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Content ArticleIn honour of World Health Organization World Patient Safety Day 2023, the Patient Safety Movement Foundation hosted a webinar dedicated to the theme of “Empowering Patients.”
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Content ArticlePatients’ perspectives and their active engagement are critical to make health systems safer and people-centred, and are key for co-designing health services and co-producing good health with healthcare professionals, and building trust in health systems. This report, which forms part of a series of Organisation for Economic Co-operation and Development (OECD) papers on the economics of patient safety, looks (i) the economic impact of patient engagement for patient safety; (ii) the results of a pilot data collection to measure patient-reported experiences of safety and; (iii) the status of initiatives on patient engagement for patient safety taken in 21 countries, which responded to a snapshot survey.
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Content ArticleThe Institute of Global Health Innovation (IGHI), Imperial College Healthcare NHS Trust and NIHR North West London Patient Safety Research Collaboration hosted a virtual event to celebrate World Patient Safety Day, chaired by Professor Bryony Dean-Franklin. The event started with keynote speeches from Professor the Lord Ara Darzi, Co-Director of IGHI; Dr Henrietta Hughes, England’s Patient Safety Commissioner; and Rosie Bartel, patient advocate, emphasising the importance of hearing patient’s voices. This was followed by an excellent panel session on how clinicians, researchers, and patients and carers can work together to support patients and their families to feel safe and engage with their care. The event was co-designed with patient representatives from NIHR North West London Patient Safety Research Collaboration and Imperial College Healthcare NHS Trust.
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Content ArticleFamily-activated medical emergency teams (MET) have the potential to improve the timely recognition of clinical deterioration and reduce preventable adverse events. Adoption of family-activated METs is hindered by concerns that the calls may substantially increase MET workload. Brady et al. aimed to develop a reliable process for family activated METs and to evaluate its effect on MET call rate and subsequent transfer to the intensive care unit (ICU).
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Content Article
The Forgiveness Project
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The Forgiveness Project shares stories of forgiveness in order to build hope, empathy and understanding. -
Content ArticleThe focus of this year's World Patient Safety Day is engaging patients in “recognition of the crucial role patients, families and caregivers play in the safety of healthcare”. In this Comment in the Lancet, Jane O'Hara and Carolyn Canfield outline how supporting patients and families to be partners in care safety is both a logical and moral imperative. That is, we need to do it for safer care, but we also should do it because safer care relies on relationships, reciprocal trust, and collaboration.
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News Article
NHS Scotland to improve patient safety through 'compassionate communication'
Patient Safety Learning posted a news article in News
A study conducted by NHS Education for Scotland and Health Improvement Scotland found patients felt safer by having someone listen to their experiences after adverse events. The findings were published in the BMJ and have been positively received by NHS boards across the country. Healthcare Improvement Scotland’s Donna Maclean said: “The compassionate communications training has seen an unprecedented uptake across NHS boards in Scotland, with the first two cohorts currently under way and evaluation taking place also.” Clear communication and a person-centred approach was seen as being central to helping those who have suffered from traumatic events. Researchers found many said their faith was restored in the healthcare system if staff showed compassion and active engagement. This approach is likely to enhance learning and lead to improvements in healthcare. Health boards were advised that long timelines can have a negative impact on the mental health of patients and their families. Rosanna from Glasgow, who was affected by an adverse event, said: “I believe this study and its findings are crucial to truly understanding patients and families going through adverse events. “Not only does the study capture exactly what needs to change, but it also highlights the elements that are most important to us: an apology and assurance that lessons will be learnt is all we really want. Read full story Source: The National, 30 May 2022 -
