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News Article
NHS gender identity service for children can’t cope with demand, review finds
Patient Safety Learning posted a news article in News
The only NHS gender identity service for children in England and Wales is under unsustainable pressure as the demand for the service outstrips capacity, a review has found. The interim report of the Cass Review, commissioned by NHS England in 2020, recommends that a network of regional hubs be created to provide care and support to young people with gender incongruence or dysphoria, arguing their care is “everyone’s business”. Led by the paediatrician Hilary Cass, the interim report explains that the significant rise in referrals to the Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS foundation trust in London has resulted in overwhelmed staff and waiting lists of up to two years that leave young people “at considerable risk” of distress and deteriorating mental health. Last spring, the Care Quality Commission demanded monthly updates on numbers on waiting lists and actions to reduce them in a highly critical report on GIDS. Differing views and lack of open discussion about the nature of gender incongruence in childhood and adolescence – and whether transition is always the best option – means that patients can experience a “clinician lottery”, says the new review, which carried out extensive interviews with professionals and those with lived experience. It notes that the clinical approach used by GIDS “has not been subjected to some of the usual control measures” typically applied with new treatments. Another significant issue raised with the review team was that of “diagnostic overshadowing”, whereby once a young person is identified as having gender-related distress, other complex needs – such as neurodiversity or a mental health problem that would normally be managed by local services – can be overlooked. Read full story Source: The Guardian, 10 March 2022 -
News Article
NHS England to replace cancer targets
Patient Safety Learning posted a news article in News
The two-week wait cancer target should be scrapped and replaced with a different measure, as part of an overhaul of cancer standards, NHS England has said. After piloting a new measure which aims to see 75% of patients given the all-clear or a diagnosis within 28 days of referral, NHS England has recommended .The new “faster diagnosis target” would replace the current ‘two-week wait’ target, which is for 93% to have seen a specialist within two weeks, but not necessarily had a diagnosis. This proposal, and other changes to the way cancer waiting time targets are organised, will be consulted on until 6 April. The nine current cancer targets were created in 2000. The current headline measure along with the two-week wait — a two-month wait from urgent GP referral to first treatment — has not been hit since December 2015. The document containing the proposals said the current two-week standard saw some patients given an appointment at which no test was taken, purely to hit the target. For some suspected cancers, “many trusts… offer outpatient appointments to ensure they hit the target”, without improving diagnosis. The move to scrap the two-week wait was welcomed – with significant caveats — by Cancer Research UK Cancer Research UK chief executive Michelle Mitchell said: “The new Faster Diagnosis Standard is a more meaningful target than the current two-week wait that will hopefully improve early diagnosis. If all trusts met the 75 per cent target, it would be an improvement to where we are now. However, in the long-term to improve cancer survival, we’d like to see a 95 per cent target originally proposed in the 2015 cancer strategy in Sajid Javid’s upcoming 10-year plan for cancer. “We recognise the target was set lower because of a shortage of cancer specialists, critical to diagnosing cancer across the NHS. The government must provide the extra investment they have promised to grow the NHS workforce. Every moment of delay risks more people waiting for diagnosis and treatment.” Read full story (paywalled) Source: HSJ, 10 March 2022 -
News ArticleStaff failed to provide kind and compassionate care and did not treat children with respect at a private hospital downgraded from ‘good’ to ‘inadequate’, a report by health inspectors has revealed. Huntercombe Hospital Stafford was placed in special measures in 2016, but was rated “good” by the Care Quality Commission two years later. Now, its first inspection under provider Huntercombe Young People Ltd in October 2021 has exposed a raft of safety concerns and instances of poor care. Huntercombe Young People Ltd took over the service in February 2021. Heavy reliance on agency staff, workers spotted with their “eyes closed” on observations, and staff not respecting young people’s pronouns were among concerns inspectors flagged. Staff observation of patients was also found to be “undermined” by a blind spot where people could self-harm unseen, the CQC report, published today, said. Children also told the CQC they felt staff did not always understand their mental health condition or know how to support them, particularly those on the psychiatric intensive care ward with eating disorders or autism. Read full story (paywalled) Source: HSJ, 10 March 2022
