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News Article
Senegal midwives convicted over mother's death
Patient Safety Learning posted a news article in News
Three Senegalese midwives involved in the death of a woman in labour have been found guilty of not assisting someone in danger. They received six-month suspended sentences, after Astou Sokhna died while reportedly begging for a Caesarean. Her unborn child also died. Three other midwives who were also on trial were not found guilty The case caused a national outcry with President Macky Sall ordering an investigation. Mrs Sokhna was in her 30s when she passed away at a hospital in the northern town of Louga. During her reported 20-hour labour ordeal, her pleas to doctors to carry out a Caesarean were ignored because it had not been planned in advance, local media reported. The hospital even threatened to send her away if she kept insisting on the procedure, according to the press reports. Her husband, Modou Mboup, who was in court, told the AFP news agency that bringing the case to light was necessary. "We highlighted something that all Senegalese deplore about their hospitals," "If we stand idly by, there could be other Astou Sokhnas. We have to stand up so that something like this doesn't happen again." Read full story Source: BBC News, 11 May 2022 -
News ArticleHeart surgery patients in London have died “unnecessarily” and faced increased risk of death as botched NHS investigations into dozens of deaths reduced a hospital’s ability to treat people, a coroner has warned. “Unnecessary” patient deaths have occurred as a result of heart surgery at St George’s University Hospital Trust being restricted and emergencies diverted to other “over stretched” hospitals, following investigations by national NHS bodies. The warning that deaths have occurred and may occur in the future, comes following the conclusion of a series of inquest hearings in March, during which it was found the NHS’ wrongly blamed a team of cardiac surgeons for the deaths of dozens of patients. Coroner Fiona Wilcox, in a report published on Wednesday, has now said the “inadequate” NHS led investigations, which criticised the care of 67 patients, led to people being put increased risk of death. The NHS’ investigations into the deaths of 67 patients ruled there were “shortcomings” in care. It led to complex operations being diverted elsewhere and doctors being referred to the General Medical Council. Two doctors have sinced been exonerated following GMC hearings. According to the coroner’s findings, capacity within cardiac surgery at the unit is down by 60% and staff are becoming “deskilled.” Read full story Source: The Independent, 11 May 2022
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News Article
Plymouth maternity staff missed chances to save baby’s life, report finds
Patient Safety Learning posted a news article in News
A baby died after maternity staff repeatedly missed chances to intervene to save his life, an official investigation has found. Giles Cooper-Hall was just 16 hours old when he died after a catalogue of errors in the maternity care of his mother, Ruth Cooper-Hall, at Derriford hospital in Plymouth. A Healthcare Safety Investigation Branch (HSIB) report into the incident has exposed how inexperienced and overstretched staff failed to carry out proper checks, recognise there was an emergency or seek help from senior doctors until it was too late. It comes just weeks after the independent Ockenden report into more than 1,800 cases revealed serious failings in the maternity care provided at Shrewsbury and Telford hospital NHS Trust. It revealed how Ruth Cooper-Hall, then aged 37, was not personally seen by a consultant when she went into labour in October last year, despite recommendations made in the interim Ockenden report published in December 2020. The HSIB report also suggested Giles’ death could have been avoided if staff had known about the care plan for his mother’s labour. Instead, vital messages were not passed on, with the investigation finding this was likely to be because the staff responsible were “distracted” by other tasks. Read full story Source: The Guardian, 10 May 2022 -
News Article
‘Staff holidays’ delay death review by up to nine months
Patient Safety Learning posted a news article in News
A coroner has expressed ‘serious concern’ after a trust-wide safety review – prompted by the death of a young mother – was delayed by up to nine months due to ‘staff holidays’. An inquest heard that 25-year-old Natasha Adams, who died by suicide in August 2021, had had her level of care downgraded by Birmingham and Solihull Mental Health Foundation Trust a month earlier, in July, something her family suggested had a “dramatic impact”. She was moved from a “care programme approach” (known as CPA, which involves enhanced care for people with complex needs and/or safety concerns) to “care support” (a non-clinical programme for people with lower-level concerns and complexities). An earlier investigation into her death by the trust, finalised in December, said the trust should audit other cases to check whether the trust’s 2019 “care management and CPA/care support policy” was being complied with. Now Birmingham and Solihull coroner James Bennett has criticised a delay in carrying out the trust-wide audit – writing in a prevention of future deaths report that, as of last month, four months after the report investigating Ms Adams’ care was completed, “no action has been taken”. Read full story (paywalled) Source: HSJ, 5 May 2022 -
