not been given a first appointment, leaving her in “painful indefinite limbo”. A co-claimant, Alexander Harvey, who has been waiting for a first appointment since 2019, said the delay “means that I have to continue to live in a body which I don’t feel is mine and which does not reflect who I am”. He said he had twice tried to kill himself. In written submissions for Tuesday’s hearing, David Lock KC, representing the claimants, said delays to puberty-blocking treatment – the current waiting time for children to access services is more than two years – could cause “intense anxiety and distress” to adolescents as a result of them experiencing “permanent and irreversible bodily changes”. While NHSE accepts it has not met the 92% target across the cohort of patients for whom its health services are commissioned, it claims a breach does not give rise to enforceable individual rights. Read full story Source: The Guardian, 29 November 2022
  10. Content Article
    In this opinion piece for the Daily Mail, journalist Tom Utley recounts his recent experience of a seven hour wait at A&E after receiving abnormal blood test results from his GP. He argues that fear of litigation is causing GPs to refer patients on to A&E unecessarily, contributing to the overcrowding happening at emergency departments. He also highlights inefficiencies in the system and states that lack of staff capacity to tell him he didn't require any treatment meant he stayed an additional hour and a half in the waiting room.
  11. Content Article
    This editorial by Barbara Fain, Chief Executive of the Betsy Lehman Center in Massachusetts, highlights the need to focus on system safety and moving away from a culture of individual blame, in order to improve patient safety. Referring to the case of nurse RaDonda Vaught who was convicted of negligent homicide for a medication error at a Tennessee hospital, Barbara looks at research that demonstrates that people generally believe the best way to reduce the likelihood of medical errors is by choosing the right doctor, and argues that this cultural belief played into Vaught's conviction. She highlights the need to use evidence-based strategies to communicate with healthcare professionals and the public about the wider picture of patient safety and systems thinking.
  12. Content Article
    This is a summary of a presentation given by NHS England's Lauren Mosley and Tracey Herlihey to discuss the Patient Safety Incident Response Framework (PSIRF) to the law firm Browne Jacobsen. The session covered key elements of PSIRF, what it means for coroners, litigation and trusts. There was also feedback from an early adopter trust,
  13. Content Article
    In this blog, journalist David Hencke shares his views on the ruling of Judge Anne Martin in the case of NHS whistleblower Dr Chris Day. He argues that Judge Martin was determined to find in favour of Lewisham and Greenwich NHS Trust, glossing over the disclosure of the deliberate destruction of 90,000 emails and the use of false evidence by the Trust. She discredited the evidence of Dr Day’s witnesses, including the present Chancellor of the Exchequer, Jeremy Hunt and two senior medical experts, on the basis that they were biased.
  14. Content Article
    When medical errors result in adverse patient outcomes, many healthcare professionals are concerned about malpractice litigation. Fear of malpractice has been associated with excessive health care use through defensive medicine, which involves doctors ordering additional testing or making extra referrals to protect themselves from malpractice accusations. The authors of this study in JAMA Network Open aimed to examine the perspectives of doctors on patient harm and malpractice litigation. They conducted an online survey targeting all emergency department attending physicians and advanced practice clinicians (APCs) in acute care hospitals across Massachusetts from January to September 2020. The results showed that although clinicians feared legal action, they feared harming patients to a greater degree regardless of specialty, experience or sex.
  15. Content Article
    After the US Food and Drug Administration (FDA) first warned in 2008 of serious complications associated with transvaginal mesh, thousands of lawsuits have been filed, most of which were compiled into seven federal multidistrict litigation cases against the major manufacturers. This blog by Meghann Cuniff for Forbes Advisor provides an update on the progress of these law suits. It also advises on how to file a vaginal mesh lawsuit and joining a class action lawsuit.
