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Found 1,490 results
  1. 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
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. News Article
    A residential care home failed to notify the health watchdog about the deaths of people they were providing a service to, its report has found. Kingdom House, in Norton Fitzwarren, run by Butterfields Home Services, was rated "requires improvement". The home cares for people with conditions such as autism. The Care Quality Commission (CQC) said the registered manager and provider lacked knowledge of regulations and how to meet them. Inspectors found the provider failed to notify the CQC about the deaths of people which occurred in the home, as required by Regulation 16 of the Health and Social Care Act 2008. The report also found people were at "increased risk" because the provider had not ensured staff had the qualifications, competence, skills and experience to provide people with safe care and treatment. Inspectors did, however, praise the "positive culture" at the home, that is "person-centred", and noted the provider was "passionate about their service and the people they cared for". Read full story Source: BBC News, 2 January 2020
  8. News Article
    A woman has died after being set on fire during surgery in Romania, the country’s health ministry has said, in a case that has cast a spotlight on the ailing Romanian health system. The patient, who had pancreatic cancer, died on Sunday after suffering burns to 40% of her body when surgeons used an electric scalpel despite her being treated with an alcohol-based disinfectant. Contact with the flammable disinfectant caused combustion and the patient “ignited like a torch”, Emanuel Ungureanu, a Romanian politician, said. A nurse threw a bucket of water on the 66-year-old woman to prevent the fire from spreading. The health ministry said it would investigate the “unfortunate incident”, which took place on 22 December. “The surgeons should have been aware that it is prohibited to use an alcohol-based disinfectant during surgical procedures performed with an electric scalpel,” the Deputy Minister, Horatiu Moldovan, said. Read full story Source: The Guardian, 30 December 2019 the hub has a number of posts on preventing surgical fires: Surgical fires: nightmarish “never events” persist MHRA. Paraffin-based skin emollients on dressings or clothing: fire risk (18 April 2016) National Patient Safety Agency: Fire hazard with paraffin-based skin products (Nov 2007) How I raised awareness of fires in the operating theatre
  9. News Article
    Two people died and hundreds of others were harmed following prescription errors in North East hospitals last year, new figures reveal. Staff at North East health trusts reported 2,375 prescribing mistakes to an NHS watchdog in 2018, including patients being given the wrong drug, failure to prescribe medicine when needed or given the wrong dosage. At County Durham And Darlington NHS Foundation Trust, where 359 errors were found, 103 patients were harmed by prescription mistakes while one person died. City Hospitals Sunderland NHS Foundation Trust was the second worse in the region for patients coming to harm as a result of prescription errors. One person was killed while 56 were harmed. An NHS spokesperson said: “NHS staff dealt with over a billion patient contacts over the last three years, while serious patient safety incidents are thankfully rare, it is vital that when they do happen organisations learn from what goes wrong - building on the NHS’ reputation as one of the safest health systems in the world." “As part of the NHS Long Term Plan a medicines safety programme has been established, meaning more than ever before is been done to ensure safe medicine use, and nearly £80 million been invested in new technology to prescription systems.” Read full story Source: Chronicle Live, 22 December 2019
  10. News Article
    A coroner has criticised health professionals for failing to give a young woman who died after suffering severe anorexia the support and care she needed. Maria Jakes, 24, died of multiple organ failure in September 2018 after struggling for years with the eating disorder. Coroner Sean Horstead last week concluded that the agencies involved in the Peterborough waitress’s care missed several key opportunities to monitor her illness properly. Mr Horstead said that there had been insufficient record-keeping and a failure to notify eating disorder specialists in the weeks before her death, following treatment at Addenbrooke’s and Peterborough City Hospital. He also criticised the lack of specialist eating disorder dieticians at Addenbrookes and Peterborough hospitals, “together with a nursing team insufficiently trained and knowledgeable of eating disorder patients”, both of which had contributed to the lack of monitoring of Maria. Despite the criticism the father of another anorexia victim, whose death was described in a Parliamentary and Health Service Ombudsman’s report as an “avoidable tragedy”, has said the inquest failed to properly address or challenge the “lack of care” that Maria received from the NHS. Nic Hart, whose daughter Averil died in 2012 at the age of 19, criticised the inquest as “a very one sided process”. He told The Telegraph: “No real challengers were made of the clinical evidence or indeed of the lack of care that poor Maria received.” Read full story Source: The Telegraph, 21 December 2019
  11. News Article
