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News Article
Care home under investigation following claims of unsafe conditions
Patient Safety Learning posted a news article in News
A care home with some of the highest Covid death rates recorded in the pandemic is facing whistleblower claims over unsafe conditions. Golfhill Nursing Home, in Dennistoun in Glasgow's East End, Scotland, is run by Advinia Healthcare, which confirmed a "large scale" investigation was taking place. A report by the Crown Office, published in April, showed Golfhill care home recorded 11 deaths related to coronavirus, among the highest rates. The Care Inspectorate investigation is said to have followed "months of complaints" about sub-standard and unsafe conditions at the home, including residents being admitted to hospital suffering from dehydration. The problems are said to centre on the intermediate care unit, where elderly residents are transferred after being discharged from hospital, requiring a higher level of care and remaining there for around a month before being sent home or into long-term care. According to a source, the unit has been short staffed "almost on a daily basis" because employees were being transferred to other areas of the home. Read full story Source: The Scotsman, 17 December 2021 -
News Article
Resident died after treatment at failing care home
Patient Safety Learning posted a news article in News
A resident at an inadequate care home died after their blood glucose increased to high levels and staff acted too slowly, a report found. Inspectors said The Berkshire Care Home in Wokingham breached guidelines in nine areas and must improve. They found residents were put at risk after medicines were not used properly and that records were not up to date. The Care Quality Commission (CQC) said an ambulance was only called for the person who died when they were found to be unresponsive. They later died in hospital. Its report said staff were "not sufficiently skilled" to safely care for people with diabetes. A resident was given paracetamol and co-dydramol eight times over three days, when they should not be used together because they both contain paracetamol, the report said. Another person was burned by a cup of tea and staff did not treat the injury properly, leading to the person developing an infection and later being admitted to hospital. Staff sometimes felt "rushed and under pressure", the report found. Read full story Source: BBC News, 18 December 2021 -
News ArticleCoroners in England are demanding changes in a series of reports highlighting how the struggling healthcare system’s responses to the pressures of the COVID-19 pandemic contributed to patients’ deaths. Coroners are obliged to write a report recommending action in any cases where they believe that this is necessary to prevent future deaths. Reports now emerging suggest that factors in deaths during the pandemic include the move by GPs to telephone consultations, the requirement for vulnerable patients to attend hospital appointments alone, and the lack of safeguards for patients in care homes. The replacement of in-person appointments by telephone consultations reduced GPs’ ability to pinpoint patients’ needs, the coroners said, and the absence of family members from consultations with vulnerable patients meant that clinicians were often unable to get a full picture of their needs. An example is in the Yorkshire and Humber region which saw an increased incidence of children with severe nutritional anaemia in 2020, resulting in two deaths. Maya Zab, who died aged 11 months, was one of the two. Language barriers had caused missed opportunities for primary carers to see Maya, but this was compounded by the pandemic, said Ian Pears, coroner. The “stay at home” message resulted in fewer one-to-one consultations and meant that healthcare professionals were unable to spot signs of her condition, while the limitation of social contact meant that other professionals and friends were unable to report concerns. Read full story Source: BMJ, 8 December 2021
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News Article
Surgery 'may have played role in woman's death'
Patient Safety Learning posted a news article in News
An inquest into whether a pioneering surgery technique played any role in a Gloucestershire woman's death has opened. Jacqui Kingston, from Marshfield, died on 16 March 2020 after having mesh fitted for a prolapsed bowel at Southmead Hospital in Bristol. On Monday an inquest opened at Avon Coroner's Court examining whether the surgery performed by colorectal surgeon Tony Dixon contributed to her death. It is due to run until Thursday. Pathologist Edward Sheffield told the hearing that the use of the mesh for a prolapsed bowel - which was fitted in 2016 - may have contributed to her death. The inquest heard that Mrs Kingston was a fragile patient with many underlying health conditions who developed complications. Mr Dixon was dismissed by the North Bristol NHS Trust in 2019 after dozens of his patients were told they should have been offered alternative treatment first. Read full story Source: BBC News, 13 December 2021 -