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News Article
'Urgent action' needed on hospital waiting times in Ireland
Patient Safety Learning posted a news article in News
Urgent action is required to tackle hospital waiting times on both sides of the Irish border, according to the Economic and Social Research Institute (ESRI). A report into the primary healthcare systems of Ireland and Northern Ireland found that both jurisdictions are experiencing similar problems. These include workforce shortages and increasing expenditure. On hospital waiting times the problem is worse in Northern Ireland. The proportion of people on the waiting list in Northern Ireland for more than one year increased from 20% to 60%. In the Republic of Ireland, during the same period between 2017 and 2021, the figure increased from 12% to 20%. A key distinction between the healthcare systems is the absence of a universal healthcare system in Ireland, write the authors. That means in Northern Ireland, all residents are entitled to a wide range of free health care services, while in Ireland, the majority pay to see their GP and for other services. But despite this key difference, both systems are currently facing similar challenges, including shortages in key areas of the workforce and long waits for a range of healthcare services. Cross-border collaboration in healthcare across the island is an interesting but contentious issue. At present, according to the ESRI report, that work is relatively limited. It points to a 2011 report which identified the potential benefits to be gained from increased co-operation in healthcare including collaboration in cystic fibrosis, ear, nose and throat surgery, paediatric cardiac surgery and acute mental health services. However, this 2022 report concludes that despite some notable exceptions such as the Congenital Heart Disease Network and the North West Cancer Centre at Altnagelvin Hospital in Londonderry, "collaboration has been relatively limited". Read full story Source: BBC News, 10 March 2022 -
News Article
‘Angry’ NHSE pressures prestigious trust to make ‘public apology’
Patient Safety Learning posted a news article in News
NHS England is trying to force a prestigious cancer trust to publicly apologise to a group of whistleblowers, after being ‘shocked’ by the way it responded to a review into their concerns. As HSJ reported in January, an external review into The Christie Foundation Trust supported multiple concerns which had been raised by staff about a major research project with pharma giant Roche. The review had also noted how 20 current and former employees, some of whom were “long-standing, loyal, senior staff”, had described bullying behaviours and felt they had suffered detriment because they spoke out. In response to the review, trust chair Christine Outram and chief executive Roger Spencer issued a bullish report listing numerous “inaccuracies” and characterised the concerns as being limited to a “small number of staff who are dissatisfied or aggrieved”. It did not thank the staff for raising the issues, nor apologise for the experiences they had. However, HSJ has now learned that NHSE is trying to ensure the trust issues a public apology. At a meeting with some of the whistleblowers on 11 February, David Levy, medical director for NHSE North West, said he was “shocked” and “frankly a bit angry” at the trust’s response, saying it reflected badly on the organisation, HSJ understands. Read full story (paywalled) Source: HSJ, 9 March 2022 -
News Article
No new funding to tackle NHS work shortages, says Sajid Javid
Patient Safety Learning posted a news article in News
Sajid Javid has announced a plan to tackle NHS workforce shortages will be published by the end of the year - but the health service will not receive any additional funding to back it, he said. In a speech setting out widespread reforms, the health secretary on Tuesday said the NHS is the area where the government spends the most money, adding that spending increases have meant areas such as education have lost out. Mr Javid said the UK has now come to a “crossroads” where it must choose between “endlessly putting in more and more money, or reforming how we do healthcare”. He confirmed the government will publish a long-awaited plan for the NHS workforce by the end of the year, but in response to questions from The Independent over funding, he said it would not go above the £36 billion already promised. Mr Javid said costs for the new staffing plan would come from existing budgets. Healthcare leaders have repeatedly called for a long-term “fully funded” plan to address staff shortages across the NHS, alongside a funding commitment for health education regulator Health Education England. As part of the government’s latest plan to reform NHS services, the health secretary said patients who have been waiting the longest would travel to less busy hospitals or private facilities for care - with the NHS footing the bill for travel and accommodation. He also urged people to harness the “power of families” to make a difference for their loved ones’ health, recalling when his father quit smoking at the request of his mother. Read full story Source: The Independent, 8 March 2022 -
