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Found 1,491 results
  1. News Article
    Ministers may order a public inquiry into mental health care and patient deaths across England because of the number of scandals that are emerging involving poor treatment. Maria Caulfield, the minister for mental health, told MPs on Thursday that she and the health secretary, Steve Barclay, were considering whether to launch an inquiry because the same failings were occurring so often in so many different parts of the country. They would make a final decision “in the coming days”, she said in the House of Commons, responding to an urgent question tabled by her Labour shadow, Dr Rosena Allin-Khan. An independent investigation found this week that that three teenage girls – Christie Harnett, 17, Nadia Sharif, 17, and Emily Moore, 18 – took their own lives within the space of eight months after receiving inadequate care from the Tees, Esk and Wear Valleys (TEWV) NHS mental health trust in north-east England. They died after “multifaceted and systemic failings” by the trust, especially at its West Lane hospital in Middlesbrough, the inquiry found. Allin-Khan pointed to a series of scandals that have come to light, often through media investigations, about dangerously substandard mental health care being provided by NHS services and also private firms in England, including in Essex and in Greater Manchester. “Patients are dying, being bullied, dehumanised, abused and their medical records are being falsified, a scandalous breach of patient safety,” Allin-Khan said. “The government has failed to learn from past failings.” Read full story Source: The Guardian, 3 November 2022
  2. News Article
    Three teenage girls died after major failings in the care they received from NHS mental health services in the north-east of England, an independent investigation has found. “Multifaceted and systemic” failures by the Tees, Esk and Wear Valleys (TEWV) NHS trust contributed to the young women’s self-inflicted deaths within eight months of each other, it concluded. Christie Harnett died aged 17 on 27 June 2019 at the trust’s West Lane hospital in Middlesbrough. Nadia Sharif, also 17, died there six weeks later, on 5 August. Emily Moore, who had been treated there, died on 15 February 2020 at a different hospital in Durham. All three had complex mental health problems and had been receiving NHS care for several years. The investigation into their deaths, commissioned by the NHS, found that 119 “care and service delivery problems” by NHS services, especially TEWV, had occurred. Charlotte and Michael Harnett, Christie’s parents, said their daughter had “lost her life whilst in a hospital run by TEWV trust where there was little or no care or compassion”. Emily’s parents, David and Susan Moore, said she received “horrific care” while at West Lane. Services at the hospital were understaffed, “unstable and overstretched”, the investigation’s final report found. Both families, and also Nadia’s parents, Hakeel and Arshad Sharif, said the dangerous inadequacy of the care provided by TEWV, and the likelihood that other patients with fragile mental health had died as a result, showed that ministers should order a full public inquiry. “This mental health trust is a danger to the public,” the Moores said. The report said TEWV failed to properly monitor the girls, given their known risk of self-harm; to take seriously concerns about their care and suicide risk raised by their families; and to remove all potential ligature points. Read full story Source: The Guardian, 2 November 2022
  3. News Article
    Extreme disruption to NHS services has been driving a sharp spike in heart disease deaths since the start of the pandemic, a charity has warned. The British Heart Foundation (BHF) said ambulance delays, inaccessible care and waits for surgery are linked to 30,000 excess cardiac deaths in England. It has called for a new strategy to reduce "unacceptable" waiting times. Doctors and groups representing patients have become increasingly concerned about the high number of deaths of any cause recorded this year. New analysis of the mortality data by the BHF suggests heart disease is among the most common causes, responsible for 230 deaths a week above expected rates since February 2020. The charity said "significant and widespread" disruption to heart care services was driving the increase. Its analysis of NHS data showed that 346,129 people were waiting for time-sensitive cardiac care at the end of August 2022, up 49% since February 2020. It said 7,467 patients had been waiting more than a year for a heart procedure - 267 times higher than before the pandemic. At the same time, the average ambulance response time for a suspected heart attack has risen to 48 minutes in England against a target of 18 minutes, according to the latest NHS figures. The BHF said difficulty accessing face-to-face GP and hospital care may have also contributed to the rise. Read full story Source: BBC News, 3 November 2022
  4. News Article
