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Found 543 results
  1. News Article
    The government has proposed new legislation to make patient visiting a legal right and also give the Care Quality Commission (CQC) fresh powers to enforce it. The Department of Health and Social Care has launched a consultation to seek views from patients, care home residents, families, professionals and providers on the introduction of new legislation which will require health and care settings, including hospitals, to accommodate visitors in most circumstances. It said the new visiting laws will also provide the CQC with a “clearer basis for identifying where hospitals and care homes are not meeting the required standard”, and enable it to enforce the standards by issuing requirement or warning notices, imposing conditions, suspending a registration or cancelling a registration. It said although the CQC currently has powers “to clamp down on unethical visiting restrictions”, the expected standard of visiting rules is not “specifically outlined in regulations”. Read full story (paywalled) Source: HSJ, 21 June 2023
  2. News Article
    Dozens of former patients are launching legal action against a group of scandal-hit children’s mental health hospitals after The Independent exposed a culture of “systemic abuse”. More than 30 people, some of who are still children, are taking action after claiming they were mistreated at children’s hospitals run by The Huntercombe Group between 2003 and 2023. Allegations include children being injured during restraint, inappropriate force-feeding and patients being over-medicated. Among the claimants are: A boy who has been left “traumatised” after being “drugged out of his mind” while staying at one of the hospitals. A girl who alleges she was groped by a member of staff and now needs more intensive inpatient care. A woman who says she was “forced to wee in bins” as there were not enough staff to take patients to the toilet. A mother of one claimant told The Independent: “It is diabolical, I hope [the claims] can stop them from doing any more damage because it is just awful. Our beautiful girl has just been so ruined by them.” Read full story Source: The Independent, 18 June 2023
  3. News Article
    An NHS trust has been accused of adding to the records of a man the day after he took his own life to "correct their mistakes". Charles Ndhlovu, 33, died under the care of Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) in 2017. Mr Ndhlovu, who was diagnosed with paranoid schizophrenia and substance misuse, had been under CPFT's care two months when he died. He had been transferred from a neighbouring trust after moving to Ely and then been taken off a community treatment order. His mother, Angelina Pattison, told the BBC that despite being heavily involved in her son's care, she was "shocked that they transferred him without even telling me". A trust serious untoward incident (SUI) review acknowledged that when he was transferred no-one from CPFT had asked about whether his family had been involved in his care. Ms Pattison said: "They didn't have any address of [my home] in his care plan and the care plan was done when he died - when they were running around to correct their mistakes, which they have done" The BBC has separately spoken to consultant nurse and psychotherapist Des McVey, who was asked by the trust to investigate a complaint in July 2021, understood to be the one from Ms Pattison. Mr McVey said: "I noticed that the deceased did have care plans, but they were written the day after his death and they were also evaluated the day after his death and I was concerned that this wasn't picked up by the SUI." He said this "really alarmed me", adding: "Surprisingly, there was no care plan to address his suicidal ideation and he had... an extensive history of trying to kill himself." Read full story Source: BBC News, 15 June 2023 .
  4. News Article
    More than three quarters of all multimillion-pound NHS medical negligence payouts are the consequences of failures in maternity care, new figures show. In total, 364 patients or families received the highest-value compensation payments of at least £3.5 million after suing the NHS last year. Of those, 279 (77%) were maternity-related damages, according to figures from NHS Resolution. The large payouts have been offered to parents whose babies were stillborn or suffered avoidable life-changing disabilities or brain injuries. Maternity makes up the bulk of NHS compensation payments. There were more than 10,000 clinical negligence claims brought against the NHS in 2021-22, with a total value of more than £6 billion. Maternity accounted for 62% of payments, or £3.74 billion. When taking into account all cost of harm, including future periodic payments and legal costs, the cost of compensating mothers and their families rises to £8.2 billion a year. Analysis by The Times Health Commission found that this is more than twice the £3 billion spent by the NHS annually on maternity and neonatal services. Maternity claims have increased during the past decade amid a string of high-profile scandals and a shortage of midwives. Read full story (paywalled) Source: The Times, 12 June 2023
