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Found 1,490 results
  1. 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.
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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
  10. News Article
    Health leaders have called for the routine recording of ethnicity and faith during the registration of deaths to help fight COVID-19, but the government appears to have rejected the idea. Leaders at West Yorkshire and Harrogate Health and Care Partnership, the second largest integrated care system in England, wrote to registrar general Abi Tierney last month and said the lack of routine collection and analysis of this data “means there is a structural barrier to understanding of inequalities in mortality”. The Home Office replied and said it is considering “a range of reliable and proportionate ways to collect the necessary information”. But HSJ understands the Home Office has indicated no immediate action will be taken on the issue. The letter said: “This absence has undoubtedly led to delays in identifying the inequalities of COVID-19 mortality and means that we remain unclear about the disparities in deaths outside of hospital. These delays have risked contributing to further loss of life in our places in recent weeks, as we have not had robust data to enable us to address impacts at sufficient pace as we have been dealing with this crisis.” Read full story (paywalled) Source: HSJ, 8 July 2020
  11. News Article
    The Care Quality Commission (CQC) staged an unannounced inspection after two deaths at a mental health unit which it had condemned as “not fit for purpose.” Two earlier CQC inspections – in 2017 and 2018 – had also been prompted by deaths on the same unit. The CQC visited the Abraham Cowley Unit, which is at St Peter’s Hospital in Chertsey and run by Surrey and Borders Partnership Foundation Trust, on 26 June. Two inpatients died in April and May on an inpatient ward for working age men. The deaths both involved “ligature harm” and have led to the trust reviewing its ligature minimisation strategy, according to board papers. Read full story (paywalled) Source: HSJ, 8 July 2020
  12. News Article
    Former patients of rogue breast surgeon Ian Paterson may have died of “unnatural deaths” two senior coroners have said. Senior coroner for Birmingham and Solihull, Louise Hunt, and area coroner Emma Brown have said they believe there is evidence to suspect victims of Ian Paterson, who was jailed for 17 counts of wounding with intent in 2017, died unnaturally as a result of his actions. They now plan to open four inquests into the deaths of patients who died from breast cancer after being treated by Paterson. “Following preliminary investigations, the senior and area Coroner believe there is evidence to have reason to suspect that some of those deaths may be unnatural. In accordance with the Coroners and Justice Act 2009, inquests will now be opened in relation to four former patients of Mr Paterson.” Deborah Douglas, a victim of Paterson who leads a support group in Solihull, told The Independent: "I have spoken to so many women over the years who have since died. This is what I have always known and fought for. "Paterson lied about pathology reports and people did develop secondary cancers." Read full story Source: The Independent, 4 July 2020
  13. News Article
    Figures released by the Office for National Statistics show that about two-thirds of fatalities from this disease during its peak from start of March to mid-May were people with disabilities. That is more than 22,000 deaths. Then dig down into the data. It indicates women under 65 with disabilities are more than 11 times more likely to die than fellow citizens, while for men the rate is more than six times higher. Even for older people the number of deaths was three times as high for women and twice as high for men. There are some explanations for such alarming figures, although they tend to reveal other profound concerns. Yet the report showed even when issues such as economic status and deprivation are taken into account, people with disabilities died at about twice the rate of their peers. So where was the fury over this obvious and deep inequality, even in death? Where was the fierce outcry over persistent failures that left many citizens and their families at risk, lacking even the most basic advice, support or protection from the state? Chris Hatton, the dedicated professor of public health and disability at Lancaster University, delved into all available data. He found people with autism and learning disabilities were in reality at least four times more likely to die at the peak of pandemic than other citizens. They also died at far younger ages. “Information released about deaths of autistic people and people with learning disabilities has been minimal, grudging and seems deliberately designed to be inaccessible,” he says. This adds up to one more shameful episode in the scandal of how Britain treats such citizens. Read full story Source: iNews, 5 July 2020
  14. News Article
    Parents of babies who died at a hospital trust at the centre of a maternity inquiry say a police investigation has come "too late". West Mercia Police said it was looking at whether there was "evidence to support a criminal case" at Shrewsbury and Telford NHS Hospital Trust. An independent review, contacted by more than 1,000 families, said it was working with police to identify relevant cases. "It's bittersweet," one mother said. "It's come too late for my daughter, she should still be here," said Tasha Turner, whose baby, Esmai, died four days after she was born at Royal Shrewsbury Hospital in 2013. Ms Turner's case is part of the Ockenden Review, an independent investigation into avoidable baby deaths at the trust, which runs Royal Shrewsbury Hospital and Telford's Princess Royal. LaKamaljit Uppal, 50, from Telford, who is also part of the review following the death of her son Manpreet in April 2003 at Royal Shrewsbury Hospital, said she hoped the police inquiry would bring some closure. "The trust put me through hell, someone should be held accountable," she said. Read full story Source: BBC News, 1 July 2020
  15. News Article
    NHS England and NHS Improvement have ordered urgent reviews into the deaths of people with a learning disability and autism during the pandemic, HSJ has learned. In May, the regulators said the COVID-19 death rates among this population were broadly in line with the rest of the population. But in early June, the Care Quality Commission published data which suggested death rates of people with learning disabilities and/or autism had doubled during the pandemic. In an announcement posted on a social media group for Royal College of Nursing members last week, NHSE/I said they were “urgently seeking clinical reviewers with experience in learning disability”. The message to the private Facebook group, seen by HSJ, added: “The effects of coronavirus are having a far-reaching impact on all our lives. As we learn more about the virus, we are taking steps to make changes to safeguard our well-being. “For people with a learning disability, the number of deaths has doubled during the covid pandemic. (compared to data on the number of deaths recorded during the same period last year). As a result, we have a large number of deaths of people with a learning disability who have died during the pandemic whose deaths we want to review.” Read full story (paywalled) Source: HSJ, 1 July 2020
  16. News Article
    Police in Bristol have launched investigations into the circumstances that led to the death of a teenager with autism and learning disabilities. Avon and Somerset Police told HSJ they are investigating the circumstances behind the death of Oliver McGowan in 2016, at North Bristol Trust. They said: “As part of the enquiry [officers] will interview a number of individuals as they seek to establish the circumstances around Oliver’s death before seeking advice from the Crown Prosecution Service.” Oliver died in 2016 at Bristol’s Southmead Hospital after being admitted following a seizure. He had mild autism, epilepsy and learning difficulties. During previous hospital spells he experienced very bad reactions to antipsychotic medications, prompting warnings in his medical records that he had an intolerance to these drugs. Despite this Oliver was given anti-psychotic medication by doctors at Southmead against his own and his parents’ wishes. This led him to suffer a severe brain swelling which led to his death. His death has since prompted a national training programme for NHS staff on the care of people with autism and learning disabilities. Read full story (paywalled) Source: HSJ, 1 July 2020
  17. News Article
    Delays in going to the emergency department because of the coronavirus pandemic lockdown may have been a contributory factor in the deaths of nine children, a snapshot survey of consultant paediatricians in the UK and Ireland has shown. Three of the reported deaths associated with delayed presentation were due to sepsis, three were due to a new diagnosis of malignancy, in two the cause was not reported, and one was a new diagnosis of metabolic disease. Read full story (paywalled) Source: BMJ, 30 June 2020
  18. News Article
    The NHS has kept secret dozens of external reviews of failings in local services – covering possible premature deaths, unnecessary and harmful operations, and rows among doctors putting patients at risk – an HSJ investigation has found. At least 70 external reviews by medical royal colleges were carried out from 2016 to 2019, across 47 trusts, according to information provided by NHS trusts, but more than 60 of these have never been published – contrary to national guidance – while several have not even been shared with the Care Quality Commission (CQC) and other regulators. These include reviews which uncovered serious failings. Bill Kirkup’s review into the Morecambe Bay scandal in 2015 recommended trusts should “report openly” all external investigations into clinical services, governance or other aspects of their operations, including notifying the CQC. Since then the CQC has asked trusts for details of external reviews when it reviews evidence, and in July 2018 it began to ask for copies of their final reports, but HSJ’s research suggests this does not always happen. James Titcombe, the patient safety campaigner whose son’s death led to the inquiry by Bill Kirkup into the Morecambe Bay maternity care scandal, said a review was now needed of whether its recommendations had been implemented. “It is not acceptable that five years [on], there are still secretive royal college reports and patients are kept in the dark,” he said. Read full story Source: HSJ, 25 June 2020
  19. News Article
    At least another 130,000 people worldwide have died during the coronavirus pandemic on top of 440,000 officially recorded deaths from the virus, according to BBC research. A review of preliminary mortality data from 27 countries shows that in many places the number of overall deaths during the pandemic has been higher than normal, even when accounting for the virus. These so-called "excess deaths", the number of deaths above the average, suggest the human impact of the pandemic far exceeds the official figures reported by governments around the world. Some will be unrecorded COVID-19 victims, but others may be the result of the strain on healthcare systems and a variety of other factors. Read full story Source: BBC News, 18 June 2020
  20. News Article
    There should be independent reviews of the NHS’ readiness for a potential second major outbreak of coronavirus in the UK, senior doctors are arguing. The Royal College of Anaesthetists said a series of reviews should be carried out, overseen by an independent group formed from clinical royal college representatives, independent scientists and academics. It would encompass investigation of what happened to care quality during the peak of infection and demand through March, April and May — there are major concerns that harm and death was caused by knock of effects, with some health services closed and people being afraid to use others. Hospitals were unable to provide many other services as staff, including most anaesthetists, were redeployed to help with critical care. Ravi Mahajan, president of the Royal College of Anaesthetists, told HSJ areas such as capacity, workforce and protective equipment were key issues to be reviewed. He said: “We can’t wait for [the pandemic] to finish and then review. [The reviews] have to be dynamic, ongoing, and the sooner they start the better. Read full story Source: HSJ, 17 June 2020
  21. News Article
    A patient almost died after being misdiagnosed and sent home from hospital on the first day of the lockdown as the NHS curtailed many normal services to focus on COVID-19. The NHS trust involved has admitted that its failings led to the man suffering excruciating pain, developing life-threatening blood poisoning, and contracting the flesh-eating bug necrotising fasciitis. He needed eight operations to remedy the damage caused by his misdiagnosis. The man, his wife and his GP spent three weeks after his discharge trying to get him urgent medical care. However, St Mary’s hospital on the Isle of Wight rejected repeated pleas by them for doctors to help him, even though his health was deteriorating sharply. The man, who does not want to be named, said his experience of seeking NHS care for something other than COVID-19 during the pandemic had been “debilitating and exhausting” and that feeling the NHS “was not there” for him had been “very distressing” for him and his wife. Mary Smith, of the solicitors Novum Law, who are representing the man in his complaint against the trust, said his plight highlighted the growing number of cases that were emerging of people whose health had suffered because they could not access normal NHS care in recent months. Read full story Source: The Guardian, 16 June 2020
  22. News Article
    A woman whose father died in a care home has launched a judicial review case in the High Court over the government’s “litany of failures” in protecting the vulnerable elderly residents who were most at risk from COVID-19. Cathy Gardner accuses England’s health and social care secretary, Matt Hancock, NHS England, and Public Health England of acting unlawfully in breaching statutory duties to safeguard health and obligations under the European Convention on Human Rights, including the right to life. Her father, Michael Gibson, who had Alzheimer’s disease, died aged 88 of probable COVID-19 related causes on 3 April at Cherwood House Care Centre, near Bicester, Oxfordshire. She claims that before his death the care home had been pressured into taking a hospital patient who had tested positive for the virus but had not had a raised temperature for about 72 hours. “I am appalled that Matt Hancock can give the impression that the government has sought to cast a protective ring over elderly residents of care homes, and right from the start,” Gardner said. “The truth is that there has been at best a casual approach to protecting the residents of care homes. At worst the government has adopted a policy that has caused the death of the most vulnerable in our society.” Read full story Source: BMJ, 15 June 2020
  23. News Article
    Relatives of 450 people who have died in the coronavirus pandemic are demanding an immediate public inquiry. The families want an urgent review of "life and death" steps needed to minimise the continuing effects of the virus and a guarantee that documents relating to the crisis will be kept. A full inquiry would take place later, says lawyer, Elkan Abrahamson, who is representing the families. The government has said its current focus is on dealing with the pandemic. But the COVID-19 Bereaved Families for Justice UK group say immediate lessons need to be learned to prevent more deaths, and that waiting for ministers to launch an inquiry will cost lives. The call for an inquiry comes as a report from the National Audit Office - assessing the readiness of the NHS and social care in England for the pandemic - has shown it is not known how many of the 25,000 people discharged from hospitals into care homes at the peak of the outbreak were infected with coronavirus. Health and Social Care Select Committee chairman Jeremy Hunt said it seemed "extraordinary that no one appeared to consider" the risk. The Department of Health says it took the "right decisions at the right time". Read full story Source: BBC News, 12 June 2020
  24. News Article
    Thousands of people lost their lives “prematurely” because care homes in England lacked the protective equipment and financial resources to cope with the coronavirus outbreak, according to council care bosses. In a highly critical report, social care directors say decisions to rapidly discharge many vulnerable patients from NHS hospitals to care homes without first testing them for COVID-19 had “tragic consequences” for residents and staff. In many places, vulnerable people were discharged into care facilities where there was a shortage of personal protective equipment (PPE) or where it was impossible to isolate them safely, sometimes when they could have returned home, the report says. “Ultimately, thousands have lost their lives prematurely in social care and were not sufficiently considered as part of wider health and community systems. And normality has not yet returned,” James Bullion, the president of the Association of Directors of Adult Social Services (Adass), said in a foreword to the report. Read full story Source: The Guardian, 11 June 2020
  25. News Article
    Senior doctors repeatedly raised concerns over safety and staffing problems at a mental health trust before a cluster of 12 deaths, an HSJ investigation has found. The deaths all happened over the course of a year, starting in June 2018, involving patients under the care of the crisis home treatment services at Birmingham and Solihull Mental Health Trust. The causes of the deaths included suicides, drug overdoses, and hanging. Coroners found several common failings surrounding the deaths and have previously warned of a lack of resources for mental health services in the city. HSJ has now seen internal documents which reveal senior clinicians had raised repeated internal concerns about the trust’s crisis home treatment teams during 2017 and early 2018. The clinicians warned of inadequate staffing levels, long waiting lists, and a lack of inpatient bed capacity. In the minutes of one meeting in February 2018, just two months before the first of the 12 deaths, a consultant is recorded as saying he had “grave concerns over safety in [the home treatment teams]”. Read full story Source: HSJ, 9 June 2020
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