News Article
WHO claims true global death toll from pandemic is nearly 15 million
Patient Safety Learning posted a news article in News
Almost 15 million people have died as a result of the Covid-19 pandemic around the world, new figures from the World Health Organisation (WHO) reveal. Estimates from the WHO show that the number of excess deaths associated directly or indirectly with the pandemic between 1 January 2020 and 31 December 2021 was approximately 14.9 million – 13% more deaths than normally expected over a two-year period. Excess mortality is calculated as the difference between the number of deaths that have occurred and the number that would be expected in the absence of the pandemic, based on data from earlier years. WHO director general Dr Tedros Adhanom Ghebreyesus said: “These sobering data not only point to the impact of the pandemic but also to the need for all countries to invest in more resilient health systems that can sustain essential health services during crises, including stronger health information systems." Most of the excess deaths (84%) are concentrated in southeast Asia, Europe, and the Americas, the WHO said, while some 68% of excess deaths are concentrated in just 10 countries globally. It also found that middle-income countries account for 81 per cent of the 14.9 million excess deaths (53% in lower-middle-income countries and 28% in upper-middle-income countries) over the 24-month period, with high-income and low-income countries each accounting for 15% and 4%, respectively. Read full story Source: The Independent, 5 May 2022 -
News Article
Baby death mother 'was not seen by obstetrician'
Patient Safety Learning posted a news article in News
A woman whose baby died after sustaining severe brain damage during labour was not seen by an obstetrician during her pregnancy, an inquest heard. It meant his mother Eileen McCarthy was unable to discuss her birthing options. Walter German was starved of oxygen during a long labour at the Royal Sussex County Hospital in Brighton. Lawyers at Fieldfisher are pursuing a civil negligence case, claiming a C-section should have been offered due to a previous third-degree tear. Walter was born in December 2020. His life-support was turned off after nine days, as his injuries were unrecoverable. Recording a narrative verdict, coroner Sarah Clarke said Walter died as a result of his brain being starved of oxygen, likely due in part to an umbilical cord obstruction. She said: "Walter's mother was not seen by an obstetrician during her pregnancy and this led to her being unable to discuss birth options regarding delivery given her previous third degree tear. "Walter's mother was in the advanced stages of labour for a prolonged period of time with an indication for an earlier obstetric review being apparent." Read full story Source: BBC News, 4 May 2022 -
News Article
Obesity ‘epidemic’ leading to 1.2m deaths a year in Europe, says WHO
Patient Safety Learning posted a news article in News
Obesity has reached “epidemic proportions” in Europe, the World Health Organization says, as a major report shows the disease is causing 200,000 cancer cases and 1.2 million deaths a year. In the first such study for 15 years, the WHO said overweight and obesity rates had hit deadly levels and were “still escalating”. No country in the region was on track to meet the WHO global noncommunicable disease (NCD) target of halting the rise of obesity by 2025, it said. Across Europe, 59% of adults are overweight or obese as well as 8% of children under five and one in three children of school age. Obesity prevalence in Europe is higher than in any other part of the world except the Americas, according to the report presented at the European Congress on Obesity. Obesity is linked to a string of other diseases, including musculoskeletal complications, type 2 diabetes, heart disease and at least 13 types of cancer. The report said excess body fat led to premature death and was a leading risk factor for disability. “Across the WHO European region, obesity is likely to be directly responsible for at least 200,000 new cancer cases annually, with this figure projected to rise in the coming decades,” the report said. “For some countries within the region, it is predicted that obesity will overtake smoking as the main risk factor for preventable cancer.” Dr Hans Kluge, the WHO regional director for Europe, said reversing the obesity epidemic in Europe was still possible. “By creating environments that are more enabling, promoting investment and innovation in health, and developing strong and resilient health systems, we can change the trajectory of obesity in the region.” Read full story Source: The Guardian, 3 May 2022 -