    Inquest finds Susan Warby, 57, received insulin she did not need after blood test mistakes. Hospital errors contributed to her death five weeks after bowel surgery, an inquest into her death has concluded. Susan Warby, 57, who died at West Suffolk hospital in Bury St Edmunds, was incorrectly given glucose instead of saline through an arterial line that remained in place for 36 hours and resulted in inaccurate blood test readings. She was subsequently given insulin she did not need, causing bouts of extremely low blood sugar (hypoglycemia) and the development of “a brain injury of uncertain severity”, recorded Suffolk’s senior coroner, Nigel Parsley. Speaking after the inquest was adjourned in January, Susan's husband, Jon Warby, said he was “knocked sideways completely” when he received an anonymous letter two months after her death highlighting blunders in her treatment. Doctors at the hospital were reportedly asked for fingerprints as part of the hospital’s investigation into the letter, a move described by a Unison trade union official as a “witch-hunt” designed to identify the whistleblower. Following January’s adjournment, Parsley instructed an independent expert to review the care that Warby received. Warby’s medical cause of death was recorded as multi-organ failure, with contributory causes including septicaemia, pneumonia and perforated diverticular disease, affecting the bowel. Recording a narrative conclusion, Parsley wrote: “Susan Warby died as the result of the progression of a naturally occurring illness, contributed to by unnecessary insulin treatment caused by erroneous blood test results. This, in combination with her other comorbidities, reduced her physiological reserves to fight her naturally occurring illness.” Jon Warby said in a statement: “The past two years have been incredibly difficult since losing Sue, and it is still a real struggle to come to terms with her no longer being here. The inquest has been a highly distressing time for our family, having to relive how Sue died, but we are grateful that it is over and we now have some answers as to what happened." “After learning of the errors in Sue’s care, I wanted to know how these occurred and what action was being taken to prevent any similar incidents in the future. The trust has now made a number of changes which I am pleased about.” Read full story Source: The Guardian, 7 September 2020
  5. News Article
    Death rates among seriously ill COVID-19 patients dropped sharply as doctors rejected the use of mechanical ventilators, analysis has found. The chances of dying in an intensive care unit (ICU) went from 43% before the pandemic peaked to 34% in the period after. In a report, the Intensive Care National Audit & Research Centre said that no new drugs nor changes to clinical guidelines were introduced in that period that could account for the improvement. However, the use of mechanical ventilators fell dramatically. Before the peak in admissions on 1 April, 75.9% of COVID-19 patients were intubated within 24 hours of getting to an ICU, a proportion which fell to 44.1% after the peak. Meanwhile, the proportion of ICU patients put on a ventilator at any point dropped 22 percentage points to 61% either side of the peak. Researchers suggested this could have been a result of “informal learning” among networks of doctors that patients on ventilators were faring worse than expected. Read full story Source: The Telegraph, 3 September 2020
  6. News Article
    The human rights watchdog for England and Wales has backed a grieving daughter’s court action against the health secretary, Matt Hancock, over his handling of the coronavirus pandemic in care homes. Cathy Gardner, who lost her father, Michael Gibson, to COVID-19 in a care home that accepted hospital discharges, is seeking a judicial review of policies that she alleges “failed to take into account the vulnerability of care home residents and staff to infection and death, the inadequacy of testing and PPE availability”. The government denies acting illegally over care homes in England, where more than 15,000 people have died with confirmed or suspected COVID-19. But the Equalities and Human Rights Commission said the case “raises potentially important issues of public interest and concern as to the way in which the rights of care home residents have been and will be protected during the current coronavirus pandemic”. “The bereaved families group isn’t backing down in its call for a public inquiry and I am not backing down in my call for a judicial review into policies I believe led to deaths in care homes,” Gardner said. ”I am delighted the EHRC have written to the court. This is a Human Rights Act case.” Read full story Source: The Guardian, 3 September 2020
  7. News Article
    COVID-19 death tolls at individual care homes are being kept secret by regulators in part to protect providers’ commercial interests before a possible second coronavirus surge, the Guardian can reveal. England’s Care Quality Commission (CQC) and the Care Inspectorate in Scotland are refusing to make public which homes or providers recorded the most fatalities amid fears it could undermine the UK’s care system, which relies on private operators. In response to freedom of information requests, the regulators said they were worried that the supply of beds and standards of care could be threatened if customers left badly affected operators. The CQC and Care Inspectorate share home-by-home data with their respective governments – but both refused to make it public. Residents’ families attacked the policy, with one bereaved daughter describing it as “ridiculous” and another relative saying deaths data could indicate a home’s preparedness for future outbreaks. “Commercial interest when people’s lives are at stake shouldn’t even be a factor,” said Shirin Koohyar, who lost her father in April after he tested positive for Covid at a west London care home. “The patient is the important one here, not the corporation.” Read full story Source: The Guardian, 27 August 2020
  8. News Article