News Article
Government launches landmark review of health and social care leadership
Patient Safety Learning posted a news article in News
The government has launched a review of leadership in health and social care. The review will be led by former Vice Chief of the Defence Staff General Sir Gordon Messenger, and will report back to Secretary of State for Health and Social Care Sajid Javid, in early 2022. The Health and Social Care Leadership Review will look to improve processes and strengthen the leadership of health and social care in England. Working with the health and care systems, retired General Sir Gordon Messenger will have a team from DHSC and the NHS to support him led by Dame Linda Pollard, chair of Leeds Teaching Hospital. The review comes as the government invests a record £36 billion to put health and social care on a sustainable financial footing and deliver the biggest catch-up programme in NHS history. Any recommendations made as the review progresses will be considered carefully and could be rapidly implemented to make every penny of taxpayer’s money count. Secretary of State for Health and Social Care, Sajid Javid, said: "I am determined to make sure the NHS and social care delivers for the people of this country for years to come and leadership is so important to that mission. We are committed to providing the resources health and social care needs but that must come with change for the better. This review will shine a light on the outstanding leaders in health and social care to drive efficiency and innovation. It will help make sure individuals and families get the care and treatment they need, wherever they are in the country, as we build back better." Read full story Source: Department of Health and Social Care, 2 October 2021 -
News ArticleVulnerable people released from immigration detention in the UK are too often left without crucial continuity of care, leading to quickly deteriorating health, concludes a report. The report comes from Medical Justice, a charity that sends independent volunteer clinicians into immigration removal centres across the UK to offer medical advice and assessments to immigration detainees. The charity said that between 1 October 2020 and 30 September 2021 a total of 21 362 people were detained in UK immigration centres and 17 283 were released into the community, having been granted bail or leave to enter the UK or remain. Of these, 2239 were considered to be “adults at risk.” One woman whose delay in treatment “could potentially have life or limb threatening consequences”, struggled to re-arrange an orthopaedic oncology appointment that she missed because she had been detained. One released Medical Justice client described how he ended up a number of times in Accident & Emergency, having been unable to secure a recommended cardiology appointment. The report found that release from detention is often unplanned, chaotic and medically unsafe. Medical Justice sees repeated cases of vulnerable people released into the community without adequate care plans, with little or no information and support about entitlement and how to access a GP, and rarely with referrals to community support services such as local mental health teams. This has included people who had very recently attempted suicide in detention. Read full story Source: BMJ, 4 March 2022
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News Article
Delayed NHS patients will be able to choose private ops online
Patient Safety Learning posted a news article in News
Patients whose operations have been delayed will be able to shop online for hospitals with the shortest waiting times in the public and private sector, under plans being announced by the health secretary this week reports The Times. Sajid Javid will unveil a three-point plan to transform the NHS as part of efforts to tackle a record backlog of more than six million people. Under the proposals, patients referred for hospital care will be able to go online to look up the waiting time at their local hospital, and compare it with times at any hospital in the country, including those in the private sector. The website will allow patients to book their treatment at any unit in the country and there are plans to make the service available on the NHS app. The proposals will be set out in a speech on Tuesday. Javid said: “The NHS constitution says already that you as a patient have the right to ask for an alternative provider for your treatment." However, is this just a distraction? writes Roy Lilley in his latest newsletter. Shopping on-line for treatment depends on getting a website organised that can collect real-time data from all Trusts, for every specialty, that can take into account staffing, rota-gaps and clinical priorities. Software might be able to cope but has the potential to throw the NHS into chaos. People arriving from ‘out of area’ will need video-out-patient consultations, some way of doing blood, imaging and other tests. And post-op? The same again for out-patients and physio, OT, aids, adaptations, pharmacy and social care support... ... to say nothing of the stress on patients and their families. None of this is impossible but the NHS is nowhere near geared up for it. Sources: The Times, 6 March 2022 (paywalled) Roy Lilley's newsletter, 7 March 2022 -