News Article
Covid: Discharging hospital patients to care homes 'unlawful'
Patient Safety Learning posted a news article in News
Government policies on discharging untested patients from hospital to care homes in England at the start of the Covid pandemic have been ruled unlawful by the High Court. The ruling comes after two women took former Health Secretary Matt Hancock and Public Health England to court. Dr Cathy Gardner and Fay Harris said it had caused a "shocking death toll". Prime Minister Boris Johnson renewed his apologies for all those who lost loved ones during the pandemic. Dr Gardner and Ms Harris partially succeeded in claims against Mr Hancock and Public Health England. The women claimed key policies of discharging patients from hospitals into care homes were implemented with no testing and no suitable isolation arrangements in the homes. A barrister representing Dr Gardner and Ms Harris told the court at a hearing in March that more than 20,000 elderly or disabled care home residents died from Covid between March and June 2020 in England and Wales. Jason Coppel QC also said in a written case outline for the judicial review that the care home population was known to be "uniquely vulnerable" to Covid. "The government's failure to protect it, and positive steps taken by the government which introduced Covid-19 infection into care homes, represent one of the most egregious and devastating policy failures in the modern era," he added. Read full story Source: BBC News, 27 April 2022 -
News Article
US doctor accused of killing 14 patients found not guilty
Patient Safety Learning posted a news article in News
In an unprecedented murder case in the United States about end-of-life care, a physician accused of killing 14 critically ill patients with opioid overdoses in a Columbus, Ohio hospital ICU over a period of 4 years was found not guilty by a jury Wednesday. The jury, after a 7-week trial featuring more than 50 witnesses in the Franklin County Court of Common Pleas, declared William Huse not guilty on 14 counts of murder and attempted murder. In a news conference after the verdict was announced, lead defense attorney Jose Baez said Husel, whom he called a "great doctor," hopes to practice medicine again in the future. The verdict, he argued, offers an encouraging sign that physicians and other providers won't face prosecution for providing "comfort care" to patients suffering pain. "They don't need to be looking over their shoulders worrying about whether they'll get charged with crimes," he said. The trial raised the specific issue of what constitutes a medically justifiable dose of opioid painkillers during the end-of-life procedure known as palliative extubation, in which critically ill patients are withdrawn from the ventilator when they are expected to die. Under medicine's so-called double-effect principle, physicians must weigh the benefits and risks of ordering potentially lethal doses of painkillers and sedatives to provide comfort care for critically ill patients. To many observers, however, the case really centered on the largely hidden debate over whether it's acceptable to hasten the deaths of dying patients who haven't chosen that path. That's called euthanasia, which is illegal in the United States. In contrast, 10 states plus the District of Columbia allow physicians to prescribe lethal drugs to terminally ill, mentally competent adults who can self-administer them. That's called medical aid in dying, or physician-assisted dying or suicide. Read full story Source: Medscape, 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
‘I thought she’d be safe’: a life lost to suicide in a place meant for recovery
Patient Safety Learning posted a news article in News
"I thought she would be safe at Chadwick Lodge,” said Natasha Darbon, recalling how she felt in April 2019 when her 19-year-old daughter, Brooke Martin, was admitted to the mental health hospital in Milton Keynes. Eight weeks later, Brooke took her own life. The jury at the inquest found that Brooke’s death could have been prevented and that the private healthcare provider Elysium Healthcare, which ran the hospital, did not properly manage her risk of suicide. It also found that serious failures of risk assessment, communication and the setting of observation levels contributed to her death. Elysium accepted that had she been placed on 24-hour observations, Brooke would not have died. In 2018, Brooke, who was autistic, was repeatedly sectioned under the Mental Health Act because of her escalating self-harm and suicide attempts. After a spell in an NHS facility in Surrey she moved to Chadwick Lodge, which specialises in treating personality disorders. After a few weeks there, Brooke was doing