    A home care worker who did not wear protective equipment may have infected a client with a fatal case of coronavirus during weeks of contradictory government guidance on whether the kit was needed or not, an official investigation has found. The government’s confusion about how much protection care workers visiting homes needed is detailed in a report into the death of an unnamed person by the Healthcare Safety Investigation Branch (HSIB), which conducts independent investigations of patient safety concerns in NHS-funded care in England. It was responding to a complaint raised by a member of the public in April. The report shows that Public Health England published two contradictory documents that month. One advised care workers making home visits to wear PPE and the other did not mention the need. The contradiction was not cleared up for six weeks. The government’s guidance had been a shambles that had placed workers and their vulnerable clients at risk, the policy director at the United Kingdom Homecare Association, Colin Angel, said on Wednesday. The association also accused the government of sidelining its expertise and publishing new guidance with little notice, sometimes late on Friday nights, meaning that it was not always noticed by the people it was intended for.
  9. News Article
    Obesity may double the risk of falling seriously ill with Covid-19 and increase the chances of dying by almost 50 per cent, according to researchers, who also warned any future vaccine may be less effective for the clinically overweight. Health issues caused by obesity include a number of pre-existing conditions known to exacerbate a Covid-19 infection – including heart disease, diabetes and high blood pressure. Now a global assessment of health data gathered since the start of the the pandemic by researchers at the University of North Carolina has found people with a Body Mass Index (BMI) of more than 30 were 113 per cent more likely to be hospitalised. Those admitted to hospital were found to be 74% more likely to be admitted to an intensive care unit, while the risk of death among obese patients increased by 48%. Read full story Source: The Independent, 26 August 2020
  10. News Article
    Safety inspectors have ordered a mental health trust to make immediate improvements after visiting two inpatient wards where three patients died inside six months. The Care Quality Commission this week warned Devon Partnership Trust it would take “urgent action” over “serious concerns about patients” unless the trust made the required improvements swiftly. The watchdog inspected the trust’s Delderfield and Moorland wards in June following concerns about three patient deaths in September, October and March, along with “a number of” patient safety incidents - including ligature incidents. The CQC also highlighted poor patient observation routines and a lack of learning from previous incidents, amid delays in completing investigations into safety incidents. Read full story Source: HSJ, 21 August 2020
  11. News Article
    Ministers have been accused of trying to cover up the findings from investigations into hundreds of health and social care worker deaths linked to coronavirus after it emerged the results will not be made public. The Independent revealed on Tuesday that medical examiners across England and Wales have been asked by ministers to investigate more than 620 deaths of frontline staff that occurred during the pandemic. The senior doctors will review the circumstances and medical cause of death in each case and attempt to determine whether the worker may have caught the virus during the course of their duties. But now the Department of Health and Social Care (DHSC) said the results will be kept secret with the aim of helping local hospitals to learn and improve protection for staff. Separately, trade unions and NHS Providers, which represents hospital trusts, have urged the government to ensure full investigations into every death and to be transparent about findings to reassure health and social care staff ahead of any second wave. Sir Ed Davey, acting leader of the Liberal Democrats, said: “We currently have one of the highest number of deaths of health and care workers in Europe. The government has utterly failed to protect staff in both hospitals and care homes. The fact that now they are trying to cover up how and why each tragic death occurs is a disgrace." Read full story Source: The Independent, 15 August 2020
  12. News Article
    A teenager with a severe nut allergy died in part because of human error, a coroner has ruled. Shante Turay-Thomas, 18, had a severe reaction to eating a hazelnut. The inquest heard a series of failures meant that an ambulance took more than 40 minutes to arrive at her home in Wood Green, north London. Her mother Emma Turay, who said she felt "badly let down" by the NHS, wants an "allergy tsar" to be appointed to help prevent similar deaths. The inquest heard call staff for the NHS's 111 non-emergency number failed to appreciate the teenager's worsening condition was typical of a severe allergic reaction to nuts. A telephone recording of the 111 call, made by her mother, at 23:01 BST on Friday 14 September 2018, revealed how the 18-year-old could be heard in the background struggling to breathe. "My chest hurts, my throat is closing and I feel like I'm going to pass out," she said before asking her mother to check how long the ambulance would be, then adding: "I'm going to die." The inquest heard Ms Turay-Thomas had tried to use her auto-injector adrenaline pen, however it later emerged she had only injected a 300 microgram dose, rather than the 1,000 micrograms needed to stabilise her condition. It also emerged she was unaware of the need to use two shots for the most serious allergic reactions and had not received medical training after changing her medication delivery system from the EpiPen to a new Emerade device. The inquest at St Pancras Coroner's Court was told an ambulance that was on its way to the patient had been rerouted because the call was incorrectly categorised as requiring only a category two response, rather than the more serious category one. Read full story Source: BBC News, 13 January 2020