News Article
GP surgeries are told to open late and at weekends
Patient Safety Learning posted a news article in News
GP surgeries must open for routine appointments between 9am and 5pm on Saturdays and during weekday evenings, NHS bosses have said. From October, patients will be able to book weekend and evening slots with “the full multi-disciplinary team” in a local practice, including for services such as screening, vaccinations and health checks. The British Medical Association said it was “bitterly disappointed” by the changes, which had been imposed without its agreement. A letter tells GPs the appointments must be made available at least two weeks in advance. Same-day online booking should be possible “up until as close to the time slot as possible”. Any unused slots should be available for NHS111 to allocate to callers. Some may be remote appointments, but networks are told to “ensure a reasonable number” of appointments are face-to-face consultations. Rachel Power, chief executive of the Patients Association, said: “There’s a great deal in this letter that patients will welcome, given the struggles they have had since the start of the pandemic to see their GPs face-to-face or even get through to their surgeries.” Read full story (paywalled) Source: The Times, 2 March 2022 -
News Article
Parents sue over failures in child hearing service at NHS Lothian
Patient Safety Learning posted a news article in News
More than a dozen families are seeking compensation following "significant failures" at NHS Lothian's hearing service for children. The health board apologised to more than 155 families after an independent investigation found serious problems diagnosing and treating hearing loss. Sophie was born partly deaf and failed repeated hearing tests for years. Her family say no help was offered by the paediatric audiology department at NHS Lothian who kept saying she would be fine. But her parents say she is not. Sophie is now seven. Her speech and language has not developed fully and is sometimes hard to understand. Her confidence has been affected. Her mum Sarah said: "They failed Sophie. You kind of trust what they were doing, you thought maybe she doesn't need hearing aids, maybe she will just catch up and now she's almost eight years old and she's still not caught up and you think 'OK, maybe there were mistakes made then'." An independent investigation by the British Academy of Audiology (BAA), published in December last year, found "significant failures" involving 155 children over nine years at NHS Lothian. Several profoundly deaf children were diagnosed too late for vital implant surgery. The health board has "apologised sincerely" to those affected. The BAA looked at more than 1,000 patient records finding "significant failures" in almost 14% of them. The BAA said it found "no evidence" that national guidelines and protocols on hearing tests for children had been followed or consistently applied "at any point since 2009". Read full story Source: BBC News, 2 March 2022 -
News Article
Private healthcare boom adds to fears of two-tier system in UK
Patient Safety Learning posted a news article in News
Growing numbers of Britons are paying for private medical treatment in a shift that could undermine the NHS and create a “two-tier” health system, a report has warned. Declining access to and quality of NHS care, both worsened by the Covid-19 pandemic, have begun to “supercharge” the trend, with one in six people prepared to go private instead of waiting. That is among the findings of a report by the left-leaning IPPR thinktank, which warns that in future getting fast, high-quality care on the NHS could become as difficult as the situation that already exists in regards to state-funded dental treatment, which has become a postcode lottery. “People are not opting out of the NHS because they have stopped believing in it as the best and fairest model of healthcare,” said Chris Thomas, the IPPR’s principal research fellow and co-author of the report. “Rather, those who can afford it are being forced to go private by the consequences of austerity and the pandemic on NHS access and quality, and those without the funds are left to ‘put up or shut up’.” The report says that unless the NHS starts performing better “people who can and are willing to do so will supplement their entitlement to NHS care with private healthcare products”. “With NHS waiting lists now at record levels, it is not surprising that more patients across the country are looking at private healthcare,” said David Hare, chief executive of the Independent Healthcare Providers Network, a trade body that represents about 100 private providers across the UK. Read full story Source: The Guardian, 2 March 2022 -