well and staff were pleased with her progress. She was due to move to Hope House, a separate unit at the hospital, to start more specialist therapy for emotionally unstable personality disorder, and was keen to make the switch. But then the teenager’s mental health deteriorated again. On 5 June 2019 she tried to kill herself. Five days later she was seen twice that evening secretly handling potential ligatures, but no appropriate action was taken. A few minutes later she was found unresponsive in her room. She received CPR but died the next day in Milton Keynes university hospital. After hearing the evidence about the care Brooke received in her final days, Tom Osborne, the coroner at the inquest, took the unusual step of issuing a prevention of future deaths notice. He sent it to Sajid Javid, the health secretary, and to Elysium Healthcare, as the owner of Chadwick Lodge. It set out the detailed criticisms that the jury had made of Elysium’s interaction with Brooke after her attempt to take her own life on 5 June. They cited the hospital’s failures to communicate information regarding Brooke’s suicide attempt, to search her room after she was found handling potential ligatures on the night she died, and to place Brooke on constant observations afterwards. Read full story Source: The Guardian, 24 April 2022 -
News Article
Father calls for overhaul of 'flawed' suicide assessments
Patient Safety Learning posted a news article in News
A father whose son took his own life in July 2020 is calling for an "urgent overhaul" of the way some counsellors and therapists assess suicide risk. His son Tom had died a day after being judged "low risk", in a final counselling session, Philip Pirie said. A group of charities has written to the health secretary, saying the use of a checklist-type questionnaire to predict suicide risk is "fundamentally flawed". The government says it is now drawing up a new suicide-prevention strategy. According to the latest official data, 6,211 people in the UK killed themselves in 2020. It is the most common cause of death in 20-34-year-olds. And of the 17 people each day, on average, who kill themselves, five are in touch with mental health services and four of those five are assessed as "low" or "no risk", campaigners say. Tom Pirie, a young teacher from Fulham, west London, had been receiving help for mental-health issues. He had repeatedly told counsellors about his suicidal thoughts - but the day before he had killed himself, a psychotherapist had judged him low risk, his father said. Tom's assessment had been based on "inadequate" questionnaires widely used despite guidelines saying they should not be to predict suicidal behaviour, Philip said. The checklists, which differ depending on the clinicians and NHS trusts involved, typically ask patients questions about their mental health, such as "Do you have suicidal thoughts?" or "Do you have suicidal intentions?" At the end of the session, a score can be generated - placing the individual at low, medium or high risk of suicide, or rating the danger on a scale between 1 and 10. Read full story Source: BBC News, 20 April 2022 -
News Article
Hospital admits negligence over failings leading to baby’s sepsis death
Patient Safety Learning posted a news article in News
A hospital has admitted clinical negligence over maternity care failings that led to the potentially avoidable death of a 10-day-old baby, The Independent has learned. Kingsley Olasupo and his twin sister Princess were born on 8 April 2019 at Royal Bolton Hospital. Kingsley died 10 days later following a catalogue of mistakes, which included failing to screen him for sepsis. Kingsley and his sister were born premature at 35 weeks. Three days later he was admitted to the special care unit due to a low temperature and “poor” feeding. Despite being reviewed by two doctors he was not screened for an infection and not given antibiotics. His condition deteriorated and on 12 April he was diagnosed with bacterial meningitis and sepsis. Days later scans revealed he had severe brain damage and would not survive. Kingsley’s family said they had been “torn apart” by their son’s death and had pursued the trust to ensure a full independent investigation was carried out and lessons learnt. BFT launched an investigation into Kingsley’s care after Mr Olasupo and Ms Daley raised concerns over their son’s death. According to the trust’s investigation report, seen by The Independent, failings in care included that Kingsley was not screened for sepsis despite several “red flags”. Had this been done he would have been given antibiotics. When midwives first escalated concerns to the neonatal team no physical medical review of Kingsley took place. The investigation also found neonatal staff did not carry out daily reviews, and reviews that were done were incomplete and contained “inaccurate” and “misleading” information. Other failings included: “Ineffective” assessment of Kingsley’s wellbeing on the postnatal ward Poor communication between staff and poor handover processes No consideration was given to the fact Kingsley was not feeding well Inadequate recording of observations. Read full story Source: The Independent, 20 April 2022 -