News ArticleA trust will not face a second prosecution over the death of a baby seven days after a chaotic birth at one of its hospitals, unless new evidence emerges. Kent police had been looking into incidents at the maternity services department of East Kent Hospitals University Foundation Trust. These incidents include the death of Harry Richford, who was born at Queen Elizabeth, the Queen Mother, Hospital in November 2017. A coroner found a string of failures in his care amounted to neglect. The trust pleaded guilty to failing to meet fundamental standards of care and was fined £733,000 in a case brought by the Care Quality Commission earlier this year. But detective chief superintendent Paul Fotheringham, head of major crime at Kent Police, said: “After careful consideration and following consultation with the Crown Prosecution Service, we took the decision that a criminal investigation would not be undertaken at this time as there is no realistic prospect of conviction against any individual or organisation based on the evidence currently available." In a statement, Harry’s family said: “We are disappointed that Kent Police, in collaboration with the CPS special crime unit in London, have not been able to take forward a charge of corporate manslaughter for Harry at this time. They have assured us that they will keep an open mind on this matter, and any other appropriate charges as and when new evidence is brought before them. “We believe that the Kirkup inquiry and investigation may allow them to revisit a raft of charges on behalf of harmed babies in east Kent in due course. Only when senior leaders are properly held to account, will there be lasting change.” Read full story (paywalled) Source: HSJ, 9 December 2021
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News Article"You hear his heartbeat and the next thing you know, you've got nothing." A woman whose son was stillborn has said she wants to change the law to enable an inquest to investigate the circumstances surrounding his death. Katie Wood's son Oscar was stillborn on 29 March 2015, but under law in England and Wales, inquests for stillborn babies cannot take place. A consultation was put out by the UK government in March 2019, but the findings have yet to be published. The UK government said it would set out its response in due course, but this delay was criticised by the House of Commons justice committee in September. Katie and her family said they have never received satisfactory answers about why Oscar died. Her pregnancy, while challenging, had not given any serious cause for concern. An investigation by the Aneurin Bevan health board found a number of failings in Katie's care. A post-mortem examination suggested a condition known as shoulder dystocia, where the baby's shoulder becomes stuck during birth, may have contributed, but this is rarely fatal. The health board said it conducted a serious incident investigation into Oscar's death and added: "Whilst we seek to find answers during any investigation, in some cases, a full understanding around the cause of death may not always be achieved and we accept the unavoidable distress this may pose for families." Clinical negligence and medical law specialist, Mari Rosser, says allowing coroners to look into the reasons for a baby's death is long overdue. "Currently parents who suffer a still birth can have the circumstances investigated, but the circumstances are investigated by the health board and of course that's less independent," she said. Read full story Source: BBC News, 9 December 2021
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News ArticleA vulnerable man detained for 10 years was failed by a system meant to care for him, an independent NHS investigation has found. Clive Treacey, a man who lived his life in the care of NHS and social care authorities, experienced an “unacceptably poor quality of life”, and was not kept safe from harm before his death at just 47. The findings of the independent review, The Independent and Sky News can reveal, have concluded Mr Treacey’s death was “potentially avoidable” and comes after years of his family “fought” for answers. His family are now pursuing a second inquest into his death after the review found a pathologist report and post-mortem used by coroners did not follow guidelines, along with new CCTV footage from the night he died. NHS England commissioned the review, under the Learning Disability Mortality Review Programme, in January 2020 – three years after Mr Treacey’s death and after his family was initially denied a review. In an exclusive interview with The Independent, Mr Treacey’s sister, Elaine Clark said: “We have fought on because Clive deserved nothing less. He spent his entire life being incarcerated and so did we, his entire family. He didn’t matter. His voice didn’t matter. His human rights didn’t matter. His life choices didn’t matter. The system and its people believed he did not matter and nobody in it had enough ambition to do anything differently." “Well Clive did matter. It matters what happened to him. It matters that it’s still happening to other people. And it matters that nothing seems to be changing we are one family but there are many others like us.” Read full story Source: The Independent, 9 December 2021