News Article
Ombudsman’s COVID report highlights ‘tragic individual cases’
Patient Safety Learning posted a news article in News
A Covid report by the Local Government and Social Care Ombudsman has highlighted some ‘tragic individual cases’ over the past months. The report analyses cases over the first 18 months of the pandemic which for the majority reveal that councils and care providers weathered the unprecedented pressures they were under fire. However, the report also reveals the ‘serious impact on people’s lives’ when things go wrong. Cases include a woman who died from COVID-19 at a care home with poor infection control procedures which was then compounded by staff trying to cover up the facts. The Ombudsman’s report focuses on the lessons that can be learned from the complaints it has received about the pandemic and welcomes that, in many cases, councils and care providers are already using their experiences from the pandemic to consider how they can make improvements to services. Michael King, Local Government and Social Care Ombudsman, said: “We have investigated some tragic individual cases over the past months. Each represents poor personal experiences where councils and care providers did not get things right. “Our investigations have shown that, while the system did not collapse under the extreme pressures placed on it, Covid-19 has magnified stresses and weaknesses present before the pandemic affecting some councils and providers. “We have always advocated how crucial good complaint handling is in any setting, so I am particularly saddened that, in some authorities, dealing with public concerns and complaints itself became a casualty of the crisis. At a time when listening to public problems was more important than ever, we saw some overstretched and under-resourced complaints teams struggle to cope. “If evidence was needed, this report proves that managing complaints should be considered a frontline service.” Read full story Source: Care Home Professional, 24 February 2022 -
News Article
Mothers who helped uncover the biggest NHS maternity scandal
Patient Safety Learning posted a news article in News
Next month, a report will be published into one of the biggest scandals in the history of the NHS, the failures of maternity care at the Shrewsbury and Telford Hospital NHS Trust. The BBC's Michael Buchanan who helped uncover the problems examines why so many failures were allowed to happen for so long. Kayleigh Griffiths' baby, Pippa, died at 31 hours old. The cause of death, the couple were later told, was an infection - Group B Strep. The Shrewsbury and Telford Hospital NHS Trust told the family they would carry out an investigation. But after several weeks of silence, Kayleigh contacted the trust to be told it was an internal investigation and the couple's input wouldn't be required. Kayleigh, an NHS auditor at a different trust, feared the truth was being hidden from her. That's when she decided to send the email to Rhiannon Davies, whose baby, Kate, also died at the Shrewsbury and Telford Hospital NHS Trust As the bond between the mothers deepened, their conversations morphed into something else. Armed with little more than a gnawing suspicion, they started to scour the internet, coroner's records and death notices to see if any other families had received poor maternity care at the Shropshire trust. They collated 23 cases dating back to 2000 - including stillbirths, neonatal deaths, maternal deaths and babies born with brain injuries. Appalled by what they had found, they wrote to the then health secretary Jeremy Hunt in December 2016, asking him to order an investigation. He agreed and in May 2017, senior midwife Donna Ockenden was appointed to lead the review. One of the themes the inquiry has already noted, in an interim report published in December 2020, is that in many cases the trust failed to investigate after something went wrong, or simply carried out its own inquiry. Panorama has discovered the trust even developed its own investigation system, what they called a High Risk Case Review. It was outside any national framework that has been used to help learn lessons from incidents and doesn't appear to be a system that's used in any other NHS organisation. Another consequence of the unorthodox system was that fewer incidents were reported to NHS regulators, limiting the opportunity to learn lessons. One of the earliest cases on the original list of 23 compiled by the two couples was the death of Kathryn Leigh in 2000. Panorama has investigated the case and discovered that a theme identified almost two decades ago was to come up repeatedly in subsequent incidents. The publication of the final report by Donna Ockenden next month will be a watershed moment in the history of the NHS - the revelation of multiple instances of maternity failures in a rural corner of England. Pippa Griffiths and Kate Stanton-Davies lived fewer than 40 hours between them, but their legacy, in terms of improved maternity care, could last decades. Read full story Source: BBC News, 23 February 2022 Source: -
