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News ArticleThe mother of a bullied 12-year-old girl has said her daughter struggled to get mental health support on the NHS in the months before she killed herself, and accused her school of failing to deal with inappropriate messages circulating among pupils. The mother of Charley-Ann Patterson, Jamie, told a hearing that despite being seen by three medical professionals, Charley-Ann had been unable to get mental health support in the months before her death. In a statement read at an inquest at Northumberland coroner’s court on 12 October, Jamie said her daughter had changed halfway through her first year of secondary school, when she was sent “inappropriate” and “shocking” messages by other pupils. The inquest heard that Jamie first took her daughter to a GP over self-harm concerns in June 2019, but she said she “did not believe that the GP took Charley-Ann’s self-harm seriously, potentially due to her age”. She took Charley-Ann to A&E in May 2020 after a second episode of self-harm, where she was referred to a psychiatric team and given a telephone appointment in which she was told Charley-Ann would be referred to child and adolescent mental health services (CAMHS), but that “it was likely that she would not be seen for three years”. In an appointment with a nurse she was told that she would be referred to the Northumberland mental health hub for low mood and anxiety, but later learned “that this referral was never made”. Read full story Source: The Guardian, 12 October 2022
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Content ArticleA fit and proper person review into the conduct of former Shrewsbury and Telford Hospital Trust chair Ben Reid, who left in August 2020, has been published by the board. The report follows complaints about Mr Reid’s conduct from the family of baby Kate Stanton-Davies, who died in the trust’s care and whose case – alongside that of Pippa Griffiths – sparked the original Ockenden inquiry.
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Content ArticlePeople with a learning disability are more than twice as likely to die from avoidable causes than the rest of the population. Actor Tommy Jessop and BBC Panorama investigated some of the stories of families who say they were let down by their medical care.
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Content ArticleThis article* is an update from Dr Henrietta Hughes, Patient Safety Commissioner for England.
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Content ArticleThis article* is an update from Dr Henrietta Hughes, Patient Safety Commissioner for England.
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Content ArticleThis article* is an update from Dr Henrietta Hughes, Patient Safety Commissioner for England.
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News Article
We must challenge 'doctor knows best' attitude, bereaved mother says
Patient Safety Learning posted a news article in News
Merope Mills, an editor at the Guardian, has questioned doctors' attitudes after her 13-year-old daughter Martha's preventable death in hospital. Martha had sustained a rare pancreatic trauma after falling off a bike on a family holiday, and spent weeks in a specialist unit where she developed sepsis. An inquest concluded that her death was preventable, and the hospital apologised. Ms Mills said her daughter would be alive today if doctors had not kept information from the parents about her condition, because they would have demanded a second opinion. She added that doctors' attitudes "reeked of misogyny", citing a moment when her "anxiety" was used as an argument to not send critical care to Martha. In a statement, Prof Clive Kay, chief executive of King’s College Hospital NHS Foundation Trust said he was "deeply sorry that we failed Martha when she needed us most". "Our focus now is on ensuring the specific learnings from her case are used to improve the care our teams provide - and that is what we are committed to doing." Watch video Source: BBC News, 6 October 2022 Further reading on the hub ‘We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death (The Guardian) “Are you questioning my clinical judgement?” Suppressing parents’ concerns is a serious patient safety risk -
News Article
Covid inquiry ‘marginalising’ bereaved on first day of hearing
Patient Safety Learning posted a news article in News
Bereaved families fear their experiences will be “diluted” in the UK Covid-19 Inquiry after it was confirmed their evidence would be submitted to a third-party company. Instead of the usual “pen portraits” heard in the inquiry, families will submit their evidence to a private research company as part of a parallel listening exercise that will analyse the responses and feed back the findings to the inquiry chaired by Baroness Heather Hallett. Matt Fowler, co-founder of the Covid-19 Bereaved Families for Justice campaign, said while families believe the start of the inquiry is a step in the right direction after campaigning for two years, they fear being excluded from the inquiry because of the listening exercise. “All bereaved families want from the inquiry is the same outcome that anyone should, for lessons to be learnt from our loss that can stop the monumental scale of death that took place from happening again,” Matt said following the preliminary hearing. “As Baroness Hallett herself has acknowledged, for that to happen the experiences of the bereaved must be learnt from, so why is she leaving us out in the cold instead of working with us?” A&E doctor Saleyah Ahsan, from east London, worked in intensive care units during the pandemic. She said she remembers holding hands with people and telling them they needed to be incubated as they desperately called their families – some died in intensive care. “It is very important that stories jump off the page and are real because they are real,” She added: “If we really want to make sure we get this right there is only this inquiry, it has to be right. I am a medic, I see the numbers are rising, it’s autumn. Thankfully we’ve got a booster but hospitals are getting busy – I’m worried.” Read full story Source: The Independent, 4 October 2022 -