  5. News Article
    Bereaved families of coronavirus victims feel the Welsh government has not adequately taken part in the Covid public inquiry, their solicitor says. Craig Court, who represents bereaved families, said the Welsh government had not participated "as well as they should have". He claimed the Welsh government failed to deliver crucial paperwork with just days to go before Tuesday's inquiry. The UK-wide inquiry could go on as long as three years, and will predominantly look at the UK government's approach to the pandemic. A Wales-specific inquiry was blocked by Labour members of the Senedd, with First Minster Mark Drakeford saying it should wait until after the UK-wide investigation had been completed. Mr Court told BBC Wales "there is a great concern over the duty of candour" displayed by the Welsh government. Read full story Source: BBC News, 9 June 2023
  6. News Article
    Grieving parents have been left waiting more than 14 months for answers about why their 12-day-old son died. Elijah was born at Merthyr Tydfil's Prince Charles Hospital on 25 February 2022 and died after being diagnosed with enterovirus and myocarditis. Joann and Christian Edwards said they were told they would have a report by the end of 2022, but are still waiting. Joann and Christian, from Mountain Ash, Rhondda Cynon Taf, said they were told Elijah's myocarditis was a "one off" but subsequently read about 10 babies, including one who died, getting severe enterovirus with myocarditis across south Wales. Public Health Wales (PHW) said Elijah's death was not being looked into as part of an investigation into this cluster of cases, as the dates were set at June 2022 to April 2023 to coincide with the enterovirus season. But it said it would look to include Elijah's death as part of a "wider clinical investigation" of the cases. Read full story Source: BBC News, 15 May 2023
  7. News Article
    The mother of a nine-year-old girl who died from hyponatraemia has said a new inquest that started today is "an opportunity for truth". Raychel Ferguson, from Londonderry, died at the Royal Belfast Hospital for Sick Children in June 2001. Her parents, Ray and Marie Ferguson, have long campaigned to find out the truth about their daughter's death. Hyponatraemia is an abnormally low level of sodium in blood and can occur when fluids are incorrectly administered. Mrs Ferguson said the fact there was a second inquest "speaks to the culture of cover up that has plagued her death, involving the medical and legal professions". An inquiry in 2018 into the deaths of five children in Northern Ireland hospitals, including Raychel, found her death was avoidable. The 14-year-long inquiry into hyponatraemia-related deaths was heavily critical of the "self-regulating and unmonitored" health service. In January 2022, a new inquest opened but was postponed in October after new evidence came to light. Read full story Source: BBC News, 2 May 2023
  8. Content Article
    This short blog highlights the situations where patients, carers, parents and relatives are failed by healthcare systems and by the leadership. They are left to stand alone against powerful institutions, because when staff speak up and 'blow the whistle' it often results in retaliation. Investigating and resolving the patient safety issue then becomes buried under an employment issue.
  9. Content Article
    After Steve Burrow’s mother was harmed by medical care in Wisconsin, he took time out from his successful film career to advocate for her. In this episode of Lit Health, he touches upon his fascinating career, why stories matter, and delves deeply into his experience with the medical system, its need for policy reform and the role he has taken on as an advocate in this space with host, Tracy Granzyk. Lit Health podcasts interview authors, healthcare leaders, and policymakers working to create a healthcare environment that is equitable, transparent, and that welcomes the needs of every patient – especially our vulnerable populations including the mentally ill, people of colour and women who feel they are at risk in our current system, the elderly, and anyone who feels bias or the isms affect their health and quality of life. You can also watch Steve Burrow's documentary: Bleed Out,
  10. Content Article
    Sarah Woolf shares the impact her cancer treatment had on her mental health and describes why it is important to see each patient as a whole person, understanding that their body has meaning for them
  11. Content Article
    Jenny Edwards died in February 2022 from pulmonary embolism, following misdiagnosis. In this blog, her son Tim introduces us to Jenny, illustrating the deep loss felt following her premature passing. He talks about the care she received and argues that there were multiple points at which pulmonary embolism should have been suspected. Tim found the investigation that followed Jenny’s death to be lacking in objectivity and assurance that any learning could be taken forward. He has since produced an independent report, drawing on existing data, freedom of information requests and his mother’s case, to highlight broader safety issues.