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News ArticleAround 80% of adolescents who died by suicide or who had self-harmed had consulted with their GP or a practice nurse in the preceding year, shows new research. The large study of 10 to 19-year-olds between 2003 and 2018, published in the Journal of Child Psychology and Psychiatry, also puts forward a series of proposals to deal with the problem. The study, funded by the NIHR Greater Manchester Patient Safety Translational Research Centre (NIHR GM PSTRC), a partnership between The University of Manchester and The Northern Care Alliance NHS Foundation Trust (NCA). It showed that 85% who later took their own lives consulted with their GP or a practice nurse at least once in the preceding year; the equivalent figure was 75% for those youngsters who harmed themselves non-fatally. Lower than expected rates of diagnosis of psychiatric illness, around a third in both groups, were probably down to a lack of contact with mental health services, rather than an absence of psychiatric illness, argue the research team. Depression was by far the commonest of the examined conditions among both groups, accounting for over 54% of all recorded diagnoses. Also, while suicide was more common in boys, non-fatal self-harm was more common in girls. Two-thirds of adolescents who died by suicide had a history of non-fatal self-harm. And while self-harm risk rose incrementally with increasing levels of deprivation, suicide risk did not. Read full story Source: The University of Manchester, 7 December 2021
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News Article
Britain’s drinking deaths rose at record rate in pandemic
Patient Safety Learning posted a news article in News
Britain’s lockdown drinking habits may have had fatal consequences. Deaths caused by alcohol in 2020 increased by almost 19%, marking the biggest rise since records began, according to the Office for National Statistics. There were 8,974 deaths from alcohol specific causes registered in the 12 month period, up from 7,565 deaths in 2019 – the highest year-on-year increase since the data series began in 2001. It bucks a trend in which fatalities from alcohol remained stable for the previous seven years. In England, the number of people drinking more than 14 units a week increased after the first national lockdown, according to surveys by Public Health England (PHE), and has remained at similar levels since. As pubs shut, drinking at home soared, with off-licence sales of beer rising 31% and spirits 26% compared with 2019. Dr James Tucker, the head of health analysis, said: “There will be many complex factors behind the elevated risk since spring 2020." “For instance, Public Health England analysis has shown consumption patterns have changed since the onset of the coronavirus pandemic, which could have led to hospital admissions and ultimately deaths. We’ve seen increases in loneliness, depression and anxiety during the pandemic and these could also be factors. However, it will be some time before we fully understand the impact of all of these.” Read full story Source: The Guardian, 7 December 2021 -
News Article
Jailed women in UK five times more likely to suffer stillbirths, data shows
Patient Safety Learning posted a news article in News
Women in prison are five times more likely to have a stillbirth and twice as likely to give birth to a premature baby that needs special care, new data collected by the Observer shows. Following two baby deaths in prisons since 2019 there have been increasing concerns about safety for pregnant women and their babies. Figures obtained through freedom of information requests made to 11 NHS trusts serving women’s prisons in England show 28% of the babies born to women serving a custodial sentence between 2015 and 2019 were admitted to a neonatal unit afterwards – double the national figure, according to data from the National Neonatal Research Database. The findings come as the House of Lords prepares to vote this week on proposed changes to bail and sentencing laws that would improve the rights of pregnant women and mothers facing criminal charges. A report published in September examined the circumstances of a baby’s death at Bronzefield prison in Surrey where an 18-year-old was left to give birth alone in her cell. When Anita rang her cell bell at 5.30am when she went into labour the guards said they would send somebody. It was only during the morning rounds at 7.30am that a nurse was called. She was transferred to hospital at 10.30am. Anita said: “Despite being in active labour the guards would not remove my handcuffs and ignored me when I asked them to call the baby’s father and my mum – who were eventually contacted by a doctor.” Read full story Source: The Guardian, 5 December 2021 -