News ArticleDonna Ockenden, the midwife who investigated the Shopshire maternity scandal, has been appointed to lead a review into failings in Nottingham following a dogged campaign by families. The current review will be wound up by 10 June after concerns from NHS England and families that it is not fit for purpose. It was commissioned after revelations from The Independent and Channel Four News that dozens of babies had died or been brain-damaged following care at Nottingham University Hospitals Foundation Trust. In a letter to families on Thursday, NHS England chief operating officer David Sloman said: “I want to begin by apologising for the distress caused by the delay in our announcing a new chair and to take this opportunity to update you on how the work to replace the existing Review has been developing as we have taken on board various views that you have shared with us.” “After careful consideration and in light of the concerns from some families, our own concerns, and those of stakeholders including in the wider NHS that the current Review is not fit for purpose, we have taken the decision to ask the current Review team to conclude all of their work by Friday 10 June.” “We will be asking the new national Review team to begin afresh, drawing a line under the work undertaken to date by the current local Review team, and we are using this opportunity to communicate that to you clearly.” Ms Ockenden said: “Having a baby is one of the most important times for a family and when women and their babies come into contact with NHS maternity services they should receive the very best and safest care." “I am delighted to have been asked by Sir David Sloman to take up the role of Chair of this Review and will be engaging with families shortly as my first priority. I look forward to working with and listening to families and staff, and working with NHS England and NHS Improvement to deliver a Review and recommendations that lead to real change and safer care for women, babies and families in Nottingham as soon as possible.” Read full story Source: BBC News, 26 May 2022
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News ArticleThe former health secretary Jeremy Hunt has claimed the government snubbed bereaved families’ requests for Donna Ockenden to chair a review into maternity services in Nottingham as she is “too independent”. Hundreds of families involved in the Nottingham maternity scandal review have called for Ms Ockenden, chair of the Shrewsbury maternity scandal inquiry, to take over the investigation. NHS England had attempted to appoint a former healthcare leader, Julie Dent to chair the review. However, following pressure from families not to accept, Ms Dent announced shortly after she would be declining the role. Following the families’ calls for Ms Ockenden, Mr Hunt, chair of the government’s health committee, said on Wednesday: “I can’t see any other barriers to appointing her but sounds like she still won’t be. For some reason the Department of Health appears to think she is too independent – which is of course precisely why Nottingham families do have confidence in her. It feels like another own goal.” Families involved in the Nottingham maternity review, which will now cover almost 600 cases, have said they’ve been left in limbo by NHS England after if informed them of an interim report which has been completed by the review team. This follows several letters from families to health secretary Sajid Javid raising concerns over the review and calls for it to be overhauled. Speaking with The Independent, a couple whose son died under the care of Nottingham University Hospitals Foundation Trist said: “The key to successful long term change is developing a relationship with harmed families, built on trust, sensitivity and understanding. The current review does not command this. The relationship is untenable.” Read full story Source: The Independent, 26 May 2022
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News Article
Families dismay at interim report plans despite review ‘chaos’
Patient Safety Learning posted a news article in News
Families involved in a major review into maternity failings at Nottingham University Hospitals Trust (NUH) have criticised the decision of the review team to press ahead with the publication of an interim report, despite serious concerns about its terms of reference and methodology. A “thematic review” into NUH was first announced last year after reports that dozens of babies died or were brain damaged after errors were made at the trust over the last decade. More than 460 families have since contacted the review team. The review has been overseen by NHS England and local commissioners, but, in April, the families called for an independent inquiry and asked for it to be carried out by Donna Ockenden, the senior midwife who chaired the high-profile review of Shropshire maternity services, which reported in March. Last month, NHSE chief operating officer Sir David Sloman wrote to families and said former strategic health authority chair Julie Dent would be brought in to chair the review. However, Ms Dent stepped down from the role weeks later, citing “personal reasons”. A new chair is yet to be appointed. Despite these uncertainties, families have been told by the review team that an interim report will be issued shortly. Gary Andrews, whose daughter Wynter died after being delivered by caesarean section at NUH’s Queens Medical Centre in 2019, said to issue an interim report “seems at odds with the current situation” and risked causing “significant distress” to families. He added: “We need government to get to grips with this review. Put the brakes on, ensure its structure and design and objectives are fully supported by families, before any interim report can be issued.” Read full story (paywalled) Source: HSJ, 19 May 2022 -
News Article
Trusts resist visiting rule after ‘Javid threatens to call CEOs’
Patient Safety Learning posted a news article in News