News Article
Tribunal told of 'failure' over girl's blood tests
Patient Safety Learning posted a news article in News
If doctors had tested a nine-year-old girl's blood sooner they may have changed the treatment she received before her death, an expert witness has confirmed to a medical tribunal. The hearing was told this was a "significant failure" in the care of Claire Roberts. Claire died at the Royal Belfast Hospital for Sick Children in 1996. In 2018 a public inquiry concluded she died from an overdose of fluids and medication caused by negligent care. At the time, her parents were told a viral infection had spread from her stomach to her brain. The General Medical Council (GMC) said one of the doctors involved in Claire's care, Dr Heather Steen, acted dishonestly in trying to conceal the circumstances of her death. Dr Steen denied allegations that she acted dishonestly and engaged in a cover-up. The Medical Practitioners Tribunal Service (MPTS) heard from a defence expert witness on Monday who said doctors not checking the sodium levels in Claire's blood earlier was a "significant failure" in her care. Dr Nicholas Mann told the tribunal he would have ordered more blood tests on Claire on the morning after she was admitted to hospital but he said he did not know if this would have prevented her death. "There should have been more attention to her fluids and electrolytes on the day after admission. Whether that would have altered the final outcome I don't know but certainly it would have been sensible to do that," he said. The tribunal also heard that Claire's death was not referred to a coroner, despite this being something all of the doctors caring for her would have had a duty to do. It was also told that a letter sent to Claire's parents from the hospital in 2005 contained inaccuracies. During questioning of Dr Mann, a barrister for the GMC highlighted the involvement of Dr Steen in compiling the letter which was signed by another doctor. Tom Forster KC said it was the GMC's case that Claire's family were given incorrect information about potential causes of her death despite these not being definitively diagnosed. Read full story Source: BBC News, 3 October 2022 -
News Article
Covid inquiry first preliminary hearing to begin
Patient Safety Learning posted a news article in News
The first preliminary hearing of the UK Covid public inquiry will begin today. The session, in London, will focus on the UK's pandemic preparedness before 2020. It will be largely procedural, involving lawyers and an announcement about who will be giving evidence. Public hearings where witnesses are called will not start until the spring. The inquiry formally started in the summer, with a listening exercise. But this first preliminary hearing is still being seen as an important milestone for the families who lost loved ones. Lindsay Jackson's mother, Sylvia, 87, died from Covid during the first lockdown, after contracting it at a care home. Ms Jackson, of the Covid-19 Bereaved Families for Justice campaign group, said it was essential lessons were learned. She was "really pleased" the inquiry was finally starting but it had taken too long to reach this stage. "It's two-and-a-half years since the pandemic started," she said. "We lost so many people. If people have done things wrong, they need to be held accountable. "For me, my family and the others who lost loved ones, it's important that answers are found to the questions that we have." Read full story Source: BBC News, 4 October 2022 -
News Article
Coroner criticises NHS trust’s treatment of family of woman who killed herself
Patient Safety Learning posted a news article in News
An NHS trust has “not covered itself in glory” in its dealings with the family of a vulnerable young woman who killed herself after being refused admission to hospital, a coroner has found. The three-day hearing looked at evidence withheld from the original inquest into the death of Sally Mays, who killed herself in 2014 after being turned away from a mental health unit. Mays was failed by staff “neglect” at Miranda House in Hull, a 2015 inquest ruled, after a 14-minute assessment led to her being refused a place, despite being a suicide risk. Her parents, Angela and Andy Mays, won a high court battle in December to hear details of an informal chat outside the building between Laura Elliot, a community mental health nurse who was supporting Mays, and the consultant psychiatrist Dr Kwame Fofie, which only later came to light. This was ruled to be “neither a clinical conversation nor an attempt to escalate her care” by senior coroner Prof Paul Marks on Wednesday. He said: “It was a conversation between colleagues in which the frustrations of the working day were vented.” But, he said: “The trust has not covered itself in glory with regard to its dealings with the family and the disclosing of documents.” The Mays have spent the last seven years fighting to hear details of the car park conversation, which could have changed their understanding of what happened before their daughter died. Angela Mays added: “I never considered myself to be a campaigner. I have only considered myself to be a mother who actually wants the truth about the facts relating to her daughter’s death.” Read full story Source: The Guardian, 28 September 2022 -
Content ArticleThe World Health Organisation's third World Patient Safety Day took place on 17 September. This year’s theme was medication safety. In this blog, Clare Wade, Assistant Director of Casework at the Parliamentary and Health Service Ombudsman (PHSO) discusses the impact of medication errors and gives examples of poor practice.