News Article
‘I feel so let down’: long waits for ambulances in south-west England
Patient Safety Learning posted a news article in News
More than four hours after an ambulance was called, Richard Carpenter, 71, who had had a suspected heart attack, began to despair. “Where are they?” he asked his wife, Jeanette. “I’m going to die.” She tried to reassure her husband that the crew must surely be close. Perhaps they were struggling to find their rural Wiltshire home in the dark. “But I could see I was losing him,” she said. She gave her husband CPR and urged him: “Don’t leave me.” But by the time the paramedics arrived another hour or so later, it was too late. Jeanette Carpenter, 70, a stoical and reasonable person, accepts it might have been impossible to save her husband. “But I think he would have had more of a chance if they had got here sooner,” she said. It is the sort of sad story that is becoming all too common. Across England, but in particular in the south-west, ambulances are too often not getting to patients in a timely manner. Before Covid, said one ambulance worker – who asked not to be named – he would do between six and 10 jobs in a shift. Now if the first person he is called to needs to go to hospital, he expects this will be his one job for the whole shift. “At some hospitals we are waiting outside hospitals for 10, 11 or 12 hours,” he said. “There’s nothing more demoralising than hearing a general broadcast going out for a cardiac arrest or road accident and there’s no resources to send. It’s terrible to think someone’s loved one needs help and we can’t do anything because we’re stuck at a hospital.” Read full story Source: The Guardian, 10 April 2022 -
News ArticleOn 25 March2022, a Tennessee jury convicted RaDonda Vaught, a nurse at Vanderbilt University Medical Center, of criminally negligent homicide and impaired adult abuse in a 2017 medication administration error that tragically resulted in a patient death. The Washington State Nurses Association have issued a joint statement adamantly opposed to criminalization of patient care errors. "Focusing on blame and punishment solves nothing. It can only discourage reporting and drive errors underground. It not only undermines patient safety; it fosters an environment of fear and lack of respect for health care workers." "The Vaught case has drawn intense national attention and concern. We join with health care workers and patient safety experts around the country and the world in rejecting the criminalization of medical errors. Further, we are committed to redoubling our efforts to achieve health care environments that are safe for patients and health care workers alike. This includes the ongoing, critical fight to achieve safe staffing standards in Washington state." Read full statement Source: Washington State Nurses Association, 8 April 2022
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News Article
Care home resident died after unqualified nurse administered wrong medication
Patient Safety Learning posted a news article in News
A nurse with no qualifications gave a care home resident a fatal dose of the wrong drug, leading to her death before she then tried to cover up her mistake. Katherine Hutchinson gave Fiona Jayne Thorne a fatal overdose of a powerful anti-psychotic drug, which was meant for another patient, an inquest heard. She then tried to cover up her errors which contributed to the death of the 36-year-old with learning difficulties, Derbyshire Live reported . Ms Hutchinson had, at the time, been the nurse in charge at Whitwell Park Care Home, in Whitwell, Derbyshire despite not having any qualifications. She gave Miss Thorne clozapine, which had been intended for another resident, on October 6, 2010. Instead of owning up to what she did, Ms Hutchinson then tried to cover up her mistake by taking Miss Thorne to bed and leaving her there until she was discovered, Senior Coroner Dr Robert Hunter said. Miss Thorne was "found by the care support worker around midnight, when undertaking routine checks on residents”, the inquest heard. And then Ms Hutchinson’s mistake was only discovered after an audit was carried out of the medication trolley and a dosage of clozapine was found. Read full story Source: Mirror, 8 April 2022 -
News Article
Patients continue to die and be harmed by the failure to learn from unsafe care
Patient Safety Learning posted a news article in News