Local clinical leaders are continuing to question pressure from government and NHS England to relax Covid-19 visiting restrictions. Visitors, and people accompanying patients, have been restricted throughout covid, and in recent months there has been substantial local variation. Ministers and NHSE, as well as other politicians and some patient groups, have been pressing for more relaxed restrictions for some time and in recent weeks have stepped up their instructions. National visiting guidance was eased in March, and other infection control guidance, including requiring the isolation of covid contacts, was relaxed last month. Last week, the Daily Telegraph reported health and social care secretary Sajid Javid planned to “name and shame” trusts not implementing the changes, and to call hospital chief executives directly about it. Meanwhile, chief nursing officer Ruth May reiterated the visiting rules last month, saying on Twitter: “We must not underestimate the important contribution that visiting makes to the wellbeing and personalised care of patients and make it happen.” However, an NHSE online meeting for clinical leaders on Friday was told that while “a great number of trusts have returned to previous visiting policies… we know there are trusts which haven’t implemented this fully”. One said: “It is very difficult to safely return to pre-covid visiting as some hospital’s estate can’t safely support visitors in already over-crowded [emergency departments] and increasingly busy [outpatient departments]. “Surely local risk assessment is key and should be supported rather than increasing pressure to simply blanketly return to pre-pandemic arrangements everywhere?” Read full story (paywalled) Source: HSJ, 9 May 2022 You may also be interested in: 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 -
News Article
Maternity scandal review chair resigns after pressure from families
Patient Safety Learning posted a news article in News
The newly appointed chair of a major review into poor maternity care in Nottingham has resigned following mounting pressure from families. Julie Dent was appointed by the NHS just two weeks ago to lead a review into hundreds of cases of alleged poor care at Nottingham University Hospitals NHS Trust. On 7 April, more than 100 families called for Ms Dent to decline the offer after they had previously urged NHS England to appoint Donna Ockenden, who chaired the Shrewsbury and Telford maternity inquiry. In a letter to families on Wednesday, the chief operating officer of NHS England and NHS Improvement, David Sloman, said: “After careful consideration and further conversations with her family, Julie Dent has, for personal reasons, decided not to proceed as chair of the independent review of maternity services at Nottingham University Hospitals NHS Trust.” The letter said that NHS England and NHS Improvement would still have “oversight” of the independent review, and that a new review process was being established. Mr Sloman said he would write to families to inform them of the next stage in the review “shortly”. The Nottingham independent maternity review was launched in July last year, and since then more than 500 families have come forward, the majority in the last two months. Read full story Source: The Independent, 4 May 2022 -
News Article
'Utterly inhumane' hospitals still ban bedside visitors as Covid cases plunge
Patient Safety Learning posted a news article in News
Hospitals are still banning patients from having bedside visitors in ‘immoral’ Covid restrictions. Last night, MPs, patient groups and campaigners criticised the postcode lottery that means some frail patients are still denied the support of loved ones. Nine trusts continue to impose total bans on any visitors for some patients, The Mail on Sunday has found. Almost half of trusts maintain policies so strict that they flaunt NHS England’s guidance that patients should be allowed at least two visitors a day. Shrewsbury and Telford Hospital NHS Trust, Sandwell and West Birmingham Hospitals NHS Trust and Royal Papworth Hospital NHS Foundation Trust are among those continuing total bans on visiting for some of their patients. University College London Hospitals NHS Foundation Trust (UCLH) has even been imposing its draconian restrictions on disabled patients who need special help for their care – only allowing visits on three days a week for a maximum of an hour each time. Tory MP Alicia Kearns said: ‘It is utterly unforgivable and immoral. There is no scientific evidence for any remaining inhumane restrictions on visiting. Trusts are breaching the rights of families. 'Visitors save lives, they advocate and calm their loved ones. When will this madness end?’ Read full story Source: MailOnline, 1 May 2022 You may also be interested in: 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 -
News Article
Maternity scandal families slam NHS over no confidence vote ‘silence’
Patient Safety Learning posted a news article in News