  16. News Article
    Attending physicians and advanced practice clinicians in US emergency departments are more concerned about medical errors resulting in patient harm than in malpractice litigation, according to a study published JAMA Network Open. The findings are based on an online survey of 1,222 ED clinicians across acute care hospitals in Massachusetts from January to September 2020. Respondents used a Likert scale of 1 (strongly disagree) to 6 (strongly agree) to indicate their degree of agreement with statements on how fearful they are of making a mistake that leads to a patient harm in their day-to-day practice, and how fearful they are of an error that results in being sued. The mean score was greater for fear of harm (4.40) than fear of being sued (3.40), the findings showed. Researchers said the mean scores for both fear of harm and fear of suit were similar regardless of whether the survey was completed before or after onset of the COVID-19 pandemic. Although previous studies have associated clinicians' fear of legal concerns with "excessive healthcare use through defensive medicine," the role fear of patient harm may play in clinical decision-making is less documented, researchers said. "Although the study did not delineate the association between this concern and potential overuse of testing, it suggested that fear of harm should be considered with, and may be more consequential, than fear of suit in medical decision-making," researchers said. Read full story Source: Becker's Hospital Review, 21 November 2022
  17. Content Article
    This article in Computer Weekly outlines the tribunal proceedings and judgement in high-profile case brought by whistleblower Chris Day. Dr Day claimed that Lewisham and Greenwich NHS Foundation Trust had concealed evidence when a director deleted up to 90,000 emails before he was due to testify at an earlier tribunal, concerning allegedly false and detrimental public statements about Dr Day made by the Trust. Dr Day’s lengthy legal battle first began when he was a junior doctor working at Queen Elizabeth Hospital Woolwich’s intensive care unit in 2013, where he spoke up about under-staffing at the ICU.
  18. News Article
    An orthodontist whose methods around shaping the jawline have gone viral advised treatment to young children that “carried a risk of harm”, a tribunal has heard. Dr Mike Mew, whose “mewing” techniques have racked up nearly 2 biillion views on TikTok, faces a misconduct hearing at the General Dental Council (GDC). Opening the hearing in central London on Monday, Lydia Barnfather, representing the GDC, said comments made by Mew, who claims to help “alter the cranial facial structure” on his YouTube channel, were “pejorative” about orthodontists. Barnfather told the professional conduct committee that Mew seeks to treat children with “head and neck gear” and “lower and upper arch expansion appliances” to help align teeth and shape the jawline. “The GDC alleges this is not only very protracted, expensive, uncomfortable and highly demanding of the child, but it carries the risk of harm", Barnfather said. It was heard that between September 2013 and May 2019, advice and treatment were provided to two children, referred to as Patient A and Patient B. Mew was accused of failing to “carry out appropriate monitoring” of their treatment and “ought to have known” this was liable to cause harm. Barnfather said: “The GDC allege you are not to have treated patients the way you did.” She argued that both children had “perfectly normal cranial facial development for their age” before treatment took place. She added that the treatment was “not clinically indicated” and that Mew “had no adequate objective evidence” it would achieve its aims. Read full story Source: The Guardian, 14 November 2022
  19. News Article
    A senior doctor is to be removed from the medical register after she was found to have attempted to cover-up the circumstances of a young girl's death. Paediatrics consultant Dr Heather Steen was found to be unfit to practise after an investigation into the death of nine-year-old Claire Roberts in 1996. A medical tribunal examining the doctor's case ruled that the majority of allegations against her were true. Claire's mother said it was "just the start of getting full justice". "I am angry at Dr Steen for putting us through 26 years of mental torment," said Jennifer Roberts. At the time of Claire's death, her parents were told she had a viral infection that had spread from her stomach to her brain. But in 2018 a public inquiry determined that she had died from an overdose of fluids and medication caused by negligent care at the Royal Belfast Hospital for Sick Children. The inquiry also concluded there had been "cover up" and the girl's death had not been referred to the coroner immediately to "avoid scrutiny". The case was then put to the Medical Practitioners Tribunal Service (MPTS), which rules on doctors' fitness to practise. When the case reached the tribunal stage Dr Steen twice applied to be voluntarily removed from the medical register and was twice refused. Had that been successful the tribunal would have been halted as she would no longer have been a doctor. However the tribunal continued and examined allegations that between October 1996 and May 2006 Dr Steen "knowingly and dishonestly carried out several actions to conceal the true circumstances" of Claire. Read full story Source: BBC News, 11 November 2022
  20. News Article
    Mental health patients are being held “unlawfully” in A&Es across the country as long waits for care and beds force staff into “fudging” the law, The Independent has been told. The University Hospital of North Midland Trust has been sanctioned by the Care Quality Commission (CQC) for holding mental health patients without any legal authority. However, experts have told The Independent the problem is widespread and occurs across every emergency department in the country with some patients waiting “days” and even “weeks” in A&E. Leaders at Barking, Havering and Redbridge NHS Trust have raised repeated concerns in recent months over patients waiting days in their A&E for mental health care. The CQC raised concerns about the assessment of mental health patients at UHNM following an inspection in October and served the trust with a warning notice. In a letter seen by The Independent, the CQC said two patients were “restricted within hospital unlawfully”. It said although staff were working in the patient’s best interests in both cases it was clear that legal procedures “were not being followed”. “Therefore, this can be seen as a significant infringement of any personal or welfare,” it said. Read full story Source: The Independent. 8 November 2022
  21. Content Article
    The investigation and tribunal hearing of Dr Manjula Arora generated significant anger and anxiety among the medical profession. The case raised once again the perception of a regulatory process lacking in fairness; of a system in which the stakes seem much higher if you are a black and minority ethnic doctor. The General Medical Council (GMC) acknowledged that strength of feeling, making clear it would not oppose Dr Arora’s appeal against the sanction and commissioning a review of the case to understand lessons to be learned for future cases.