  13. News Article
    Inspectors raise ‘serious concerns’ about medical wards and emergency care at Shropshire NHS trust A patient bled to death on a ward at Shrewsbury and Telford Hospitals Trust after a device used to access his bloodstream became inexplicably disconnected, The Independent has learnt. The incident came to light as new concerns arose about quality of care at the Shropshire trust, with the Care Quality Commission (CQC) warning of “serious concerns” about its medical wards and emergency department following an inspection last month. Although the report from the inspection has not yet been published, it is understood that the trust has been served with a legal notice by the regulator to comply with more than a dozen conditions. It remains in special measures following the inspection and is rated inadequate overall. See full article in The Independent here
  14. News Article
    The deaths of hundreds of NHS and social care workers infected with coronavirus are under investigation by medical examiners, The Independent has learnt. Ministers have asked medical examiners in England and Wales to review all deaths of frontline health and social care staff infected with the virus to determine whether the infection was caught as a result of their work. The review, which started last month, is likely to cover more than 620 deaths including nurses, doctors and care home staff across England and Wales, since the beginning of March. It could trigger a number of investigations by hospitals, the Health and Safety Executive, and coroners into the protection, or lack of, for staff during the pandemic when many hospitals ran out of protective masks and clothing for staff. Hospitals have already been ordered to risk assess workers who may be more susceptible to the virus, such as those from a black and minority ethnic backgrounds or those with existing health conditions. Read full story Source: The Independent, 12 August 2020
  15. News Article
    Ambulance chiefs are looking at alternative defibrillators after coroners highlighted confusion over how to correctly use their existing machines. London Ambulance Service (LAS) Trust has received two warnings from coroners since 2016 after the delayed use of Lifepak 15 defibrillators “significantly reduced” the chances of survival for patients, including a 15-year-old boy. Coroners found some paramedics were unaware the machines had to be switched from the default “manual” mode to an “automatic” setting. The first warning came after the death of teenager Najeeb Katende in October 2016. A report by coroner Edwin Buckett said the paramedic who arrived had started the defibrillator in manual mode and did not detect a heart rhythm that was appropriate for administering the device, so it was not used until an advanced paramedic arrived on scene 24 minutes later. The report stated the defibrillator had been started in manual mode but it needed to be switched to automatic to detect a shockable heart rhythm. The coroner warned LAS that further deaths could occur if action was not taken to prevent similar confusion. But another warning was issued to the LAS in March this year, following the death of 35-year-old Mitica Marin. Again, a coroner found the paramedic, who was on her first solo shift, had started the machine in manual mode and had not detected a shockable rhythm. It was suggested this caused a four minute delay in the shock being administered. Coroner Graeme Irvine said this was “not an isolated incident” for LAS and noted the trust had reviewed other cases of delayed defibrillation. They found that the defibrillator’s manual default setting was a “contributing factor” to the delays. Read full story (paywalled) Source: HSJ, 10 August 2020
  16. News Article
    Patients suffering heart attacks during the coronavirus lockdown stayed away from hospitals with some dying as a result, a new study has found. In an analysis of more than 50,000 patients who suffered heart attacks and were treated in 99 NHS hospitals in England both before and after lockdown, researchers found the proportion of deaths for patients with a milder form of heart attack jumped during the first month of lockdown. Those suffering more severe heart attacks actually saw a lower death rate with hospitals keeping their emergency heart services running. Dr Jianhua Wu, associate professor in biostatistics at the University of Leeds and lead author of the study, said: “It has revealed that although patients were able to get access to high levels of care, the study suggests a lot of very ill people were not seeking emergency treatment and that may have been an unintended consequence of the ‘stay at home’ messaging.” Read full story Source: The Independent, 5 August 2020
  17. News Article
    Hospital trust ‘truly sorry that mistakes were made in care’ of Luchii Gavrilescu, who died after being sent home from hospital with undiagnosed tuberculosis. An NHS trust investigated over maternity care failings has apologised after a six-week-old child was found to have died due to mistakes at one of its hospitals. East Kent Hospitals University Trust was embroiled in a major scandal after The Independent revealed the trust had seen more than 130 babies over a four-year period suffer brain damage as a result of being starved of oxygen during birth. A report into the trust concluded in April that there had been “recurrent safety risks” at its maternity units. Read full article here.