News Article
NHS cuts to cover Covid costs may hit patient care, Labour warns
Patient Safety Learning posted a news article in News
Patient care may suffer as a result of cuts to the NHS budget to fund the continuing costs of Covid, NHS leaders and Labour have said, after Sajid Javid refused to say where the axe would fall. The Department of Health and Social Care (DHSC) is trying to make savings from its budget to fund free lateral flow tests for elderly people, Covid surveillance studies and genomic sequencing, after the Treasury refused its request for £5bn in extra funding. Although the government announced an end to most free mass testing and contract tracing on Monday, remaining Covid measures are expected to cost more than £1bn. The Treasury and the DHSC refused to say exactly how much cash would be needed or which services would have to be cut back, prompting fears that the NHS could have to find savings at a time of a huge waiting list backlog. It is understood that DHSC officials are working on identifying savings in the department’s £178.5bn budget for 2022-23, to fund the measures agreed on Monday, including maintaining a “baseline” testing capability that can be scaled up if necessary. They have ruled out hitting Javid’s plan for tackling waiting lists, but a government source would not rule out any other areas being affected, saying a “significant amount of money” would have to be found by “reprioritising”. Saffron Cordery, the deputy chief executive of NHS Providers, warned the government against abandoning its commitment to give the NHS “whatever it needs” to tackle Covid and called for transparency about “where the impact of these extra costs will fall”. “Trust leaders are understandably anxious over reports that the ongoing and significant costs of living with Covid will be met by ‘reprioritising’ the NHS’s existing budget,” she said. “There is a very real risk of trade-offs affecting the quality of patient care – something no one wants to see.” Read full story Source: The Guardian, 23 February 2022 -
News Article
Families to take part in Nottingham maternity inquiry
Patient Safety Learning posted a news article in News
Seventy families have come forward to be a part of an independent review into maternity services at Nottingham University Hospitals Trust (NUH). The aim of the review is to "drive rapid improvements to maternity services". It comes after an investigation found 46 babies suffered brain damage and 19 were stillborn between 2010 and 2020. The Clinical Commissioning Group (CCG) and NHS England are jointly leading the review of maternity incidents, complaints and concerns at Nottingham University Hospitals (NUH). Cathy Purt, programme director of the review, said during a Nottingham City Council Health Scrutiny Committee meeting on Thursday: "We have had 70 families come forward 19 families have had their first interview with us." "We have secured via the CCG specialist psychological support for the rest of the families so they will now be able to come forward and have their interviews as well. "40 staff have come forward so far and more are coming as we go." The review will cover information dating back to 2006, and is expected to be completed by November 30 2022. Read full story Source: BBC News, 18 February 2022 -
News Article
NHSE wants ‘urgent’ meetings over ambulance handovers risk
Patient Safety Learning posted a news article in News
NHS England and the Care Quality Commission have asked systems with large numbers of ambulance handover delays to urgently hold a meeting to try to fix the problem by “balancing the risks” of long 999 waiting times. The request was made in an email to chief executives, which warned the service was “in a difficult position with all parts of the urgent and emergency care pathway under considerable strain… most acutely in ambulance response times which in turn is linked to challenges in handing patients over to emergency departments”. The NHSE headed letter was signed by its chief operating officer, nursing director and medical director, but also by the CQC’s chief inspector of hospitals Ted Baker. It said there was a “strong correlation” between handover delays at hospitals — which take place where A&Es are unable to receive patients from ambulances — and long delays for category two ambulances. This is because ambulances have to wait for long periods outside the hospitals. The letter said: ”It is vital that we have a whole-system approach to considering risks across the urgent and emergency care pathway to provide the best outcomes for our patients. This may mean consideration of actions to be taken downstream to help improve flow and reduce pressures on emergency departments.” Read full story (paywalled) Source: HSJ, 17 February 2022 -