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News ArticleFamilies have blasted a NHS Trust after it said it did not intend to publish an independent review into their loved ones deaths. Three young people died in nine months at the same mental health unit. A Coroner was told last week that the review will be "ready" this month. Rowan Thompson, 18, died while a patient at the unit, based in the former Prestwich Hospital, Bury, in October 2020, followed by Charlie Millers, 17, in December that year, and Ania Sohail, 21, in June last year. Earlier this year, Greater Manchester Mental Health NHS Foundation Trust (GMMH), which runs the hospital, commissioned an 'external report' into the deaths. A pre-inquest hearing into the death of Rowan - who used the pronoun 'they' - heard that the full report would be available for the coroner to read 'on or around September 30'. Asked by the Manchester Evening News if the review would be published a spokesperson for the Trust said the Trust "always act on the wishes of the family regarding publication of reports," adding "and so in line with this we have no immediate plans to make the report public." But the parents of both Rowan Thompson and Charlie Mllers said they wanted the report publishing. Charlie's mother, Sam, said: "We want it published. It needs to be put out there, otherwise there is no point in having it. We are hoping they (The Trust) will learn lessons. We want answers but it should also be published for the benefit of the wider public - and the parents of other young people who are being treated in that unit." Read full story Source: The Manchester News, 13 September 2022
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News Article
UK care homes still stopping family reunions months after Covid rules eased
Patient Safety Learning posted a news article in News
Two and a half years after Boris Johnson announced the first UK lockdown, and seven months after the last domestic measures ended, some care homes in Britain are still denying people access to their elderly relatives due to Covid restrictions. Grandchildren have been banned by some homes, which put age limits on visitors. Others exclude whole families except for one relative named as “essential caregiver”, something that was dropped from government guidance in April. Support groups the Relatives & Residents Association (R&RA), and Rights for Residents also said there were homes not allowing people to see their parents, husbands or wives in their rooms, instead insisting that the visits take place in pods outside. And some only allow limited timed-visiting slots. About 70% of older care home residents have dementia and often find it distressing to be moved, only settling by the end of the slot. Campaigners have been calling for action to protect care home residents since the first lockdown, because relatives are often best able to help. Research from John’s Campaign shows that people who know someone with dementia are much better at interpreting their behaviour and giving comfort. Read full story Source: The Guardian, 25 September 2022 You may also be interested to read these two original blogs posted on the hub: Visiting restrictions and the impact on patients and their families: a relative's perspective It’s time to rename the ‘visitor’: reflections from a relative -
Content ArticleSpecialised services typically care for small numbers of patients with rare or complex conditions. They are commonly overlooked in debates around the future of the NHS. This is despite costs growing by over 50% in eight years, and now exceeding £20bn per year. The spotlight is returning, with proposals from NHS England to change how these services are planned, with power and responsibility being devolved down to new Integrated Care Boards – sub-regional structures across England. This report sets out a series of recommendations which Policy Exchange believe should underpin these reforms, including refinement of the services into more logical groupings, an expanded role for patient and carer input into service design, and stronger ministerial and financial oversight to ensure the sustainability of service delivery for the longer term.
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Content ArticleVonda Vaden Bates is an alliance builder and leadership coach. For over 30 years Vonda has guided professionals to succeed on behalf of their organisations and careers. She helps people move from potential to action, set and reach goals, manage engaged teams, and communicate with influence. In 2013 Vonda decided to contribute her skills on behalf of safety in healthcare after researching how her husband, Yogiraj Charles Bates, died from one of the most common preventable causes of death, hospital-associated venous thromboembolism. Advocating for every person in the care system, Vonda brings a compassionate voice, strategic skills, and collaboration expertise to improve communication and safety in healthcare. The Patient Safety Movement share her story.
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Content ArticleInvestigations of healthcare harm often overlook the valuable insights of patients and families. This review from Lauren et al. aimed to explore the perspectives of key stakeholders when patients and families were involved in serious incident investigations.
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Content ArticleA blog from the Patients Association for World Patient Safety Day on why patient partnership is key to the safe prescribing, supply and taking of medicines. "Being prescribed medication is one of the most common interactions between patient and healthcare professional: this World Patient Safety, let’s ensure all medicine prescribed today is done so following a discussion of its benefits and risks and with the patient’s full participation."