  18. News Article
    The safety of maternity services in the NHS are to be investigated by MPs after a string of scandals involving the deaths of mothers and babies highlighted by The Independent. The Commons health select committee, chaired by former health secretary Jeremy Hunt, has announced it will hold an inquiry looking at why maternity incidents keep re-occurring and what needs to be done to improve safety. The committee will also examine whether the clinical negligence process needs to change and the wider aspects of a “blame culture” in the health service and its affects on medical advice and decision making. Read the full article here
  19. News Article
    NHS England and Improvement have launched an independent review into the care and death of a man with learning disabilities, following concerns raised by HSJ. The regulator has appointed Beverley Dawkins to carry out an independent review of the case of Clive Treacy, as part of the learning disability mortality review programme. Clive, who died in 2017, had previously been denied a review under LeDer and, according to emails seen by HSJ, his death was never officially recorded by the programme, which is meant to record all deaths of people with a learning disability. NHS England and Improvement overturned the decision earlier this year after HSJ presented evidence of a series of failures in his care between 2012 and 2017. Today, it was confirmed to us that Ms Dawkins has been commissioned to carry out the review, and that it would review his care throughout his life, as well as his death. Read full story Source: HSJ, 23 July 2020
  20. News Article
    Hundreds more cases of potentially avoidable baby deaths, stillbirths and brain damage have emerged at an NHS trust, raising concerns about a possible cover-up of the true extent of one the biggest scandals in the health service’s history. The additional 496 cases raise further serious concerns about maternity care at Shrewsbury and Telford hospital NHS trust since 2000. The cases involving stillbirths, neonatal deaths or baby brain damage, as well as a small number of maternal deaths, have been passed to an independent maternity review, led by the midwifery expert Donna Ockenden. They bring the total number of cases being examined to 1,862. They will also be passed to West Mercia police, which last month launched a criminal investigation into the trust’s maternity services. Detectives are trying to establish whether there is enough evidence to bring charges of corporate manslaughter against the trust or individual manslaughter charges against staff involved. The extra 496 cases had not emerged until now because an “open book” initiative led by the NHS in 2018 asked only for digital records of cases identified as a cause for serious concerns. The vast majority of the 496 further cases were recorded only in paper documents. Read full story Source: The Guardian, 21 July 2020
  21. News Article
    African American children are three times more likely than their white peers to die after surgery despite arriving at hospitals without serious underlying conditions, the latest evidence of unequal outcomes in health care, according to a study published in the journal Pediatrics, “We know that traditionally, African Americans have poorer health outcomes across every age strata you can look at,” said Olubukola Nafiu, the lead researcher and an anaesthesiologist at Nationwide Children’s Hospital in Columbus, Ohio. “One of the explanations that’s usually given for that, among many, is that African American patients tend to have higher comorbidities. They tend to be sicker.” But his research challenges that explanation, he said, by finding a racial disparity even among otherwise healthy children who came to hospitals for mostly elective surgeries. Out of 172,549 children, 36 died within a month of their operation. But of those children, nearly half were black – even though African Americans made up 11% of the patients overall. Black children had a 0.07% chance of dying after surgery, compared with 0.02% for white children. Postoperative complications and serious adverse events were also more likely among the black patients and they were more likely to require a blood transfusion, experience sepsis, have an unplanned second operation or be unexpectedly intubated. Read full story Source: The Independent, 20 July 2020
  22. News Article