Press release: 7 April 2022 Today the charity Patient Safety Learning has published a new report, ‘Mind the implementation gap: The persistence of avoidable harm in the NHS'. The report is an evidence-based summary of the failures over decades to translate learning into action and safety improvement. It highlights that avoidable unsafe care kills and harms thousands of people each year in the UK and costs the NHS billions of pounds for additional treatment, support, and compensatory costs. The report highlights how we fail to learn lessons from incidents of unsafe care and are not taking the action needed to prevent harm recurring. The report focuses on six sources of patient safety insights and recommendations, ranging from inquiry reports into patient safety scandals, such as the recent Ockenden report into maternal and neonatal harm at Shrewsbury and Telford Hospital, to the findings of Coroner’s Prevention of Future Deaths reports. It calls on the Government, parliamentarians, and NHS leaders to take action to address the underlying causes of avoidable harm in healthcare and proposes recommendations in each policy area. Patient Safety Learning is calling for system-wide action in healthcare to transform our approach to learning and safety improvement. Helen Hughes, Chief Executive of Patient Safety Learning, said: “Today’s report highlights the all too frequent examples of where healthcare organisations fail to learn lessons from incidents of unsafe care and not taking the action needed to prevent future harm. Time and time again there is a lack of action and coordination in responding to recommendations, an absence of systems to share learning and a lack of commitment to evaluate and monitor the effectiveness of safety recommendations.” “This is a shocking conclusion that is an affront to all those patients and families who have been assured that ‘lessons have been learned’ and ‘action will be taken to prevent future avoidable harm to others’. The healthcare system needs to understand and address the barriers for implementing recommendations, not just continually repeat them. Hope is not a strategy.” This report has been published as part of the Safety for All Campaign, which calls for improvements in, and between, patient and healthcare worker safety to prevent safety incidents and deliver better outcomes for all. The campaign is supported by Patient Safety Learning and the Safer Healthcare and Biosafety Network. Notes to editors: Patient Safety Learning is a charity and independent voice for improving patient safety. We harness the knowledge, insights, enthusiasm and commitment of health and social care organisations, professionals and patients for system-wide change and the reduction of avoidable harm. Safer Healthcare and Biosafety Network an independent forum focused on improving healthcare worker and patient safety and has been in existence more than 20 years. It is made up of clinicians, professional associations, trades unions and employers, manufacturers and government agencies with the shared objective to improve occupational health and safety and patient safety in healthcare. COVID-19 pandemic has provided a stark reminder of the vital role healthcare professionals play in providing care to those in our society who need it most and this was recognized in the WHO Patient Safety Day in September 2020: only when healthcare workers are safe can patients be safe. In 2020, the Network launched a campaign called ‘Safety for All’ to improve practice in, and between, patient and healthcare worker safety to prevent safety incidents and deliver better outcomes for all. -
News Article
Police investigating deaths of two babies last year at scandal-hit trust
Patient Safety Learning posted a news article in News
Detectives have begun an investigation into the deaths of two babies at the hospital trust at the centre of the largest maternity scandal in NHS history. The babies died in separate incidents last year at the Shrewsbury and Telford Hospital NHS Trust, both during birth. One of them was a twin. The cases were among 600 examined by West Mercia police alongside an inquiry by Donna Ockenden, a senior midwife and manager, into failings at the trust. Her report revealed last week that 201 babies had died and 94 suffered brain damage as a result of avoidable mistakes. Nine mothers also died because of errors in care. Detectives are working with prosecutors to determine whether charges should be brought over the two deaths last year, after years of warnings that maternity services were in crisis. West Mercia police said they were investigating the trust as an organisation as well as individuals. The trust could face a charge of corporate manslaughter if it is found that the way the hospital organised and managed its services caused a death that amounted to a “gross breach” of its duty of care. If found guilty, the trust would face an unlimited fine. Individuals charged with gross negligence manslaughter could go to jail if convicted. The move by the police comes amid growing fears that the unsafe care identified in the report could be taking place in maternity services in other parts of the country. Read full story (paywalled) Source: The Times, 3 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
Nurse's conviction should be wake-up call for health system leaders, IHI says
Patient Safety Learning posted a news article in News