    Sick newborns in some areas of the UK are dying at twice the rate of seriously ill babies in other areas, a new report has revealed. The findings raise serious questions about the quality of care in some neonatal units, with experts warning action needs to be taken to tackle the “striking variation”. Across the country neonatal units are also short of at least 600 nurses with four in five failing to meet required safe staffing levels for specialist nurses. The regions with the highest mortality rate at 10 per cent were Staffordshire, Shropshire and the Black Country, where 107 babies died. This compared with a rate of 5 per cent in north central and northeast London. The Shropshire region includes the Shrewsbury and Telford Hospitals Trust, which is at the centre of the largest maternity scandal in the history of the NHS, with hundreds of alleged cases of poor care now under investigation. Dr Sam Oddie, a consultant neonatologist at Bradford Teaching Hospitals Trust and who led the work for the Royal College of Paediatrics and Child Health, said he was “surprised and disappointed” by the differences in death rates between units. “The mortality differences are very striking, with some units having a mortality rate twice that of the lowest. This variation in mortality is a basis for action by neonatal networks to ensure they are doing everything they can to make sure their mortality is as low as possible,” he said. Read full story Read MBBRACE-UK report Source: The Independent, 18 December 2019
  12. News Article
    An 88-year-old woman with a broken neck died after being transferred three times between two hospitals in the space of just 48 hours, The Independent has reveal. The death of Jean Waghorn, who died after contracting pneumonia in hospital, sparked criticism from a coroner who said the NHS trust had ignored earlier warnings over moving patients between hospitals. Senior coroner Veronica Deeley had issued two official alerts to Brighton and Sussex Hospitals Trust last year after the deaths of frail elderly patients who were wrongly shuttled between hospitals. But despite this, in June this year Ms Waghorn, who broke her neck after falling at home, was repeatedly transferred between the Princess Royal Hospital in Sussex and Brighton’s Royal Sussex County Hospital. She caught pneumonia and died two days later. The hospital, which is rated good by the CQC, has now apologised and said it has learned lessons from the case. A spokesperson said it did take action following the previous warnings and added that work was ongoing to ensure the changes were consistently applied. Read full story Source: The Independent, 17 December 2019
  13. News Article
    A hospital has been fined £45,000 after the death of a leukaemia patient who was given five times the amount of drugs she needed. Royal Bournemouth Hospital Trust ignored repeated warnings from inspectors raising concerns about the unit where the 80-year-old patient, who was taking part in a clinical trial, was given the wrong dose on two separate occasions. The trust was fined at Bournemouth Crown Court on Monday after pleading guilty in August to supplying a medicinal product that was not of the nature or quality demanded. Investigations revealed that, while staff spotted the incorrect dosage, they were wrongly told it was fine, meaning the pensioner, who was terminally ill, was given five times the prescribed amount over four days rather than a lower dose over 10 days. An investigation by the Medicines and Healthcare products Regulatory Agency (MHRA) found staff were working “beyond capacity”. Inspections in 2012, 2013, 2015 and 2017 all found the unit was running over capacity and highlighted it as an issue that urgently needed addressing to prevent any mistakes being made. Read full story Source: The Independent, 12 December 2019
  14. News Article
    Patients are more likely to die on wards staffed by a high number of temporary nurses, a study has found. Researchers say the findings, published in the Journal of Nursing Scholarship, are a warning sign that the common practice by many hospitals of relying on agency nurses is not a risk-free option for patients. The University of Southampton study found that risk of death increased by 12 per cent for every day a patient experienced a high level of temporary staffing – defined as 1.5 hours of agency nursing a day per patient. For an average ward, this increased risk could apply when between a third and a half of the staff on each shift are temporary staff, according to Professor Peter Griffiths, one of the study’s authors. He told The Independent: “We know that patients are put at risk of harm when nurse staffing is lower than it should be. “One of the responses to that is to fill the gaps with temporary nursing staff, and that is an absolutely understandable thing to do, but when using a higher number of temporary staff there is an increased risk of harm. “It is not a solution to the problem.” Read full story Source: The Independent, 10 December 2019
  15. News Article
    More deaths could occur unless action is taken to keep people safe when obtaining medications from online health providers, says a UK coroner. Nigel Parsley has written to Health Secretary Matt Hancock highlighting the case of a woman who died after obtaining opiate painkillers online. Debbie Headspeath, 41, got the medication, dispensed by UK pharmacies, after website consultations. Her own GP was unaware of what she had requested from doctors on the internet. The Suffolk coroner has now written to the Department of Health asking for urgent action to be taken. The General Pharmaceutical Council – the independent regulator for pharmacies – said it was responding to the coroner's report and would continue to take necessary action to make sure medicines are always supplied safely online. Read full story Source: BBC News, 9 December 2019