Families impacted by the Nottingham maternity scandal say they have been left in “limbo” following silence from NHS England in response to their concerns over a major review, as 50 more come forward. The review into failures in maternity services at Nottingham University Hospitals Foundation Trust has now had 512 families come forward with concerns, up from 460 last month, and has spoken to 71 members of staff. The update comes as families told The Independent they were yet to receive a direct acknowledgement or response to their warning on Monday that they had no confidence in newly appointed review chairwoman Julie Dent. In response to a letter outlining her appointment, the families asked for Ms Dent to decline the offer and instead pushed for NHS England to ask Donna Ockenden, who is chairing a similar inquiry into Shrewsbury maternity care. Former health secretary and health committee chairman, Jeremy Hunt, has now also challenged the NHS on Ms Dent’s appointment, and echoed the families’ call to ask Ms Ockenden. Read full story Source: The Independent, 29 April 2022 -
News Article
Failing NHS negligence system must change, say MPs
Patient Safety Learning posted a news article in News
A major reform of the way NHS clinical negligence claims are handled in England is needed, MPs say. The House of Commons' Health and Social Care Committee said the current system was too adversarial, leading to bitter and long legal fights for patients. More than £2bn a year is paid out on claims, but 25% goes to legal fees. An independent body should be set up to adjudicate on cases and the need to prove individual fault should be scrapped, the cross-party group said. Instead, the focus should be whether the system failed, which the MPs believe would create a better culture for learning from mistakes. The committee heard from families who had lost children or whose babies had been left with brain injuries from mistakes made during birth. Parents described how they had to fight for years to get recognition for the harm that had been caused. One woman criticised the "complacent attitude" of the hospital involved, saying they just wanted to put it down to one mistake and carry on as normal. Another woman whose daughter died aged 20 months after errors in her care said she felt lessons had not been learnt despite a settlement in her favour. She said the whole process had left her feeling devastated. The average length of time for these settlements was over 11 years, the committee was told. Read full story Source: BBC News, 27 April 2022 -
News ArticleThe death of a young woman a day after she was discharged from a mental health facility has sparked renewed calls for a public inquiry into a scandal-hit trust. Abbigail Smith, 26, who had autism and learning difficulties, was found dead in a park in Essex in February, 24 hours after she was allowed to leave the Linden Centre run by the Essex Partnership University Hospitals Foundation Trust (EPUT). The trust has launched an investigation into the care she received before she died, according to a letter seen by The Independent, and Essex Coroner’s Court will examine her death. The Independent can reveal 97 patient deaths have been declared by the trust between February 2021 and February 2022 under the national patient safety alert system. The trust is already facing an independent inquiry into 1,500 patient deaths between 2000 and 2020. Deaths after December 2020 will not be looked at by that inquiry. At least 68 families have called for a public inquiry into mental health services in Essex, led by Melanie Leahy, whose son Matthew died at the Linden Centre in 2012. Nina Ali, a solicitor at Hodge Jones & Allen, which is supporting the Wolffs and other families, told The Independent: “It is worrying that the government has and continues to completely ignore the call led by Melanie Leahy, now supported by some 68 families and individuals, for the current independent inquiry to be converted to a full statutory inquiry on the basis that the current inquiry – which lacks the statutory power to compel relevant documentary evidence to be obtained and to compel witnesses to attend and give their evidence under oath – will ultimately prove to be a complete waste of time and money.” Read full story Source: The Independent, 25 April 2022
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News Article
Governance scandal trust failing to manage complaints
Patient Safety Learning posted a news article in News
A trust which is facing major governance issues is failing to respond to hundreds of complaints properly, with patients and families waiting more than twice as long as the NHS target for responses to their concerns, an external review has found. Cornwall Partnership Foundation Trust, which is subject to regulatory action by NHS England, was found to be “not classifying complaints, concerns and comments accurately”, while staff had “no formal training”, meaning complaints were “not investigated appropriately”. Last year, the trust was embroiled in a governance scandal in which NHSE investigated multiple allegations of finance and governance failings, resulting in the departure of former CEO Phil Confue. Rachel Power, chief executive of the advocacy group Patients Association, told HSJ patient complaints often contain “vital intelligence” on how trusts can improve services and “essential warnings about any area where things might be going wrong”. According to the review, the backlog had stemmed from several factors. These included more work being needed on investigations that had not been thorough enough, and the relevant service teams not responding to enquiries by the complaints team. Additionally, there was a “lack of formal monitoring and review” to ensure complaint points were reported appropriately and consistently, and an “apparent lack of accountability by local teams for complaints” triaged through the trust’s patient liaison and complaints team. Read full story (paywalled) Source: HSJ, 12 April 2022- Posted