RaDonda Vaught's conviction for a fatal medical error has already damaged patient safety and should serve as a wake-up call for health system leaders to improve harm prevention efforts, the Institute for Healthcare Improvement has said. Ms. Vaught was convicted 25 March of criminally negligent homicide and abuse of an impaired adult for a fatal medication error she made in December 2017 while working as a nurse at Vanderbilt University Medical Center in Nashville, Tenn. "We know from decades of work in hospitals and other care settings that most medical errors result from flawed systems, not reckless practitioners," IHI said. "We also know that systems can learn from errors and improve, but only when those systems encourage reporting, transparently acknowledge their mistakes and are held accountable for those errors." The organization said criminal prosecution of errors over-focuses on the individual and diverts attention from necessary system-level issues and improvements. "Were this practice to be repeated in future cases of a serious or fatal error, there will be more damage, less transparency, less accountability and more lives lost," IHI said. "Instead, this case should be a wake-up call to health system leaders who need to proactively identify system faults and risks and prevent harm to patients and those who care for them." -
News ArticleSeaman Danyelle Luckey “didn’t die in combat or any military operation. She died from gross negligence of the medical providers on the ship she served, the USS Ronald Reagan,” said her father, Derrick Luckey. Danyelle Luckey died from sepsis on 10 October 2016. The 23-year-old had been on the ship for two weeks, and had been going back and forth to medical from 3 to 9 October with worsening symptoms. “Her death was very preventable. She died in excruciating pain, instead of being properly treated,” Derrick Luckey told lawmakers during a hearing about patient safety and the quality of care in the military medical system. “If the medical providers had given her a simple treatment of antibiotics instead of turning her away, she would be alive today,” he said. Luckey and Army veteran Dez Del Barba, who said he lost part of his left leg and suffered 70% muscle and tissue damage after his strep infection went untreated, urged lawmakers to make changes so others in the military community don’t have to suffer.Both contend this could have been avoided if proper medical care, such as antibiotics, had been provided. And both said they haven’t been able to get any information on investigations, or any actions to hold anyone accountable.Read full story Source: Yahoo News, 31 March 2022
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News Article
Shrewsbury maternity scandal: Sajid Javid’s statement to the Commons
Patient Safety Learning posted a news article in News
Sajid Javid has issued an apology for the maternity service failings reported at Shrewsbury and Telford Hospital NHS Trust. The health secretary spoke in the Commons on Wednesday after an independent inquiry into the UK’s biggest maternity scandal found that 201 babies and nine mothers could have - or would have - survived if the NHS trust had provided better care. Speaking in the Commons, the health secretary said Donna Ockenden - a maternity expert who led the report - told him about “basic oversights” at “every level of patient care” at the trust. He said the report “has given a voice at last to those families who were ignored and so grievously wronged”. Javid said the report painted a tragic and harrowing picture of repeated failures in care over two decades which led to unimaginable trauma for so many people. Rather than moments of joy and happiness for these families their experience of maternity care was one of tragedy and distress and the effects of these failures were felt across families, communities and generations. The cases in this report are stark and deeply upsetting. Mr Javid offered reassurances that the individuals who are responsible for the “serious and repeated failures” will be held to account. Read full story and Sajid Javid's statement Source: The Independent, 30 March 2022 -
News Article
The NHS’s multimillion-pound blunders laid bare in new report
Patient Safety Learning posted a news article in News
The reasons behind the most catastrophic blunders in emergency departments have been laid bare in a NHS Resolution report highlighting some of the biggest pay outs for NHS A&E errors. NHS Resolution conducted a deep dive into compensation claims concerning emergency departments in England, including 16 cases which saw more than £1 million handed out after life-changing or deadly errors. The average “high-value claim” was £2,069,029, with many of them related to spinal cord injuries which, left undetected, can have a life-long impact on patients. The report detailed the case of a woman who suffered permanent neurological damage and now has bladder, bowel and sexual dysfunction symptoms, as well as loss of mobility, after a spinal condition was misdiagnosed as sciatica. The report also looked at 86 deaths which resulted in average pay outs of more than £45,000. After reviewing 220 claims between 2014 and 2018, the authors highlighted a number of “common themes”, including: diagnostic errors, including missing signs a patient was deteriorating a failure to recognise the significance of repeat attendance at A&E delays in care problems with communication, including problems with different hospital departments talking to each other. Read full story Source: In Your Area News, 29 March 2022 -