  12. Content Article
    Fundamentals of Health Care Improvement: A Guide to Improving Your Patient’s Care, 4th edition, is intended to help health professional learners diagnose, measure, analyse, change and lead improvements in healthcare, with the aim to shape reliable, high-quality systems of care in partnership with patients. Copublished by Joint Commission Resources and the Institute of Healthcare Improvement, this fourth edition includes updated resources, including examples, figures, tables, and tools. New to this edition is a focus on health equity and disparities of care brought to light by the COVID-19 pandemic. This focus explores the relationship between social determinants of health and how improvement methods and skills can help identify and close disparity gaps in systems of care. Also new to this edition is an expanded discussion of effective teamwork and the importance of creating multidisciplinary health care teams that partner with patients and families.
  13. Content Article
    Patient safety incident investigations (PSII) are system-based responses to a patient safety incident for learning and improvement. Typically, a PSII includes four phases: planning, information gathering, synthesis, and interpreting and improving. More meaningful involvement can help reduce the risk of compounded harm for patients, families and staff, and can improve organisational learning, by listening to and valuing different perspectives.
  14. Content Article
    The Invited Reviews service was formed in 1998 and offers consultancy services to healthcare organisations on which they may require independent and external advice. Reviews provide an opportunity to healthcare organisations to deal with issues and concerns at an early stage. Medical directors (MDs) or chief executive officers (CEOs) of healthcare organisations can request an invited review when they feel the practice of clinical medicine is compromised and there are potential concerns over patient safety. The Royal College of Physicians (RCP) Invited Reviews service has gained a wealth of experience dealing with demanding situations involving individuals, teams, departments and services. This is their learning from invited reviews report. It brings together their experiences across multiple specialities, identifying common themes and crystallising some of our generic findings, which will prove useful to all in clinical leadership roles.
  15. Content Article
    An expert review of the clinical records of 44 deceased patients who had been under the care of neurologist Dr Michael Watt has found there were “significant failures” in their treatment and care. Dr Watt, a former Belfast Health and Social Care Trust consultant neurologist, was at the centre of Northern Ireland’s largest ever recall of patients, which began in 2018, after concerns were raised about his clinical work. More than 4,000 of his former patients attended recall appointments. At the direction of the Department of Health, in August 2021, the Regulation and Quality Improvement Authority (RQIA) commissioned the Royal College of Physicians to undertake an expert review of the clinical records of certain deceased patients who had been under the care of Dr Watt, with the intention to understand his clinical practice, to ensure learning for others and to help make care better and safer in the future.
  16. Content Article
    A recently published report highlights the shortcomings in care provided by the NHS. Peter Walsh, Joanne Hughes and James Titcombe emphasise how millions could be saved if people were empowered early on to have their needs met without the need to turn to litigation
  17. Content Article
    This open letter from patient safety campaigner Richard von Abendorff calls for patients, their families and safety campaigners to help improve patient investigation and patient inclusive systems. Richard highlights a new role coming up at the new Health Services Safety Investigations Body (HSSIB).
  18. Content Article
    Keeping patients safe during their care and treatment should be at the heart of any health system, including the NHS. Yet avoidable harm still occurs every day, around the world. There have been major efforts to prioritise patient safety in England, but the pandemic has shone a light on areas of care where progress has stalled, or safety has deteriorated. This report by Imperial College London's Institute of Global Health Innovation, commissioned by Patient Safety Watch, brings together publicly available data to present a national picture of patient safety in England. 