News ArticleA police investigation into allegations of cover-up and medical negligence over dozens of deaths at the Royal Sussex county hospital (RSCH) in Brighton has been expanded to include more recent cases, amid internal claims about dangerous surgery. In June the Guardian revealed that Sussex police were investigating the deaths of about 40 patients in the general surgery and neurosurgery departments at the RSCH. The force initially said the investigation, since named Operation Bramber, related to allegations of medical negligence in these departments between 2015 and 2020. It has now extended the scope of the investigation to more recent cases, amid internal allegations that the departments continue to be unsafe and fail to properly review serious incidents. An insider said the police should review what was considered to be an avoidable death after a procedure in July. The source said some of the surgeons remained a danger to the public. “You would not want your family members touched by these people,” they said. They added: “This is not a historic issue, it is ongoing. The same surgeons that were involved in previous problems remain in place.” They cited a woman who lost the power of speech in April after an alleged mistake in surgery to remove a brain tumour led to a stroke, and a man who was left with a brain abscess in May after being operated on despite a heightened risk of infection. Read full story Source: The Guardian, 13 September 2023
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News Article
Trust heavily criticised by coroner for delays to death investigations
Patient Safety Learning posted a news article in News
A coroner has strongly criticised a mental health trust for failing to investigate serious incidents promptly. Tees Esk and Wear Valleys Foundation Trust has been told that delays in probing serious incidents may “compromise the quality” of these investigations and hence “their value in preventing deaths”. The warnings, from Jeremy Chipperfield, senior coroner for County Durham and Darlington, come amid an ongoing inquest into the death of TEWV patient Ian Darwin. Mr Darwin died aged 42 in March, and the serious incident review into his death is still ongoing. A recently published prevention of future deaths report relating to Mr Darwin’s death said TEWV’s serious incident death investigations, “at all levels of seriousness, are routinely (if not invariably) significantly delayed and I understand there is no expectation of immediate, or any timetable for eventual rectification”. “In permitting delay of ‘serious incident’ investigations, TEWV may permit lethal hazard to persist for longer than necessary, and compromise the quality of such investigations and hence their value in preventing avoidable deaths.” -
News Article
BMA writes to trust chiefs over ‘concerns about doctors’ safety’
Patient Safety Learning posted a news article in News
The British Medical Association has written to trust chief executives warning of ‘concerns regarding the safety of our members and the patients they serve’ due to flawed concrete beams. The BMA has written to trust chiefs, copying in their medical committee leads, in the wake of a wave of publicity around reinforced autoclaved aerated concrete in recent weeks. The letter said: “The HSJ has reported that many NHS hospital buildings have been constructed with RAAC, which is in some cases reaching the end of safe use and causing danger to staff and patients. “Unfortunately, your trust may be one of the affected hospitals. We have concerns regarding the safety of our members and the patients they serve, and would appreciate answers to the following.” It also requested the trusts provide answers, under the Freedom of Information Act, to questions including whether they had identified RAAC, what assessments they had made, what mitigations were planned or in place, and emergency plans such as evacuation. It is thought the letter was sent to all or most provider trusts. Read full story (paywalled) Source: HSJ, 12 September 2023 -
News Article
Teaching trust reviewing decisions made under Letby CEO
Patient Safety Learning posted a news article in News
A trust which hired the former chief executive of the Countess of Chester Hospital as an interim CEO has launched a review of decisions about safety and whistleblowing taken under his leadership. Jacqui Smith, chair-in-common at Barts Health and Barking, Havering and Redbridge University Hospitals trusts, made the announcement at a board meeting, following the nurse Lucy Letby’s conviction for murdering seven babies, and attempting to murder six more, during a year-long period between June 2015 and June 2016. Tony Chambers was Countess of Chester Hospital Foundation Trust CEO for six years from December 2012 to September 2018, and resigned shortly after Letby’s initial arrest. His role – and that of fellow senior managers in Chester – in responding to concerns raised by doctors, has come under intense scrutiny since the verdicts. Mr Chambers served as BHRUT’s interim chief from January 2020 until August 2021, and Ms Smith told BHRUT’s board: “In the light of concerns, particularly around listening to staff and patients, and given the seriousness of the events, we will undertake a look at the periods of Tony Chambers’ tenure. “To see whether there are, firstly, any significant decisions taken regarding quality and safety that we need to look at again, and [secondly], checking our log of whistleblowing cases and other concerns to make sure that they have been appropriately followed up." Read full story Source: HSJ, 8 September 2023 -