News Article
Stillborn baby's parents receive £2.8m from Nottingham hospital trust
Patient Safety Learning posted a news article in News
A couple whose child died in the womb after mistakes by maternity staff have received a £2.8m settlement. Sarah Hawkins was in labour for six days before Harriet was stillborn at Nottingham City Hospital in April 2016. Hospital bosses initially found "no obvious fault", but an external inquiry identified 13 failings in care. Solicitors representing Mrs Hawkins and husband Jack said it was believed to be the largest payout for a stillbirth clinical negligence case. Mrs Hawkins was nearly 41 weeks' pregnant when Harriet was delivered, almost nine hours after dying. The couple were first told their child had died of an infection but refused to accept this and launched their own investigation. A Root Cause Analysis Investigation Report published in 2018 concluded the death was "almost certainly preventable". The report said errors included a delay in applying appropriate foetal monitoring, the important omission of information on an antenatal advice sheet and a failure to follow the Risk Management Policy for maternity. It also found failures to record or pass on information correctly, failure to follow correct guidelines and delays in administering the correct treatment. Following the report's publication, the hospital trust apologised and said major changes would be made. Read full story Source: BBC News, 6 December 2021 -
News Article
HSIB launches national investigation into ambulance delays
Patient Safety Learning posted a news article in News
The national patient safety watchdog has launched an investigation into the “significant patient harm” caused by ambulances being forced to wait with patients outside of A&E. The Health and Safety Investigation Branch (HSIB) has confirmed it intends to launch an investigation after it received several alerts expressing concerns over the issue of ambulance delays this year. The investigation comes after The Independent revealed 160,000 patients had either died or come to harm as a result of delayed ambulance response times during 2020-21, which were being driven by delays in paramedics being able to hand over patients to hospitals. The damning report, from the Association of Ambulance Chief Executives, included examples of severely ill patients not being treated properly, being forced to go to the toilet in ambulances, and being denied food and drink, as well as antibiotics and fluids. There have been multiple reports of patients dying while waiting for ambulances or while waiting outside of A&Es on the back of ambulances. In a statement to The Independent, HSIB said: “We recognise that handover delays pose a serious safety risk, potentially leading to significant patient harm and impacting on the wellbeing of NHS staff. We welcome the review by AACE as they have provided detailed insight and highlighted key safety concerns. HSIB has already received several referrals expressing similar concerns, which will be taken forward to a national investigation. We will work with AACE and others across the NHS to provide systemic safety learning to help address the challenges created by handover delays.” Read full story Source: The Independent, 2 December 2021 -
News Article
Elizabeth Dixon: Lessons not learned after baby death cover-up, says family
Patient Safety Learning posted a news article in News
The family of a baby who died after errors in her care have criticised the failure of the NHS to learn lessons. Elizabeth Dixon died due to a blocked breathing tube shortly before her first birthday and a subsequent independent investigation found a 20-year cover-up. A year on, Elizabeth's mother Anne told the BBC: "My daughter has not been a catalyst for change." The Department of Health said it was working on the report's recommendations and will publish "a full response". Elizabeth Dixon, known as Lizzie, was born prematurely at Frimley Park Hospital, in Surrey, in December 2000. But a series of errors by the hospital and by Great Ormond Street Hospital, which took over her care shortly after birth, left Elizabeth with brain damage and needing to breathe through a tracheostomy. She was further let down by Nestor Primecare, a private nursing agency, which was hired to support her parents when Elizabeth returned home. She died 10 days before her first birthday. An official investigation, published last year, found a "20 year cover-up" by health workers, with some of those involved described as "persistently dishonest". "I would have expected them to take it seriously," Mrs Dixon said in response to the lack of action. She believes that if a similar incident happened today, there would be a danger it would also be covered up. "That's the default option - if its bad enough, they'll cover up," she said. Read full story Source: BBC News, 1 December 2021 -