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News Article
Nottingham review scope 'wider than UK's biggest maternity scandal'
Patient Safety Learning posted a news article in News
The midwife leading a review into failings by Nottingham's maternity services said the scope was wider than the UK's biggest maternity scandal. Donna Ockenden previously led the review at Shrewsbury and Telford NHS Trust that found failings led to the deaths of more than 200 babies. The terms of reference for the review in Nottingham were set out on Tuesday. A category of severe maternal harm has been added to include cases that did not lead to a death or injury. Earlier this year Ms Ockenden completed her inquiry into the UK's biggest maternity scandal at Shrewsbury and Telford NHS Trust. She said the scope of the review in Nottingham was wider because an additional category had been added to the investigation. It aims to identify cases of severe maternal harm, like an unexpected admission to intensive care or a major obstetric haemorrhage. Ms Ockenden said: "We felt adding in the category of severe maternal harm would help us to understand women's experiences and help us to learn and help the trust to learn from those cases as well. "So actually there's been a widening of the scope which our review team felt was important and when we tested it out with some families they felt it was important too. "Perhaps there's a mum out there saying 'well I'm ok, and my baby's ok, but x,w,z of my maternity experience really worried me or frightened me' then she can send in her experiences." She said fathers could also send in their experiences. Read full story Source: BBC News, 14 September 2022 -
Content Article
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Copy of the speech from Helen Hughes, Chief Executive of Patient Safety Learning, given at the Professional Standards Authority for Health and Social Care (PSA) Parliamentary launch of the publication 'Safer care for all - Solutions from professional regulation and beyond'. -
News Article
It is crucial that doctors listen to patients – and their families
Patient Safety Learning posted a news article in News
Merope Mills’s recent article in the Guardian should be mandatory reading for all medical and nursing students. All of us who are senior doctors or nurses will recognise only too well the dangerous conditions that Merope describes: the senior doctors with overinflated egos; the internecine warfare between departments; the nursing staff and junior doctors who are rendered impotent by repeated attempts to galvanise action from off-site but know-it-all seniors; the lack of integrated thinking that results when there is no consistent lead clinician; and, most dangerous, not listening to the patient or their relatives, and not directly examining the patient. Candour and co-production are terms much used in healthcare, but for some staff these aspects of care are a million miles away from the ego-driven practice in which they engage. This is why Merope’s advice is so important. Do not have blind faith in your clinician. Do not leave all the thinking to them. Do equip yourself with knowledge and, most of all, do demand to be treated as an equal partner in the care of your body or your loved one. Current and former healthcare professionals respond to Merope Mills’s account of losing her daughter after a series of catastrophic medical errors. Read full story Source: The Guardian, 11 September 2022 -
Content ArticleCall 4 Concern enables patients, relatives and carers to call for help/advice from the Acute Intervention Team when they are concerned about a patient’s condition, and/or they feel that their concern is not being addressed by the ward team. County Durham and Darlington share their Call 4 Concern leaflet.
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News Article
Nottingham maternity failings: Hundreds of families contact review team
Patient Safety Learning posted a news article in News
More than 350 families have already contacted a review team which is examining failings at maternity units in two Nottingham hospitals. The review was opened on 1 September by Donna Ockenden, who previously led an inquiry into the maternity scandal at Shrewsbury and Telford NHS Trust. She will examine how dozens of babies died or were injured in Nottingham. Nottingham University Hospitals NHS Trust has apologised for "unimaginable distress" caused by its failings. More affected families, as well as staff with concerns, have been asked to come forward. Ms Ockenden said: "We are really pleased with the large numbers of families and staff that have already come forward in the first week of the review, and we actively encourage others to do the same." Read full story Source: BBC News, 12 September 2022 -
Content Article
The Josie King Foundation
Patient Safety Learning posted an article in International patient safety
On 22 February 2001, eighteen-month-old Josie King died from medical errors. More than 250,000 people die every year from medical errors, making it the third leading cause of death in the United States. The Josie King Foundation’s mission is to prevent patients from dying or being harmed by medical errors. By uniting healthcare providers and consumers, and funding innovative safety programs, we hope to create a culture of patient safety, together. -
Content ArticleSharing her story in the Guardian, Merope gives a heart breaking account of how her daughter, Martha Mills, was allowed to die, but also what happens when you have blind faith in doctors – and learn too late what you should have known to save your child’s life.
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