News Article
Scotland’s A&Es facing ‘patient safety crisis’ as waiting times hit new high
Patient Safety Learning posted a news article in News
The Royal College of Emergency Medicine (RCEM) estimated 36 Scots died as a direct result of avoidable delays in the week to 30 March. It comes as the number of people in hospital with Covid reached another record high, the worst cancer waiting times were reported since records began in 2006, and the Royal College of Nursing issued a warning that patient care is under “serious threat” from record-high staffing shortages. The RCEM said it would “welcome” a decision to extend the legal requirement to wear face coverings in Scotland to protect the NHS. “Anything that can continue to reduce the spread and therefore try and relieve as much pressure as possible in the healthcare system would be welcomed,” said RCEM Vice President in Scotland Dr John Thomson. Dr Thomson, an emergency medicine consultant at Aberdeen Royal Infirmary, said the government must understand the “unconscionable” harm coming to patients. “We have clear evidence that prolonged weeks in an emergency department lead directly to patient deaths,” he said. “Good evidence that, irrespective of what the medical problem is that they present with, that long wait alone is associated with death. “We can measure that quite clearly. One in 72 patients who wait in an emergency department beyond eight hours will die as a direct result. “In the last week alone we would estimate there were 36 avoidable deaths due to waits beyond eight hours. That's unconscionable.” A&E’s in Scotland are facing the “biggest patient safety crisis for a generation”, he said. Read full story Source: The Scotsman, 29 March 2022 -
News Article
Baby deaths inquiry: Shrewsbury NHS trust condemned for ‘repeated failures’
Patient Safety Learning posted a news article in News
A damning report into hundreds of baby deaths has condemned the trust at the centre of the biggest maternity scandal in the history of the NHS for blaming mothers while repeatedly ignoring its own catastrophic blunders for decades. The independent inquiry into maternity practices at Shrewsbury and Telford hospital NHS trust uncovered hundreds of cases in which health officials failed to undertake serious incident investigations, while deaths were dismissed or not investigated appropriately. Instead, grieving families were denied access to reviews of their care and mothers were blamed when their babies died or suffered horrific injuries. A combination of an obsession with natural births over caesarean sections coupled with a shocking lack of staff, training and oversight of maternity wards resulted in a toxic culture in which mothers and babies died needlessly for 20 years while “repeated failures” were ignored again and again. Tragically, it meant some babies were stillborn, dying shortly after birth or being left severely brain damaged, while others suffered horrendous skull fractures or avoidable broken bones. Some babies developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries. The report, led by the maternity expert Donna Ockenden, examined cases involving 1,486 families between 2000 and 2019, and reviewed 1,592 clinical incidents. “Throughout our final report we have highlighted how failures in care were repeated from one incident to the next,” she said. “For example, ineffective monitoring of foetal growth and a culture of reluctance to perform caesarean sections resulted in many babies dying during birth or shortly after their birth. “In many cases, mother and babies were left with lifelong conditions as a result of their care and treatment. The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the trust and a culture of not listening to the families involved. “There was a tendency of the trust to blame mothers for their poor outcomes, in some cases even for their own deaths. What is astounding is that for more than two decades these issues have not been challenged internally and the trust was not held to account by external bodies. “This highlights that systemic change is needed locally, and nationally, to ensure that care provided to families is always professional and compassionate, and that teams from ward to board are aware of and accountable for the values and standards that they should be upholding. Going forward, there can be no excuses.” Read full story Source: The Guardian, 30 March 2022