  19. News Article
    Two out of five maternity units in England are providing substandard care to mothers and babies, the NHS watchdog has warned. “The quality of maternity care is not good enough,” the Care Quality Commission (CQC) said in its annual assessment of how health and social care services are performing. It published new figures showing it rated 39% of maternity units it inspected in the year to 31 July to “require improvement” or be “inadequate” – the highest proportion on record. Ian Trenholm, the CQC’s chief executive, said maternity services were deteriorating, substandard care was unacceptably common and failings were “systemic” across the NHS. Its latest state of care report said: “Our ratings as of 31 July 2022 show that the quality of maternity services is getting worse, with 6% of NHS services (nine out of 139) now rated as inadequate and 32% (45 services) rated as require improvement. “This means that the care in almost two out of every five maternity units is not good enough.” The report said: “The findings of recent reviews and reports … show the same concerns emerging again and again. The quality of staff training, poor working relationships between obstetric and midwifery teams and a lack of robust risk assessment all continue to affect the safety of maternity services. These issues pose a barrier to good care.” Staff not listening to women during pregnancy and childbirth is a recurring problem, Trenholm said. Their concerns “are not being heard” by midwives and obstetricians “in the way that they should”. Read full story Source: The Guardian, 21 October 2022
  20. News Article
    More than 200 families in south-east England will learn today the results of a major inquiry into the maternity care they received from a hospital trust. The investigation into East Kent Hospitals NHS Trust follows dogged campaigning by one determined bereaved grandfather. Derek Richford's grandson Harry died at East Kent Hospitals after his life support system was withdrawn. Sixty one-year-old Derek had never campaigned for anything in his life. His initial approach was to wait for East Kent Hospitals Trust to investigate the death, as it had promised. However, one nagging issue that was to become central to Derek's view of the trust, was the hospital's continual refusal to inform the coroner of Harry's death. The family repeatedly requested it, but the trust said it was unnecessary as it knew the cause, namely the removal of the life support system. The hospital also recorded Harry's death as "expected" - again because his life support system had been withdrawn. On both points, the family were left confused and increasingly angry. In early March 2018, some four months after Harry's death, the family finally received the outcome of the trust's internal investigation - known as the Root Cause Analysis (RCA). The RCA indicated multiple errors had been made in Harry and Sarah's care and treatment, and his death was "potentially avoidable". Prior to the meeting, Derek wrote to the Kent coroner's office outlining in general the circumstances of Harry's case, asking if that was the type they would expect to be notified of. The email response from the coroner's office was clear. It said: "Based on the facts you have presented, this death should have been reported to the coroner." Despite this, at the meeting with the trust, the lead investigator into Harry's death told the family: "If we have a clear cause of death by and large we do not involve the coroner." The family's insistence eventually paid off - five weeks after that meeting, the trust informed the coroner of Harry's death. While his son and daughter-in-law started trying to recover from the trauma of losing Harry, Derek turned his attention to investigating East Kent, one of the largest hospital trusts in England. "When I started investigating what was going on with Harry, it was very much like peeling back an onion. 'Hang on a minute, that can't be right, that doesn't add up.' Ever since I was a small kid, justice has been so important to me. "What I found was that, up to that point, no-one had ever joined the dots. And that's so important. I think this had to happen, someone had to do it. There will be families before us that wish they did it. We will be saving a level of families after us." Read full story Source: BBC News, 19 October 2022
  21. News Article
    The grandfather of a baby who died at a hospital that was fined over failings in the delivery has spoken of his five-year fight for justice. Derek Richford was speaking as an independent report into baby deaths at the East Kent Hospitals Trust will be released this week. He said he "came up against a brick wall" while searching for answers over the death of grandson Harry Richford. An inquest into Harry's death at Margate's Queen Elizabeth the Queen Mother Hospital in 2017 found it was wholly avoidable and contributed to by neglect. Coroner Christopher Sutton-Mattocks said the inquest, which was finally held in 2020, was only ordered due to the family's persistence. The following year the trust was fined £733,000 after admitting failing to provide safe care and treatment for mother Sarah Richford and her son following a prosecution by the Care Quality Commission (CQC). Mr Richford said: "To start with we felt fairly alone and we felt like we were coming up against a brick wall. "The trust were refusing at that time to call the coroner. They were reporting Harry's death as 'expected'. "We didn't contact anyone other than the CQC just to say 'look there's been a problem here'." He said at a meeting with the trust, more than five months later, "we suddenly realised that there were a huge [number] of errors". Mr Richford told the BBC: "It took me about a year to come up with all the detail I needed and to speak to all the right people." He said the family then spoke to the Health Safety Investigation Branch who found there were issues. Mr Richford also tracked down a "damming" report by the Royal College of Obstetricians and Gynaecologists (RCOG). "In the end it was like peeling back the layers of an onion, and the more you took off, the more you found," he said. Read full story Source: BBC News, 18 October 2022
  22. News Article