News Article
Trust and manager charged with manslaughter
Patient Safety Learning posted a news article in News
North East London Foundation Trust has been charged with corporate manslaughter – making it only the second NHS provider to be prosecuted for the crime. The Crown Prosecution Service has authorised the Metropolitan Police to bring a charge of corporate manslaughter against the mental health provider in regard to the death of Alice Figueiredo at the trust’s Goodmayes Hospital on 7 July 2015. Goodmayes ward manager Benjamin Aninakwa has also been charged with gross negligence manslaughter, and an offence under the Health and Safety at Work Act. The trust and Mr Aninakwa will appear at Barkingside Magistrates’ Court on Wednesday, 4 October. The prosecution follows a five year investigation by Met detectives. Read full story (paywalled) Source: HSJ, 7 September 2023 -
News Article
NHS ‘a long way’ from being ‘proactive’ on safety, watchdog warns
Patient Safety Learning posted a news article in News
Integrated care systems (ICSs) should factor patient safety into all their operational and financial decisions, the Healthcare Safety Investigations Branch’s chief investigator has urged. Rosie Benneyworth, who was appointed as interim chief investigator last summer, said other safety-critical industries made decisions on the basis of a “triad” of operations, finances and safety. She said the NHS needed to be “more proactive” to take action before things go wrong. Dr Benneyworth said in an interview with HSJ: “I think it’s fundamental that ICSs put safety at the core of everything they do. And I don’t think operational decisions or financial decisions should be made without considering the implications for safety.” Dr Benneyworth – a former GP and commissioner – also spoke about whistleblowing in the wake of the Lucy Letby scandal, saying national organisations should “lead the way” on being proactive over safety and supporting whistleblowers. Major cultural problems were uncovered at HSIB several years ago, while NHSE has been under the spotlight in recent weeks for implementation of the “fit and proper person” test for board members. “I think it’s very difficult as national organisations to tell providers what they should [be] doing, if we’re not doing it ourselves,” Dr Benneyworth said. She added: “What we need is a much more proactive approach to safety, where we actually identify those things that could go wrong and take action before they do go wrong." Read full story (paywalled) Source: HSJ, 5 September 2023 -
News ArticleMore than 120,000 died waiting for NHS treatment, as backlog hits all-time high. The number of NHS patients dying while waiting for treatment has doubled in five years, new figures suggest. More than 120,000 people died while on waiting lists last year, according to an analysis of health service data. The total is even higher than it was in lockdown, with health leaders saying the pandemic and NHS strikes have made clearing backlogs more difficult. Matthew Taylor, the chief executive of the NHS Confederation, said: “These figures are a stark reminder about the potential repercussions of long waits for care. They are heartbreaking for the families who will have lost loved ones and deeply dismaying for NHS leaders, who continue to do all they can in extremely difficult circumstances." “Covid will have had an impact on these figures – but we can’t get away from the fact that a decade of under-investment in the NHS has left it with not enough staff, beds and vital equipment, as well as a crumbling estate in urgent need of repair and investment.” Read full story (paywalled) Source: The Telegraph, 31 August 2023
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News Article
NHS failed to act on brain surgeon who harmed patients
Patient Safety Learning posted a news article in News
NHS Tayside has been criticised over its handling of disgraced brain surgeon Sam Eljamel in a new report. The internal due diligence review criticised health board management for putting the doctor under indirect supervision in June 2013 rather than suspending him. The surgeon harmed dozens of patients but was allowed to continue operating until he was suspended in late 2013. Some of his patients were left with life-changing injuries. He was employed as a surgeon by NHS Tayside for 18 years and later became the head of the neurosurgery department in Ninewells Hospital in Dundee. NHS Tayside has apologised to former patients of Prof Eljamel and committed to assisting in the Scottish government's independent commission for patient concerns. The health board claimed it became aware of concerns around the surgeon in June 2013, but an NHS whistleblower told the BBC the health board knew as early as 2009 that there were serious concerns. He is now working as a surgeon in Libya. Read full story Source: BBC News, 1 September 2023