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News Article
NHS regulator ‘not fit for purpose’ for dismissing baby deaths scandal warnings
Patient Safety Learning posted a news article in News
The healthcare regulator has been branded “not fit for purpose” after dismissing warnings of the biggest maternity scandal in NHS history, The Telegraph can reveal. Letters seen by this newspaper show that the Care Quality Commission (CQC) told grieving parents it would not support an independent inquiry into baby deaths, just months before such an investigation was ordered. Rhiannon Davies wrote to the watchdog in Dec 2016, alerting the regulator to 19 avoidable deaths of mothers and babies at the Shrewsbury and Telford Hospital NHS Trust, as well as a string of cases where lives were put at risk. However, the head of the CQC at the time assured Ms Davies that the culture was “changing for the positive”, rebuffing her calls for an independent inquiry. Ms Davies had provided the watchdog with details of a string of deaths, which she and fellow bereaved parents had found from publicly available information. The information was contained in a letter to Jeremy Hunt, the health secretary at the time, and shared with the regulator, setting out why families believed an inquiry was required. On Tuesday night, Ms Davies said that the refusal of the CQC to back an investigation, and the false assurances given by its most senior figure, showed how it “never scratched beneath the surface” despite death after death. Ms Davies said that she had “absolutely no faith” in its current ability to regulate and spot future scandals, saying it had “pushed back” every effort made by families to expose the failings at Shrewsbury. “They are not fit for purpose because we cannot trust them to be doing their job properly,” she told The Telegraph. Read full story (paywalled) Source: The Telegraph, 5 April 2022 -
News Article
Families in Nottingham maternity inquiry hit out at review
Patient Safety Learning posted a news article in News
Dozens of families have written to the government expressing concern over a review into failing maternity units in Nottingham. A probe into Nottingham University Hospitals Trust is under way after dozens of babies died or were injured. But families say the review is "moving with the viscosity of treacle". They have called for Donna Ockenden, who led the inquiry into the UK's biggest maternity scandal, to take charge of a review. In a letter to Health Secretary Sajid Javid, a group of 100 people raised concerns with the current thematic review, which has been commissioned by the local clinical commissioning group (CCG) and NHS England, and NHS Improvement. According to the CCG, the review will look at themes and trends and put in "place detailed and measurable actions so improvements can be made fast". But families have questioned the independence of the review and the experience of the team to handle a probe of this magnitude. It is chaired by Cathy Purt, a long-time NHS manager who the families believe has no experience of running complex inquiries or maternity services. The letter states: "If families are to be safeguarded, real intervention is required." Read full story Source: BBC News, 7 April 2022 -
News Article
Families asked to take in Covid-positive loved ones as NHS faces ‘perfect storm’
Patient Safety Learning posted a news article in News
NHS chiefs have issued an extraordinary plea for families to help them discharge loved ones even if they are Covid-19 positive as the health service faces a “perfect storm” fuelled by heavy demand, severe staff shortages and soaring Covid cases. Hospitals and ambulance services across England are under “enormous strain”, health leaders have warned, after NHS trusts covering millions of patients declared critical incidents or issued stark warnings to residents. Dr Layla McCay, director of policy at the NHS Confederation, which represents the whole healthcare system, said the situation had become so serious that “all parts” of the health service were now becoming “weighed down”. This will have a “direct knock-on effect” on the ability of staff to tackle the care backlog, she added, as well as the current provision of urgent and emergency care. On Wednesday evening, the crisis became so acute in Hampshire and the Isle of Wight that its chief medical officer urged relatives of patients well enough to be discharged to collect them immediately – even if they were still testing positive for coronavirus. Dr Derek Sandeman, of the Hampshire and Isle of Wight Integrated Care System, revealed that almost every hospital in the two counties was full, and said the number of people with Covid-19 being cared for in hospitals across the area was 650 – more than 2.5 times higher than in early January. He added that 2,800 staff working for local NHS organisations were off sick, half of which absences were due to Covid-19. “With staff sickness rates well above average, rising cases of Covid-19 and very high numbers of people needing treatment, we face a perfect storm – but there are some very specific ways in which people can help the frontline NHS and care teams,” said Sandeman. Read full story Source: The Guardian, 6 April 2022 -
News Article