    The chief executive of an NHS trust at the centre of a maternity scandal where there were at least seven preventable baby deaths has warned staff to prepare for a "harrowing report" into what happened. In an email seen by Sky News, East Kent Hospitals University NHS Foundation Trust chief executive Tracey Fletcher told her staff to expect a "harrowing report which will have a profound and significant impact on families and colleagues, particularly those working in maternity services". An independent investigation into the trust, stretching back over a decade, will be published this week and is expected to expose a catalogue of serious failings. It is also expected to say the avoidable baby deaths happened because recommendations that were made following reports into other NHS maternity scandals were not implemented. The East Kent review is led by obstetrician Dr Bill Kirkup, who also chaired the investigation into mother and baby deaths in Morecambe in 2015. Dawn Powell's newborn son Archie died in February 2019 aged four days. In an emotional interview, Mrs Powell told Sky News she will never get over the loss of her son, who would be alive today if she or Archie had been given a routine antibiotic. "For families like us, where your child has been taken away, you have forever got that hole in your life that you will never heal," Mrs Powell said. Read full story Source: Sky News, 16 October 2022
  23. News Article
    At 9.16am Florence Wilkinson gave birth to a healthy baby boy by planned caesarean section. The team of NHS doctors and midwives worked like a well-oiled machine, performing what to them was a standard operation, while also showing real kindness. After a short stint in a close observation bay, Florence was moved onto the postnatal ward. Still anaesthetised, Florence was completely reliant on her partner Ben to help her recover from the birth and feed her son in his first hours of life. Yet just a few hours later, the scene was very different. Due to Covid protocol, Ben was not able to stay overnight. At 8pm, midwives bustled around briskly ejecting fathers and birth partners from the ward – and what followed was one of the hardest, most frightening nights of Florence's life. She was alone with a newborn, yet during the course of that night she only saw a midwife once. She was still recovering from my operation and unable to pick up her baby. An exhausted healthcare assistant told Florence she didn’t have time to help and the newborn didn’t feed for seven hours. There simply weren’t enough staff to look after the mothers, but no partner to advocate for them either. A review of the maternity policies listed on the websites of 90 hospital trusts in England reveals that 54% still restrict partners from staying overnight after birth. While a few trusts have always limited access at night, many admit to bringing in restrictions during the pandemic which they continue to implement to this day. “It is deeply concerning to hear that some Trusts are continuing to implement restrictions on visiting, such as limited postnatal visiting overnight, under the premise of Covid, particularly at this stage in the pandemic,” says Francesca Treadaway, director of engagement at the charity Birthrights. “There is overwhelming evidence, built up since March 2020, of the impact Covid restrictions in maternity had on women giving birth. It must be remembered that blanket policies are rarely lawful and any policies implemented should explicitly consider people’s individual circumstances.” Read full story (paywalled) Source: The Telegraph, 13 October 2022
  24. News Article
    An 88-year-old woman with dementia was physically and mentally abused at a luxury care home charging residents close to £100,000 a year, the Guardian can reveal. Staff misconduct was exposed by secret filming inside the home run by Signature Senior Lifestyle, which operates 36 luxury facilities mostly in the south of England. It has admitted that Ann King was mistreated at Reigate Grange in Surrey earlier this year. Distressing footage from a covert camera inside her room shows: Care staff handling King roughly, causing her to cry out in distress. On one occasion she was left on the floor for 50 minutes. King being taunted, mocked and sworn at when she was confused and frightened. The retired nurse being assaulted by a cleaner, who hits her with a rag used to clean a toilet while she is lying in bed. The cleaner threatening to empty a bin on the pensioner’s head and making indecent sexual gestures in her face. The abuse was exposed by King’s children, Richard Last and Clare Miller. They became so concerned about her wellbeing at the care home, where she lived from January 2021 to March 2022, that they installed a hidden camera on her bedside table. They have shared the footage because they fear what happened to their mother may not be an isolated incident, and because: “She has always been horrified by this type of thing and we felt she would have wanted us to show this is going on.” Read full story Source: The Guardian, 13 October 2022
  25. News Article
    There were ’obfuscations, difficulties and failures’ in a scandal-hit trust’s handling of a baby’s death, a damning review has found, although it cleared the organisation’s former chair of ’serious mismanagement’. A 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. In March 2022, the final Ockenden report into maternity services at Shrewsbury found poor maternity care had resulted in almost 300 avoidable baby deaths or brain damage cases in the most damning review of maternity services in the NHS’s history. Report author Fiona Scolding KC said she does not believe Mr Reid “lied” or acted unethically in his handling of complaints from the family and therefore this does not disqualify him from holding office within the terms of such a review. However, the report is highly critical of the trust, with Ms Scolding concluding it is “undoubtedly true” the provider had not dealt with Kate’s father Richard Stanton and her mother Rhiannon Davies in an “open and honest” way in respect of their daughter’s death. Read full story (paywalled) Source: HSJ, 13 October 2022
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