  22. News Article
    Lawyers acting for an NHS trust are being investigated over “gagging” clauses proposed in a settlement agreement with a whistleblower who raised concerns that mistakes by paramedics in the deaths of patients were being covered up. In June, the then health secretary, Sajid Javid, announced an NHS review into “tragic failings” by North East Ambulance Service after Paul Calvert went public with claims that reports into deaths were doctored to cover up failings by staff. The Guardian has learned that NEAS’s lawyers, Ward Hadaway, are also under scrutiny – by the Solicitors Regulation Authority (SRA) – over the terms proposed by the trust for his exit agreement. The agreement, offering him £41,000 in compensation, initially included confidentiality clauses relating to future disclosures. A SRA investigation does not mean there has been wrongdoing and it does not confirm or deny whether it is examining a solicitor. However, the Guardian understands that the regulator has been in contact with Calvert about the proposed agreement. Read full story Source: The Guardian, 3 November 2022
  23. Content Article
    Locum GP Manjula Arora was given a month’s suspension by the Medical Practitioners Tribunal Service (MTPS) in May 2022 after a complaint to the General Medical Council (GMC) that centred on whether or not she had been promised a laptop by her employer. The ruling was overturned and the GMC conducted a review of the case that found that a legal test around dishonesty was incorrectly applied. The two co-chairs of the GMC review highlight some of its recommendations in this opinion piece in the BMJ. They argue that while the NHS is very diverse, it is not very inclusive and that structural racism affects the treatment of and opportunities available to staff from different cultural backgrounds. They call for greater compassion and cultural competency in the GMC, and for healthcare services to manage concerns on a local level before referring cases to the GMC.
  24. Content Article
    In 1999, the pivotal report “To Err is Human” by the Institute of Medicine led to sweeping changes in healthcare. This report outlined how blaming individuals does not change the underlying factors that contribute to medical errors. It also stated that blaming an individual does little to make the system safer – or prevent someone else from similar errors. It is unusual for a nurse to be charged criminally, when there is no intent to harm a patient. However, the recent trial in America of nurse RaDonda Vaught could set a precedent for future medical errors to be treated as criminal cases. The case may ensure that for every step that has been taken forward in patient safety, we have now taken two steps backwards. This article from Human Factors 101 looks at the case of RaDonda Vaught, the criminal trial and conviction, and discusses the impact this will have on healthcare.
  25. Content Article
    Martin Anderson, author of the Human Factors 101 blog, looks at the case of US nurse RaDonda Vaught, who was found guilty of criminally negligent homicide and abuse of an impaired adult following a medication error that led to a patient death in 2017. He provides a timeline of the events that occurred in the run up to the criminal trial and highlights concerns that the case will set a precedent in bringing criminal charges against nurses when there is no intent to harm a patient. He then looks at the system factors that may have contributed to the medication error, asking a number of questions about the circumstances under which Vaught made the error. The blog goes on to outline the serious impact the case could have on healthcare professionals' willingness to report errors, take on complex cases and use innovative treatments—it may even put people off taking on a career in the healthcare sector in the first place.
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