  16. News Article
    Half of the unexpected deaths in Belgian hospitals are due to a shortage of nurses, according to a study by the University of Antwerp. Researchers from the University of Antwerp show the link between the number of nurses in hospitals and the death of the patients they care for, based on data from 34,567 patients’ medical records in four Flemish, one Walloon and two Brussels hospitals. The records showed that, on average, three out of every thousand patients in the hospital died ‘unexpectedly’. A death is considered as unexpected when a patient suddenly dies during active treatment, with no care plan for the end of their life having been started. “We know from previous research that part of these unexpected deaths can be avoided, which is always heartbreaking for the family as well as the staff,” said Filip Haegdorens, a researcher at the university. “As a sector, we must do everything we can to prevent this,” he added. The average nurse in Belgium is responsible for 9.7 patients at a time. For 89% of all departments, the number of nurses per hospital department was too low to be able to ensure good quality care. “Compared to, for example, Australian hospitals, where legal minimums exist, our Belgian figures could be improved,” said Haegdorens. The study also shows a link between the training level of nurses and the number of unexpected deaths in the hospital. “In some hospital services, we found that more nurses with a high level of education would reduce the risk of unexpected deaths,” Haegdorens added. Read research paper Read full story Source: The Brussels Times, 4 December 2019
  17. News Article
    One of the main brands of adrenaline auto-injector pen, which can save lives during serious allergy attacks, is being recalled in the UK after the death of a teenager whose family say the product failed. Shante Turay-Thomas, 18, died in September last year after it is claimed that her adrenaline pen did not work although she tried it twice. She told her mother, “I’m going to die,” as she succumbed to an allergic reaction to hazelnuts. Her death was the subject of an inquest hearing last month, which resumes this week. The Medicines and Healthcare products Regulatory Agency (MHRA) confirmed this weekend that all batches of Emerade auto-injector had been recalled from pharmacies after an error was identified that can cause some pens to fail to activate. Between July and November, the agency said it had been made aware of 16 suspected activation failures. The agency said it was aware of two fatalities of patients reported to have used the pens but the fault had not been confirmed as a contributor to the deaths. Read full story Source: The Times, 8 December 2019
  18. News Article
    Safety incidents at hospital, mental health and ambulance trusts were linked to more than 4,600 patient deaths in the last year, data shows. The types of patient safety issues recorded by the National Reporting & Learning System (NRLS), which compiles NHS data, include problems with medication, the type of care given, staffing and infection control. In total 4,668 deaths were linked to patient safety incidents, of which 530 deaths specifically linked to mental health trusts and 73 to ambulance trusts. Guidance accompanying the data from the NRLS, which was set up in 2003, states deaths are not always “clear-cut” and cannot always be attributed to patient safety incidents. However, under the “degree of harm” section recorded on the system, there were 4,688 cases listed as death. In total, 4,356,277 reports of patient safety incidents were reported between November 2018 and October 2019. They are described as issues where unintended or unexpected incidents which could have – or did – lead to harm of a patient under the care of the NHS. Other safety incidents had links to consent, paperwork, facilities, and in some cases patient abuse by staff or a third party. Read full story Source: The Guardian, 9 December 2019
  19. News Article
    Maternity services at Shrewsbury and Telford Hospitals Trust were 50 midwives short of what was safe, hospital inspectors have said. A new report by the Care Quality Commission, published today, revealed the trust, which is at the centre of the largest maternity scandal in the history of the NHS, had a 26% vacancy of midwives in April this year. An independent investigation has been examining poor maternity care at the hospital since 2017 and the trust was put into special measures and rated inadequate by the CQC in 2018. Read full story Source: The Independent, 6 December 2019
  20. News Article
    Two patients have died as a result of NHS hospitals failing to heed warnings about the use of super-absorbent gel granules, which patients mistakenly eat thinking they are sweets or salt packets. A national patient safety alert has been issued by NHS bosses to all hospitals, ambulance trusts and care homes instructing them to stop using the granules unless in exceptional circumstances. An earlier alert in 2017 warned the granules, which are used to prevent liquid being spilled, had caused the death of one patient who choked to death after eating a sachet left in an empty urine bottle in their room. The 2017 alert warned hospitals there had been a total of 15 similar incidents over a six-year period between 2011 and 2017. The latest warning from NHS England says most hospitals concentrated on “raising awareness” rather than stopping the use of gel granules. Read alert Read full story Source: The Independent, 4 December 2019
  21. News Article
    The family of a father-to-be have criticised hospital staff who left him "screaming out in pain" in the final hours of his life. Adam Hurst, 31, died from a rare type of hernia a few hours after arriving at Hinchingbrooke Hospital in Cambridgeshire, last December. The hospital found Mr Hurst's pain management and the communication with him and his relatives was "inadequate". The Medical Director of North West Anglia NHS Foundation Trust, Dr Kanchan Rege, said: "Our staff strive to provide high quality care at all times and this was not the case in this instance." At the inquest into his death, the coroner concluded it was "not possible to say whether on the balance of probabilities earlier surgery would have resulted in a different outcome due to the rare and complex nature of the surgery". But the hospital's serious incident report, seen by the BBC, found Mr Hurst's pain "should have been more aggressively managed, from the outset". It also found the frequency of his observations was "inadequate" and stated the documentation in the emergency department "was generally very poor from the nursing staff that cared for the patient". The report also said "clear explanations to the patient and relatives are essential to allay fears and reduce anxiety". Read full story Source: BBC News, 5 December 2019
  22. News Article
    NHS bosses have been accused of using a 2013 report to “maintain a false narrative” about maternity services in Shropshire, which meant poor practices and conditions went unchallenged for years. The Independent has obtained a 2013 report, commissioned by NHS managers in Shropshire, which concluded maternity services at the Shrewsbury and Telford Hospital Trust were “safe”, of “good quality”, and “delivered in a learning organisation”. The report, written by rheumatologist Dr Josh Dixey (now high sheriff of Shropshire), delivered a glowing assessment of the care given to women and babies and appeared to gloss over hints of deeper problems within the service. Sources within the Shropshire and Telford clinical commissioning groups (CCGs), which paid £60,000 for the report, said since it was written it had been “proven to be wrong, inaccurate and to have come to the wrong conclusions and recommendations”, but also stressed it was based on the information received from the trust at the time. A leaked report last month revealed dozens of mothers and babies had died at the Shrewsbury and Telford Hospital Trust, with incidents of poor care stretching over four decades, due to repeated failures to learn from mistakes. Read full story Source: The Independent, 4 December 2019
  23. News Article
    How many people die in California psychiatric facilities has been a difficult question to answer. No single agency keeps tabs on the number of deaths at psychiatric facilities in California, or elsewhere in the nation. In an effort to assess the scope of the problem, The Times submitted more than 100 public record requests to nearly 50 county and state agencies to obtain death certificates, coroner’s reports and hospital inspection records with information about these deaths. The Times review identified nearly 100 preventable deaths over the last decade at California psychiatric facilities. It marks the first public count of deaths at California’s mental health facilities and highlights breakdowns in care at these hospitals as well as the struggles of regulators to reduce the number of deaths. The total includes deaths for which state investigators determined that hospital negligence or malpractice was responsible, as well as all suicides and homicides, which experts say should not occur among patients on a psychiatric ward. It does not include people who died of natural causes or other health problems while admitted for a psychiatric illness. Read full story Source: Los Angeles Times, 1 December 2019
  24. News Article
    More than 200 new families have contacted an inquiry into mother and baby deaths at a hospital trust in Shropshire. Investigators were already looking at more than 600 cases where newborns and mothers died or were left injured while in the care of the Shrewsbury and Telford Hospital Trust. One expert says the scandal, spanning decades, may be the tip of the iceberg. Dr Bill Kirkup says it suggests failure might be more widespread in the NHS. The surge in new cases follows the leak of an interim report last week. Read full story Source: BBC News, 27 November 2019
  25. News Article
    A GP who gave wrongly dated and misleading medical notes to police inquiring into the death of a 12 year old boy from undiagnosed Addison’s disease has been suspended from the UK medical register for nine months. Ryan Morse died in the early hours of 8 December 2012, hours after his mother rang the local Blaenau Gwent surgery twice in a day, reporting high temperature, extreme drowsiness, and involuntary bowel movement. The second time, she spoke to GP Joanne Rudling, telling her that the boy’s genitals had turned black. But Rudling failed to check the notes of the first call or give adequate weight to the fact that the mother was calling again, the tribunal found. She failed to obtain an adequate history or reach an appropriate conclusion about the change in genital colour. Read full story (paywalled) Source: BMJ, 25 November 2019
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