    Babies are at risk of dying from common treatable infections because NHS staff on maternity wards are not following national guidance and are short-staffed and overworked, an investigation has revealed. The Healthcare Safety Investigation Branch (HSIB), a national safety watchdog, has warned that NHS staff on maternity wards face sometimes conflicting advice on treating women who are positive for a group B streptococcus (GBS) infection. They are also making errors in women’s care because of the pressure of work and a lack of staff, with antibiotics not being administered when they should be. HSIB’s specialist investigators examined 39 safety incidents in which GSB had been identified, and found that the infection had contributed to six baby deaths, six stillbirths and three cases of babies being left with severe brain damage. In its report, the watchdog warned that the problems on maternity wards meant that even in cases where mothers were known to be positive for GBS infection, this wasn’t shared with the mother or noted in the record, resulting in the standard care and antibiotics not being provided. It added: “The identification and escalation of care for babies who show signs of GBS infection after birth was missed. This has resulted in severe brain injury and death for some of the affected babies.” Read full story Source: The Independent, 19 July 2020
  23. News Article
    Matt Hancock has ordered an urgent review into how Public Health England (PHE) calculates daily COVID-19 death figures. It comes after scientists said they believed PHE was “over-exaggerating” the daily coronavirus death toll, by counting people if they die of any cause at any time after testing positive for the disease. Professor Yoon K Loke, of the University of East Anglia, and Carl Heneghan, professor of evidence-based medicine at the Nuffield Department of Primary Care, said on Thursday night that a “statistical flaw” in the way PHE compiles data on deaths created a disparity in figures published by the different UK nations. “It seems that PHE regularly looks for people on the NHS database who have ever tested positive, and simply checks to see if they are still alive or not,” they wrote. “PHE does not appear to consider how long ago the Covid test result was, nor whether the person has been successfully treated in hospital and discharged to the community. Anyone who has tested Covid-positive but subsequently died at a later date of any cause will be included on the PHE Covid death figures.” Read full story Source: The Independent, 17 July 2020
  24. News Article
    Five NHS trusts in the South West have been ordered to make immediate improvements after the death of a 20-year-old prisoner who needed healthcare. Lewis Francis was arrested in Wells, Somerset, in 2017 after stabbing his mother while “acutely psychotic” and taken into custody. Although his condition mandated a transfer to a medium secure mental health hospital, there was “no mechanism” in place to move Mr Francis and he was taken to prison, where he died by suicide two days later, according to a coroner. Contributory factors to his death included “insufficient collaboration, communication and ownership between and within organisations… together with insufficient knowledge of… the Mental Health Act,” according to Nicholas Rheinberg, the assistant coroner for Exeter and Greater Devon. In a Prevention of Future Deaths report, Mr Rheinberg said a memorandum of understanding was in place for the transfer of “mentally ill prisoners direct from police custody” in the West Midlands, and he called on the South West Provider Collaborative to agree a similar deal with “relevant organisations and agencies”. Read full story (paywalled) Source: HSJ, 14 July 2020
  25. News Article
    A wide disparity in coronavirus mortality rates has emerged in English hospitals, with data seen by the Guardian showing that one hospital trust in south-west England had a death rate from the disease of 80% while in one London trust it was just 12.5%. The figures, which NHS England has compiled but never published, show the age-standardised mortality rates that all of the country’s 135 acute hospital trusts have recorded during the pandemic. Doctors regard age as the single biggest predictor or risk factor for dying from COVID-19. They cover the period from the start of the coronavirus crisis in March, through its peak in late March and April, up until 15 May, by which time 42,850 (85%) of the 50,219 deaths so far in all settings had occurred in England and Wales. It is the first such data to emerge about how many people have lived or died in each trust after being treated there because they had been left critically ill by the disease. They are based on patients who were treated in an intensive care or high-dependency unit or on a ward. Senior doctors said the dramatic gap in death rates of 67.5 percentage points between the trusts with the highest and lowest rates was notable and may mean that some hospitals needed to learn lessons from others. Read full story Source: Guardian, 14 June 2020
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