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Found 1,491 results
  1. News Article
    A baby with a serious heart condition has died after she received an infection from mould in a Seattle hospital's operating room, her mother says. Elizabeth Hutt was born with a heart condition that she battled for the entirety of her six-month-long life. The young child underwent three open heart surgeries, and after the third one is when it's believed she contracted an Aspergillus mould infection in the hospital's operating room. The mould in the hospital's operating rooms was first detected in November, around the same time as the child's third surgery. It was later determined the infection was contracted from the mould discovered in three of the 14 operating rooms at the hospital in November. The mould came from the hospital's air-handling units in the operating rooms, and 14 patients have developed infections from the mould since 2001, the hospital revealed. Seven of those 14 children have since died from their infections. Elizabeth's parents have joined a class action suit against Seattle Children's Hospital in January, which alleges facility managers knew about the mould since 2005 and failed to fix the problem. Read full story Source: The Independent, 14 February 2020
  2. News Article
    The boss of an NHS trust at the centre of concerns about preventable baby deaths has claimed the scale of the failings is not clearly defined. Susan Acott, Chief Executive of East Kent Hospitals Trust, said there had only been "six or seven" avoidable deaths at the trust since 2011. However, the BBC revealed on Monday that the trust previously accepted responsibility for at least 10. Ms Acott said some of the baby deaths were "not as clear-cut". A series of failings came to light during the inquest of Harry Richford who died seven days after his birth at the Queen Elizabeth the Queen Mother Hospital in Margate in November 2017. A coroner ruled Harry's death was "wholly avoidable" and was contributed to by hospital neglect. Ms Acott added she had not read a key report from 2015 drawing attention to maternity problems at the trust until December 2019. Ms Acott claims that from 2011 to 2020 there were "about six or seven" baby deaths that were viewed as preventable. She says the other deaths were being investigated adding "these things aren't always black and white". Read full story Source: BBC News, 12 February 2020
  3. News Article
    The Streatham terrorist attack has again highlighted one of the most difficult decisions the emergency services face – deciding when it is safe to treat wounded people. In the aftermath of the stabbings by Sudesh Amman, a passer-by who helped a man lying on the pavement bleeding claimed ambulance crews took 30 minutes to arrive. The London Ambulance Service (LAS) said the first medics arrived in four minutes, but waited at the assigned rendezvous point until the Metropolitan police confirmed it was safe to move in. Last summer, the inquest into the London Bridge attack heard it took three hours for paramedics to reach some of the wounded. Prompt treatment might have saved the life of French chef Sebastian Belanger, who received CPR from members of the public and police officers for half an hour. A LAS debriefing revealed paramedics’ frustration at not being deployed sooner. A group of UK and international experts in delivering medical care during terrorist attacks have highlighted alternative approaches in the BMJ. In Paris in 2015, the integration of doctors with specialist police teams enabled about 100 wounded people in the Bataclan concert hall to be triaged and evacuated 30 minutes before the terrorists were killed. The experts writing in the BMJ believe the UK approach would have delayed any medical care reaching these victims for three hours. These are perilously hard judgment calls. Policymakers and commanders on the scene have to balance the likelihood that long delays in intervening will lead to more victims dying from their injuries against the increased risk to the lives of medical staff who are potentially putting themselves in the line of fire by entering the so-called 'hot zone'. First responders themselves need to be at the forefront of this debate. As the people who have the experience, face the risks and want more than anyone to save as many lives as possible, their leadership and insights are vital. In the wake of the Streatham attack the government is looking at everything from sentencing policy to deradicalisation. Deciding how best to save the wounded needs equal priority in the response to terrorism. Read full story Source: The Guardian, 7 February 2020
  4. News Article
    A BBC News investigation has uncovered more preventable baby deaths at an NHS trust that has already been criticised for its maternity services. Four families said their babies would have survived had East Kent Hospitals NHS Trust provided better care. The NHS's Healthcare Safety Branch is investigating 25 maternity cases at the hospitals in Margate and Ashford. The trust has apologised for the care provided in two of the cases and said they were investigating a third. It has denied any wrongdoing in the fourth case. The government is due to receive the Healthcare Safety Branch's report into the 25 cases later, as well as a Care Quality Commission report from an inspection carried out in January. Last month, the BBC discovered at least seven preventable deaths may have occurred at the trust since 2016. Four further families have now spoken out, saying their babies would not have died if medics had provided better care. In two of the cases, the mothers said the actions of the trust left them feeling they were to blame for their babies' deaths. In a statement, East Kent Hospitals Trust it had set up a board sub-committee "to ensure we are complying with national safety standards and ensure we are implementing the coroner's recommendations fully and swiftly". "We are deeply saddened by the stories of families who have suffered the death of a much-loved baby, and we are extremely sorry for their loss," it added. Read full story Source: BBC News, 10 February 2020
  5. News Article
    A woman described as a "high risk" anorexia patient faced delays in treatment after moving to university, an inquest has heard. Madeline Wallace, 18, from Cambridgeshire, was told there could be a six-week delay in her seeing a specialist after moving to Edinburgh. The student "struggled" while at university and a coroner said there appeared to be a "gap" in her care. Ms Wallace died on 9 January 2018 due to complications from sepsis. A parliamentary health service ombudsman report into her death was being written at the time of Ms Wallace's treatment in 2017 and issues raised included moving from one provider to another and higher education. Coroner Sean Horstead said Ms Wallace only had one dietician meeting in three months, despite meal preparation and planning being an area of anxiety she had raised. Dr Hazel said she had tried to make arrangements with the Cullen Centre in Edinburgh in April 2017 but had been told to call back in August. The Cullen Centre said it could only accept her as a patient after she registered with a GP and that an appointment could take up to six weeks from that point. Read full story Source: BBC News, 10 February 2020
  6. News Article
    It has been revealed that three patients a day are dying from starvation or thirst or choking on NHS wards. In 2017, 936 hospital deaths were attributed to one of those factors, with starvation the primary cause of death in 74 cases.The Office for National Statistics data reveals malnutrition deaths are 34% higher than in 2013. Over-stretched nurses are simply too busy to check if the sick and elderly are getting nourishment. However, Myer Glickman from the ONS says the data is not conclusive proof of poor NHS care. He said:“There has been an increase over time in the number of patients admitted to hospital while already malnourished. This may suggest that malnutrition is increasingly prevalent in the community, possibly associated with the ageing of the population and an increase in long-term chronic diseases.” Yet campaigners say too many vulnerable people are being “forgotten to death” in NHS hospitals and urgent action is needed to identify and treat malnutrition. In a recent pilot scheme the number of deaths among elderly patients with a fractured hip was halved by simply having someone to feed them. Six NHS trusts employed a junior staff member for each ward tasked with getting 500 extra calories a day into them. More survived and the patients spent an average five days less in hospital, unblocking beds and saving more than £1,400 each. It wasn’t just the calories though – it helped keep their morale up. Because, as one consultant said: “Food is a very, very cheap drug that’s extremely powerful.” Read full story Source: Mirror, 4 February 2020
  7. News Article
    The toxicity of a commonly prescribed beta blocker needs better recognition across the NHS to prevent deaths from overdose, a new report warns today. The Healthcare and Safety Investigation Branch (HSIB) report focuses on propranolol, a cardiac drug that is now predominately used to treat migraine and anxiety symptoms. It is highly toxic when taken in large quantities and patients deteriorate quickly, making it difficult to treat. The investigation highlighted that these risks aren’t known widely enough by medical staff across the health service, whether issuing prescriptions to at risk patients, responding to overdose calls or carrying out emergency treatment. Dr Stephen Drage, ICU consultant and HSIB’s Director of Investigations, said: “Propranolol is a powerful and safe drug, benefitting patients across the country. However, what our investigation has highlighted is just how potent it can be in overdose. This safety risk spans every area of healthcare – from the GPs that initially prescribe the drug, to ambulance staff who respond to those urgent calls and the clinicians that administer emergency treatment." The report also emphasises that there is a link between anxiety, depression and migraine, and that more research is needed to understand the interactions between antidepressants and propranolol in overdose. Read full story Source: HSIB, 6 February 2020
  8. News Article
    A whistleblower raised the alarm over patient safety at West Suffolk Hospital because of concerns about the behaviour of a doctor who had been seen injecting himself with drugs, the Guardian has revealed. The incident had already prompted internal complaints from senior staff at West Suffolk hospital, but the whistleblower decided to take matters a step further when the same doctor was later involved in a potentially botched operation. The whistleblower then wrote to relatives of a dead patient and urged them to ask questions about the conduct of the doctor and his background. When they did this, the hospital launched a widely criticised “witch-hunt” in an attempt to find out the identity of the leaker. The doctor’s drug use, which the trust has never acknowledged until now, helps explain why it demanded fingerprint and handwriting samples from staff – tactics which the NHS regulator roundly condemned in a hard-hitting report last week. Read full story Source: Guardian, 5 February 2020
  9. News Article
    In early January, authorities in the Chinese city of Wuhan were trying to keep news of a new coronavirus under wraps. When one doctor tried to warn fellow medics about the outbreak, police paid him a visit and told him to stop. A month later he has been hailed as a hero, after he posted his story from a hospital bed. It's a stunning insight into the botched response by local authorities in Wuhan in the early weeks of the coronavirus outbreak. Dr Li was working at the centre of the outbreak in December when he noticed seven cases of a virus that he thought looked like SARS - the virus that led to a global epidemic in 2003. On 30 December he sent a message to fellow doctors in a chat group warning them about the outbreak and advising they wear protective clothing to avoid infection. What Dr Li didn't know then was that the disease that had been discovered was an entirely new coronavirus. Four days later he was summoned to the Public Security Bureau where he was told to sign a letter. In the letter he was accused of "making false comments" that had "severely disturbed the social order". "We solemnly warn you: If you keep being stubborn, with such impertinence, and continue this illegal activity, you will be brought to justice - is that understood?" He was one of eight people who police said were being investigated for "spreading rumours". At the end of January, Dr Li published a copy of the letter on Weibo and explained what had happened. In the meantime, local authorities had apologised to him but that apology came too late. For the first few weeks of January officials in Wuhan were insisting that only those who came into contact with infected animals could catch the virus. No guidance was issued to protect doctors. "A safer public health environment… requires tens of millions of Li Wenliang," said one reader of Dr Li's post. Read full story Source: BBC News, 4 February 2020
  10. News Article
    A nurse from South Gloucestershire died after doctors missed signs of her cervical cancer amid a series of "gross" failings, a coroner has ruled. Julie O’Connor’s cancer was not picked up by North Bristol NHS Foundation Trust despite abnormalities in a smear test in 2014 and a biopsy in 2015. She went for multiple further checks for gynaecological problems in 2016 and 2017 and was referred three times to specialists. However, Ms O'Conner only received a cancer diagnosis once she decided to seek private treatment at Spire Hospital in Bristol. An inquest into her death was held in Flax Bourton, Somerset, this week. Maria Voisin, Senior Coroner for the Avon area, found the cause of Ms O’Connor’s death to be of “natural causes contributed to by neglect". She recorded three instances of "gross failures" including the inaccurate smear test as well as mistakes in two further assessments. Deputy medical director Tim Whittlestone said: “We accept the findings of the coroner and support her actions to build on our correspondence with the Royal College of Obstetricians and Gynaecologists." “...I would like to reaffirm that North Bristol has investigated these errors and more importantly that we have learnt lessons from our mistakes." Read full story Source: Nursing Times, 31 January 2020
  11. News Article
    The hospital at the centre of a whistleblowing inquiry has been downgraded by the care watchdog and issued with a warning notice amid concerns over leadership and patient safety. West Suffolk Foundation Trust has been rated requires improvement by the Care Quality Commission (CQC) in a damning report having previously been rated outstanding since 2017. The trust, whose Chief Executive Stephen Dunn received a CBE for services to patient safety in 2018, has faced criticism after bosses threatened senior doctors with a fingerprint and handwriting analysis to try and identify a whistleblower. In a new report published today, the CQC inspectors said they had significant concerns about the safety of mothers and babies in the trust’s maternity unit and the criticised the culture of the trust leadership referencing what they called “threatening” actions. In the West Suffolk hospital maternity unit the CQC found staff had not completed key safety training, did not protect women from domestic abuse, and staff did not always report safety incidents. They also found maternity staff were not taking observations and the unit lacked enough staff with the right qualifications to keep women safe. The trust was issued with a warning notice by the trust demanding it make improvements before the end of this month. On the trust leadership the CQC report said: “The style of executive leadership did not represent or demonstrate an open and empowering culture. There was an evident disconnect between the executive team and several consultant specialities." Read full story Source: The Independent, 30 January 2020
  12. News Article
    Harry Richford's death underlines the need for the health secretary to bring back the national maternity safety training fund – and there are other issues that require urgent attention – The Independent reports. Harry Richford had not even been born before the NHS failed him. An inquest has concluded he was neglected by East Kent University Hospitals Trust in yet another maternity scandal to rock the NHS. His parents and grandparents have fought a tireless campaign against a wall of obfuscation and indifference from the NHS. In their pursuit of the truth they have exposed a maternity service that did not just fail Harry, but may have failed dozens of other families. As with the family of baby Kate Stanton-Davies at Shrewsbury and Telford Hospitals Trust, or Joshua Titcombe at the University Hospitals of Morecambe Bay Trust, it has taken a family rather than the system to expose what was going wrong. It is known that there are about 1,000 cases a year of safety incidents in the NHS across England, including baby deaths, stillbirths and children left brain damaged by mistakes. Last week, the charity Baby Lifeline, joined The Independent to call on the Department of Health and Social Care (DHSC) to reinstate the axed maternity safety training fund. This small fund was used to train maternity staff across the country. Despite being shown to be effective, it was inexplicably scrapped after just one year. There are other issues that also need urgent attention. The inquest into Harry’s death, which concluded on Friday, lasted for almost three weeks. Without pro bono lawyers from Advocate, Brick Court Chambers and Arnold & Porter law firm, the family would have faced an uphill struggle. At present, families are not automatically entitled to legal aid at an inquest, yet the NHS employs its own army of lawyers who attend many inquests and can overwhelm bereaved families in a legal battle they are ill-equipped to fight. Even the chief coroner, Mark Lucraft QC, has called for this inequality of legal backing to end, but the government has yet to take action. Read full story Source: The Independent, 26 January 2020
  13. News Article
    England's care watchdog has carried out a no-notice inspection of an NHS trust at the centre of concerns over the possible preventable deaths of babies. The Care Quality Commission (CQC) is investigating East Kent Hospitals NHS Trust but has not yet decided whether to prosecute. It comes as the trust is likely to be heavily criticised at an inquest into the death of baby Harry Richford. On Thursday, the BBC revealed significant concerns have been raised about maternity services at the trust, and a series of preventable baby deaths may have occurred there. On Wednesday and Thursday this week, the trust's maternity services were subject to an unannounced inspection from the CQC. On Thursday night, East Kent Hospitals University NHS Foundation Trust said in a statement: "We are truly sorry for the death of baby Harry and our thoughts and deepest sympathies go out to Harry's family. We accept that Harry's care fell short of the standard that we expect to offer every mother giving birth in our hospital and we are fully cooperating with the CQC's investigation into Harry Richford's death." Read full story Source: BBC News, 24 January 2020
  14. News Article
    At least seven preventable baby deaths may have occurred at one of the largest groups of hospitals in England since 2016, a BBC investigation has found. Significant concerns have been raised about maternity services at the trust. East Kent NHS Foundation Trust has apologised, saying it has "not always provided the right standard of care". The trust has struggled to improve maternity care for years, despite repeatedly being made aware of the problems. In 2015, the medical director asked experts from the Royal College of Obstetricians and Gynaecologists to review maternity care, amid "concerns over the working culture". Their review, seen by the BBC, found poor team working in the unit, a number of consultants operating as they saw fit, a lack of performance management of the consultant body and out of date clinical guidelines. It highlights consultants who: failed to carry out labour ward rounds, review women, make plans of care or attend out of hours when requested rarely attended CTG training were reported "as doing their own thing rather than follow guidelines". Read full story Source: BBC News, 23 January 2020
  15. News Article
    Up to half of all patients who suffer an acute aortic dissection may die before reaching crucial specialist care, according to a new Healthcare Safety Investigation Branch (HSIB) report. The report highlights the difficulty which can face hospital staff in recognising acute aortic dissection. The investigation was triggered by the case of Richard, a fit and healthy 54-year old man, who arrived at his local emergency department by ambulance after experiencing chest pain and nausea during exercise. It took four hours before the diagnosis of an acute aortic dissection was made, and he spent a further hour waiting for the results of a CT scan. Although Richard was then transferred urgently by ambulance to the nearest specialist care centre, he sadly died during the journey. The report has identified a number of risks in the diagnostic process which might result in the condition being missed. These include aortic dissection not being suspected because patients can initially appear quite well or because symptoms might be attributed to a heart or lung condition. It also highlighted that, once the diagnosis is suspected, an urgent CT scan is required to confirm that an acute aortic dissection is present. Gareth Owens, Chair of the national patient association Aortic Dissection Awareness UK & Ireland, welcomed the publication of HSIB’s report, saying: “HSIB’s investigation and report have highlighted that timely, accurate recognition of acute Aortic Dissection is a national patient safety issue. This is exactly what patients and bereaved relatives having been telling the NHS, Government and the Royal College of Emergency Medicine for several years." Read full story Source: HSIB, 23 January 2020
  16. News Article
    A coroner has today slammed a hospital for a series of serious failings after a mother bled to death when a medic refused to allow her vital clotting products. Gabriela Pintilie, 36, from Grays, Essex, gave birth to her healthy baby girl, Stefania, in February last year following a C-section after a long labour. But she suffered a major haemorrhage and died from a cardiac arrest hours later. Basildon University Hospital, in Essex, came under fire after it emerged a locum haematologist refused to give Mrs Pintilie the blood after he followed the wrong set of guidelines. The fresh frozen plasma, which could have saved her life, remained outside the theatre after senior staff were not told it was available. Essex Coroner Caroline Beasley-Murray today slammed the hospital for a lack of clear leadership and teamwork during the crucial minutes and hours when Mrs Pintilie suffered a massive haemorrhage. The court heard how the on-call haematologist Dr Asad Omran, who was at home, was called but refused to give permission for vital blood-clotting drugs to be issued until further tests were run. An expert witness said she believed the use of clotting drugs in the 'extreme situation' would have 'significantly increased' the chances of a different outcome. Dr Omran did not initially issue blood-clotting drugs because he followed the wrong protocol. He was following protocol for a normal adult, instead of a woman in labour, which was 'completely at odds with clinical guidelines'. Read full story Source: Mail Online, 20 January 2020
  17. News Article
    The daughter of a man with dementia who died after being pushed by another patient in a care facility, has said her family has been let down by authorities. John O'Reilly died a week after sustaining a head injury at a dementia care unit in County Armagh. The 83-year-old was pushed twice by the same patient in the days leading up to the fatal incident. His family were not made aware of this until after his death. On 4 December 2018, Mr O'Reilly was pushed by another dementia patient causing him to hit his head off a wall. His family have said he was pushed with such force that it left a dent in the wall. He was admitted to Craigavon Area Hospital with severe head injuries and died a week later. Last week, an inquest heard that the dementia patient who pushed Mr O'Reilly had a history of aggressive behaviour linked to dementia. The Southern Trust is carrying out as Serious Adverse Incident (SAI) investigation into Mr O'Reilly's death. Maureen McGleenon said: "Our experience of the SAI process has been dreadful. In our view it allows the trust to park the fact that something catastrophic has happened to a family. We were told it would be a 12-week process. It's over a year now and we've expended so much energy trying to figure out this process and find things out for ourselves." She added: "The system just knocks you down and makes you want to give up." "We'll never get over what happened to dad and we can't give up on trying to understand it." Read full story Source: BBC News, 20 January 2020
  18. News Article
    Hospital bosses have been accused of launching a witch hunt to find a whistleblower who told a widower about blunders in the treatment his wife received. The row emerged as an inquest began into the death of Susan Warby who died five weeks after bowel surgery. The 57-year-old died at West Suffolk Hospital in Bury St Edmunds after a series of complications in her treatment. Her family received an anonymous letter after her death highlighting errors in her surgery, the inquest in Ipswich heard, and both Suffolk Police and the hospital launched investigations. These investigations confirmed that there had been issues around an arterial line fitted to Ms Warby during surgery, Suffolk’s senior coroner Nigel Parsley said. Doctors were reportedly asked for fingerprints as part of the hospital’s investigation, with an official from trade union Unison describing the investigation as a “witch hunt” designed to identify the whistleblower who revealed the blunders. Read full story Source: The Independent, 17 January 2020
  19. News Article
    One in five deaths around the world is caused by sepsis, also known as blood poisoning, shows the most comprehensive analysis of the condition. The report estimates 11 million people a year are dying from sepsis - more than are killed by cancer. The researchers at the University of Washington said the "alarming" figures were double previous estimates. Most cases were in poor and middle income countries, but even wealthier nations are dealing with sepsis. There has been a big push within the health service to identify the signs of sepsis more quickly and to begin treatment. The challenge is to get better at identifying patients with sepsis in order to treat them before it is too late. Early treatment with antibiotics or anti-virals to clear an infection can make a massive difference. Prof Mohsen Naghavi said: "We are alarmed to find sepsis deaths are much higher than previously estimated, especially as the condition is both preventable and treatable. We need renewed focus on sepsis prevention among newborns and on tackling antimicrobial resistance, an important driver of the condition." Read full story Source: BBC News, 17 January 2020
  20. News Article
    The inquiry into Britain's worst maternity scandal is now reviewing 900 cases, a health minister has confirmed. The Ockenden Review, which was set up to examine baby deaths in the Shrewsbury and Telford Hospital Trust, was initially charged with examining 23 cases, but Nadine Dorries, a health minister, confirmed to the Commons that an additional 877 cases are being reviewed. A leaked report in November said a "toxic culture" stretching back 40 years reigned at the hospital trust as babies and mothers suffered avoidable deaths. The review will conclude at the end of the year. Jeremy Hunt, the former health secretary, said it was "deeply shocking" to hear of the new details and asked that the inquiry is "resolved as quickly as possible". Read full story Source: The Telegraph, 16 January 2020
  21. News Article
    Medical examiners are doctors who look at every hospital death with a fresh pair of eyes to make an independent judgement about what took place. It is impossible to overestimate the importance of their role, and it is vital that NHS hospitals now get on with appointing them as a matter of urgency, says Jeremy Hunt, former Foreign Secretary, in an article in the Independent newspaper. The big issue is not that bad things happen (sadly in an organisation of 1.4 million people there will inevitably be things that go wrong) but that they take so long to identify and put right. Mid Staffs took four years, Morecambe Bay took nine years and it now looks like the problems at Shrewsbury and Telford could have taken place over 40 years. Anyone who has spoken to brave patient-safety campaigners who lost loved ones because of poor care will know that their motivation is never money, simply the desire to stop other families having to go through what they have suffered. That is why they and other patient groups all campaign for medical examiners – a process through which every death is examined by a second, independent doctor. It was first recommended following the Shipman inquiry but has taken a long time to implement – inevitably for cost reasons. Where they have been introduced, medical examiners have been transformational. The main pilot sites in Sheffield and Gloucester, which scrutinised over 23,000 deaths, found that “medical examiners have triggered investigations that identified problems with post-operative infections faster than other audit procedures, based on surprisingly few cases”. Doctors also felt confident in raising concerns, as they were protected and supported by the independent medical examiner. Remarkably, pilot studies found that 25% of hospital death certificates were inaccurate and 20% of causes of death were wrong. Read full story Source: The Independent, 16 January 2020
  22. News Article
    A coroner has criticised an ambulance trust after it took nearly four hours to reach a woman who had taken an overdose. Taking the unusual step of publishing a prevention of future deaths report before an inquest had concluded, coroner for Gateshead and South Tyneside Terence Carney said “the real and imminent danger of [the deceased Maureen Wharton’s] admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way”. Ms Wharton called North East Ambulance Service Trust to say she was dying of cancer and had taken prescribed drugs, including an opioid-based medication and sleeping pills. She threatened to take more and later called back, appearing drowsier. North East Ambulance Service graded the 61-year-old’s call as “category three”, which meant she should have received a response within two hours. It took three hours and 45 minutes for the ambulance service to access her flat, by which time she was already dead. Mr Carney pointed out no attempts had been made to identify family or other support for her, or to contact other agencies which could have responded. The inquest into her death is expected to conclude later this year. In a statement, NEAS said it has already made changes to safeguard patients in mental health cases, including implementing greater oversight in its control rooms, improving call transfers to crisis teams, mapping available local mental health services, introducing more staff training, and telling patients in a crisis but not at risk of physical harm about other, more appropriate, services. Read full story (paywalled) Source: HSJ, 14 January 2020
  23. News Article
    Multiple failings have been found in the Parliamentary Health Service Ombudsman's (PHSO) investigation into the death of a young woman with anorexia. PHSO has admitted to multiple failings in how it handled a three-and-a-half year investigation into the systemic failings by NHS providers in Cambridgeshire and Norfolk which led to the death of Averil Hart in 2012. The findings come as a senior coroner in Cambridgeshire investigates whether there are links between the failures in Averil’s care and that of four other women with an eating disorder who were under the care of the same services. The PHSO’s failings have been revealed in an internal review, published today, which ruled the regulator’s investigation took too long and should’ve been completed in half the time. It also found “insufficient” resource was allocated to the Averil’s investigation, despite staff requesting it, which led to significant delays. Read full story Source: HSJ, 10 January 2020
  24. News Article
    A backlog of thousands of deaths of people with learning disabilities awaiting official review has grown further, despite NHS England committing in spring last year to “address” the buildup. Information obtained by HSJ shows the number of incomplete reviews increased slightly between May and November last year – from 3,699 to 3,802. The “national learning disabilities mortality review” programme – known as LeDeR – was launched in 2016 and is meant to review all deaths of people aged four and over. Mencap head of policy and public affairs, Dan Scorer, said: “It is unacceptable that thousands of deaths have still not been reviewed despite NHS England announcing further funding to make sure all reviews were carried out quickly and thoroughly. These latest figures show that little progress has been made; the programme is still failing to address outstanding reviews as well as keep pace with incoming referrals." “Behind these figures are families whose loved ones’ deaths may have been potentially avoidable and they have a right to know that health and care services are learning and acting on LeDeR reviews’ recommendations.” Read full story (paywalled) Source: HSJ, 8 January 2020
  25. News Article
    Mother Natalie Deviren was concerned when her two-year-old daughter Myla awoke in the night crying with a restlessness and sickness familiar to all parents. Natalie was slightly alarmed, however, because at times her child seemed breathless. She consulted an online NHS symptom checker. Myla had been vomiting. Her lips were not their normal colour. And her breathing was rapid. The symptom checker recommended a hospital visit, but suggested she check first with NHS 111, the helpline for urgent medical help. To her bitter regret, Natalie followed the advice. She spoke for 40 minutes to two advisers, but they and their software failed to recognise a life-threatening situation with “red flag” symptoms, including rapid breathing and possible bile in the vomit. Myla died from an intestinal blockage the next day and could have survived with treatment. The two calls to NHS 111 before the referral to the out-of-hours service were audited. Both failed the required standards, but Natalie was told that the first adviser and the out-of-hours nurse had since been promoted. She discovered at Myla’s inquest that “action plans” to prevent future deaths had not been fully implemented. The coroner recommended that NHS 111 have a paediatric clinician available at all times. In her witness statement at her daughter’s inquest in July, Natalie said: “You’re just left with soul-destroying sadness. It is existing with a never-ending ache in your heart. The pure joy she brought to our family is indescribable.” Read full story Source: The Times, 5 January 2020
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