NHSE warned of ‘inaccurate’ and ‘unethical’ investigation into man’s death
Patient Safety Learning posted a news article in News
An independent investigation into the death of a man with autism and learning difficulties in NHS care may never be published in full as his sister has rejected several drafts as inaccurate, telling NHS England they were ‘totally unethical’. Anthony Dawson died from a burst gastric ulcer in Ashmount, a residential care home run by Surrey and Borders Partnership Foundation Trust, in May 2015. The jury at an inquest into his death found there were gross failings in his care and his death was contributed to by neglect. NHS England commissioned an independent investigation into the incident from Sancus Solutions in June 2017. But seven years after Mr Dawson’s death the investigation’s report has yet to be published, despite several reports being submitted. His sister, Julia Dawson, has written to NHS chief executive Amanda Pritchard in recent weeks saying: “The investigation has not had my brother at its heart which we were assured would be the case” and that its reports had been “totally unethical”. Ms Dawson has asked that only the executive summary of the latest draft of the investigation be published, alongside a statement saying that she feels it has inaccuracies and misses out important points. She says that successive drafts have misrepresented her brother’s situation and failed to address what she believes was the real cause of his death – the frequent use of NSAIDs (ibuprofen) without any measures taken to protect his stomach. This ultimately led to the undiagnosed gastric ulcer bursting. An expert witness told the inquest into his death that treatment with proton pump inhibitors and stopping NSAIDs would have eradicated the ulcer. Read full story (paywalled) Source: HSJ, 4 April 2022 -
News Article
Abuse of staff at ‘dangerous level’, say NHS bosses
Patient Safety Learning posted a news article in News
Healthcare leaders have written an open message to NHS staff, drawing attention to “the dangerous level” of abuse many are confronted with, “simply for going to work”. In the message, more than 40 NHS leaders in London said that every year “tens of thousands” of NHS staff are “confronted with violence and aggression from patients”. “Now, the abuse is at a dangerous level, with many of our once hailed heroes fearing for their safety,” they said. “We, leaders of the NHS in London, are speaking with one voice to say that aggression and violence towards our staff will not be tolerated.” Signatories include Andrew Ridley, the NHS England London interm regional director, integrated care system leaders, leaders from general practice and community pharmacy, and many trust bosses from the capital, including Central and North West London FT chief executive and national director for mental health Claire Murdoch. The message thanked NHS staff for continuing to care for people and encouraged the reporting of “all forms of verbal and physical abuse from patients, their families and friends so that we may take action”. They also sent a message to patients and their families: “We will strive to do our best for you and your loved ones. People who are most unwell do need to be seen most urgently, but all our patients are important to us and will receive the care needed. While we are thankful for the support shown by so many, to those who show violence and aggression let it be known: abusing our staff is never ok.” Read full story (paywalled) Source: HSJ, 21 March 2022 -
News Article
Failure to act on sepsis led to man’s death
Patient Safety Learning posted a news article in News
A man died after an NHS trust failed to diagnose and treat sepsis quickly enough, a Parliamentary and Health Service Ombudsman investigation has found. Stephen Durkin died after suffering organ failure from sepsis. Stephen’s wife Michelle made a complaint to the Ombudsman after she was left floored by his sudden death which she believed was avoidable. Stephen was an otherwise healthy 56-year-old when he attended Wye Valley Trust A&E in July 2017 with chest pain. Hospital staff suspected he had a major blood vessel blockage and admitted him to a ward overnight. The next morning his overall condition had worsened but staff did not monitor him more closely, as national guidance advises, and he continued to deteriorate throughout the day. The next day Stephen was admitted to intensive care and treated for sepsis but tragically died later that evening. In the space of 48-hours his condition deteriorated rapidly but staff did not act quickly enough and the critical care team attended Stephen ten hours too late. His wife Michelle arrived at the hospital to visit Stephen, only to find that he was critically ill and unresponsive. She was left devastated by his death and turned to the Ombudsman to look into what had happened with his care. Ombudsman Rob Behrens said: "Stephen’s tragic death could so easily have been avoided. His case shows why early detection of sepsis, as set out in national guidelines, is crucial." "Sadly, this is not the first time we have had to highlight this issue. There is clearly more the NHS needs to do. It is vital that NHS trusts ensure their staff are sepsis-aware to reduce the number of avoidable deaths from this life-threatening condition." Read full story Source: PHSO, 3 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
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:
