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Found 1,489 results
  1. News Article
    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
  2. News Article
    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
  3. News Article
    The 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
  4. News Article
    "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
  5. News Article
    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
  6. News Article
    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
  7. News Article
    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
  8. News Article
    On 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
  9. News Article
    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
  10. News Article
    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.
  11. News Article
    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
  12. News Article
    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
  13. News Article
    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."
  14. News Article
    Seaman 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
  15. News Article
    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
  16. News Article
    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
  17. News Article
    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
  18. News Article
    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
  19. News Article
    A doctor's bid to be voluntarily removed from the medical register on health grounds has been rejected. It means Dr Heather Steen, who is accused of failings following the death of Claire Roberts in 1996, will still face a fitness to practice tribunal. The tribunal would have been halted if she had been removed from the register, as she would no longer have been a doctor. Claire Roberts died at the Royal Belfast Hospital for Sick Children, where Dr Steen worked, in October 1996. The nine-year-old's death was examined as part of the hyponatraemia inquiry. Her father Alan said his family welcomed the decision to refuse the paediatrician's application. He said the tribunal hearing was "in the public interest" and should proceed "to maintain public confidence in the medical profession, the regulatory process and to ensure that professional standards are upheld". Read full story Source: BBC News, 28 March 2022
  20. News Article
    A whistleblower who worked at a hospital trust where hundreds of babies died or were left brain-damaged says there was "a climate of fear" among staff who tried to report concerns. Bernie Bentick was a consultant obstetrician at the Shrewsbury and Telford NHS Trust for almost 30 years. "In Shrewsbury and Telford there was a climate of fear where staff felt unable to speak up because of risk of victimisation," Mr Bentick said. "Clearly, when a baby or a mother dies, it's extremely traumatic for everybody concerned. "Sadly, the mechanisms for trying to prevent recurrence weren't sufficient for a number of factors. "Resources and the institutionalised bullying and blame culture was a large part of that." More than 1,800 cases of potentially avoidable harm have been reviewed by the inquiry. Most occurred between 2000 and 2019. Mr Bentick worked at the Trust until 2020. He said from 2009 onwards, he was raising concerns with managers. "I believe there were significant issues which promoted risk because of principally understaffing and the culture," he said. He also accuses hospital bosses of prioritising activity - the number of patients seen and procedures performed - over patient safety. "I believe that the senior management were mostly concerned with activity rather than safety - and until safety is on a par with clinical activity, I don’t see how the situation is going to be resolved," he said. Read full story Source: Sky News, 27 March 2022
  21. News Article
    RaDonda Vaught, a former nurse criminally prosecuted for a fatal drug error in 2017, was convicted of gross neglect of an impaired adult and negligent homicide on Friday after a three-day trial in Nashville, Tenn., that gripped nurses across the country. Vaught faces three to six years in prison for neglect and one to two years for negligent homicide as a defendant with no prior convictions, according to sentencing guidelines provided by the Nashville district attorney's office. Vaught is scheduled to be sentenced 13, and her sentences are likely to run concurrently, said the district attorney's spokesperson, Steve Hayslip. Vaught was acquitted of reckless homicide. Criminally negligent homicide was a lesser charge included under reckless homicide. Vaught's trial has been closely watched by nurses and medical professionals across the U.S., many of whom worry it could set a precedent of criminalising medical mistakes. Medical errors are generally handled by professional licensing boards or civil courts, and criminal prosecutions like Vaught's case are exceedingly rare. Read full story Source: OPB, 26 March 2022 See also: As a nurse in the US faces prison for a deadly error, her colleagues worry: Could I be next?
  22. News Article
    An investigation has been launched after a woman died during childbirth at a hospital's maternity unit. It was the third death of a mother in just over three years at Basildon University Hospital in Essex, in addition to a newborn baby's death. The trust that runs the hospital said it could not comment on the case while it was under investigation. Basildon University Hospital is part of Mid and South Essex NHS Foundation Trust, which also runs Southend and Broomfield hospitals. The latest fatality follows the death of 36-year-old Gabriela Pintilie in February 2019. Ms Pintilie died after losing six litres of blood giving birth to her second child at the unit. In separate incidents, a mother died and another woman had a stillborn baby at the unit in March 2019, while the trust was being inspected by the Care Quality Commission (CQC) following Ms Pintilie's death. The unit at Basildon had its rating upgraded from "inadequate" to "requires improvement" in December by the CQC. The hospital also apologised for the death of newborn Frederick Terry after he suffered a brain haemorrhage during a failed forceps delivery in November 2019. Read full story Source: BBC News, 27 March 2022
  23. News Article
    When Debbie Greenaway was told by doctors that she should try to deliver her twin babies naturally, she was nervous. But the doctor was adamant, she recalls. “He said: ‘We’ve got the lowest caesarean rates in the country and we are proud of it and we plan to keep it that way'." For Greenaway, labour was seemingly endless. She was given repeated doses of syntocinon, a drug used to bring on contractions. By the second day, the midwife was worried for one of the babies, whom the couple had named John. “She was getting really concerned that they couldn’t find John’s heartbeat.” Her husband remembers “the midwife shaking her head”. “She said a number of times that we should be having a caesarean.” By the time doctors finally decided to perform an emergency C-section, it was too late. Starved of oxygen, baby John had suffered a catastrophic brain injury. When he was delivered at 3am, he had no pulse. Efforts to resuscitate him failed. Their son’s death was part of what is now recognised as the largest maternity scandal in NHS history. The five-year investigation will reveal that the experiences of 1,500 families at Shrewsbury and Telford Hospital Trust between 2000 and 2019 were examined. At least 12 mothers died while giving birth, and some families lost more than one child in separate incidents, the report is expected to show. The expert midwife Donna Ockenden and a team of more than 90 midwives and doctors will deliver a damning verdict on the Shrewsbury trust, its culture and leadership — and failure to learn from mistakes or listen to families. At its heart is how a toxic obsession with “normal birth” — fuelled by targets and pressure from the NHS to reduce caesarean rates — became so pervasive that life-or-death decisions on the maternity ward became dangerously distorted for nearly two decades. Read full story (paywalled) Source: The Times, 26 March 2022
  24. News Article
    More than 1,500 patient deaths are to be investigated in the largest-ever independent inquiry into “unacceptable” mental health care. A probe into the deaths of patients who were cared for by NHS mental health services across Essex has revealed its investigation will cover deaths from 2000 to 2020. All 1,500 people died while they were a patient on a mental health ward in Essex, or within three months of being discharged from one. In 2001, following an investigation into 25 deaths, police criticised the trust for “clear and basic” failings but did not pursue a corporate manslaughter prosecution. And in 2021, the Health and Safety Executive fined the trust £1.5m due to failures linked to the deaths of 11 patients. The regulator said the trust did not manage the risks of ligature points for a period of more than 10 years. In January 2021, following pressures, former patient safety minister Nadine Dorries commissioned former NHS England mental health director Dr Geraldine Strathdee to chair an independent inquiry. While it is not known yet how many of the 1,500 deaths were caused by neglect, Dr Strathdee said evidence had so far shown some “unacceptable” and “dispassionate” care. Melanie Leahy, who has campaigned for change within Essex mental health services since her son died in 2012, has been leading the call for it to become a public inquiry on behalf of the families. Her son, Matthew Leahy, died as an inpatient at the Linden Centre, following multiple failings in his care. A 2018 parliamentary health service ombudsman report on his death, and that of another young man called Richard Wade, identified “systemic” failings on behalf of the trust. These included the failure to manage his risk level, to look after his physical health and to take action when he reported being raped in the unit. Read full story Source: The Independent, 28 March 2022
  25. News Article
    An NHS trust has apologised over the death of a 27-year-old events manager after a locum gynaecologist mistook aggressive cervical cancer for a hormonal or bowel problem. The family of Porsche McGregor-Sims, who died a day after being admitted to Queen Alexandra hospital in Portsmouth, told her inquest that she had felt she was not listened to and that the misdiagnosis had robbed them of a chance to say goodbye. The area coroner Rosamund Rhodes-Kemp said the case was one of the most “shocking and traumatic” she had dealt with and she would write to Portsmouth hospitals university NHS trust expressing her concern. In December 2019, McGregor-Sims’ GP referred her to a consultant after she complained of abdominal pain and vaginal bleeding. She saw Dr Peter Schlesinger, an agency locum at the Queen Alexandra hospital, at the end of January 2020. He did not physically examine her and believed her symptoms were linked to changing hormones or irritable bowel syndrome (IBS). After the UK went into lockdown two months later, McGregor-Sims continued to report symptoms but was prescribed antibiotics over the phone and was seen in person only after a GP thought she might have Covid because she had shortness of breath. McGregor-Sims was finally diagnosed with an aggressive form of cervical cancer and on 13 April was taken to hospital, where she died a day later. During the inquest, her family accused Schlesinger of having denied them their chance to say goodbye. Her mother, Fiona Hawke, told him: “You robbed us of the opportunity to prepare for her death and say goodbye to her.” Schlesinger insisted McGregor-Sims’ symptoms – including bleeding after sex – did not lead him to think she had a serious illness. Dr Claire Burton, a consultant gynaecologist, said Schlesinger should have physically examined McGregor-Sims, and apologised for the care she received at the trust. Read full story Source: The Guardian, 24 March 2022
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