News ArticleA watchdog is "very concerned" about the safety of people using the services of Greater Manchester Mental Health NHS Trust. The damning report says inspectors found there was not always enough nursing staff and that permanent staff did not feel safe if bank or agency workers were used as they didn't have the relevant training. It follows an unannounced inspection in September by the Care Quality Commission "due to on-going concerns about the safety of services". Three young patients died in nine months at Prestwich Hospital, one of the Trust's units. A campaign group and the families are campaigning for a full investigation into those cases by NHS England. The CQC's two-day inspection of eight wards across five of the the Trust's seven sites found: The service did not always have enough nursing staff, who knew the patients or received basic and essential training to keep patients safe from avoidable harm. The environment on Poplar ward (Park House) was not clean on the first day of inspection and space on the ward was limited for patients. It was not clear that immediate concerns or learning from incidents was shared across the locations, although local learning and reviews were taking place. The wards did not all have up to date and recently reviewed ligature risk assessments. Staff on two wards could not locate the ligature risk assessments at the time of the inspection. Read full story Source: Greater Manchester News, 26 November 2021
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News ArticleDying patients are going without care in their own homes because of a collapse in community nursing services, new data shared with The Independent reveals. Across England a third of district nurses say they are now being forced to delay visits to end of life care patients because of surging demand and a lack of staff. This is up from just 2% in 2015. The situation means some patients may have to wait for essential care and pain medication to keep them comfortable. Other care being delayed includes patients with pressure ulcers, wounds which need treating and patients needing blocked catheters replaced. More than half of district nurses said they no longer have the capacity to do patient assessments and psychological care, in an investigation into the service. Professor Alison Leary, director of the International Community Nursing Observatory, said her study showed the country was “sleepwalking into a disaster,” with patients at real risk of harm. She said the situation was now so bad that nurses were being driven out of their jobs by what she called the “moral distress” they were suffering at not being able to provide the care they knew they should. “People are at the end of their tether. District nurses are reporting having to defer work much more often than they did two years ago. What they are telling us is that the workload is too high. This is care that people don’t have time to do.” Read full story Source: The Independent, 29 November 2021
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News Article
Drug and alcohol treatment sees rise in deaths in England
Patient Safety Learning posted a news article in News
There has been a 27% rise in people dying while in treatment for drug and alcohol addiction during the pandemic, an official report shows. Changes to support and reduced access to healthcare during lockdowns are likely to have been factors, it says. Between April 2020 and March 2021, 3,726 people died while in contact with drug and alcohol services - up from 2,929 the year before. The figures, published by the Office for Health Improvement and Disparities, for England, show a small 2% rise in the overall numbers of adults receiving help for drug and alcohol problems from 2020 to 2021. Out of more than a quarter of a million people affected, more than half were in treatment for problems with opiates - medicines to treat pain - and a quarter with alcohol problems. The proportion of deaths in treatment for alcohol addiction rose by 44% to 1,064 and for opiate addiction by 20% to 2,418. UKAT, a group providing residential detox treatment, said a "concerning" number of services closed their doors to addicts during the pandemic. "But drug and alcohol treatment is critical care intervention and cannot be simply put on pause," said Nuno Albuquerque, head of treatment for the group. "It cannot be a coincidence that more people have subsequently lost their lives when they were in fact trying to save it." Read full story Source: BBC News, 25 November 2021 -
News Article
Did bad vaccine advice cost Samantha Willis her life?
Patient Safety Learning posted a news article in News
When the UK’s jab programme began, expectant mothers were told to steer clear – so Samantha decided to wait until she had had her baby. Two weeks after giving birth, she died in hospital from Covid. Samantha was unvaccinated – she had received advice against getting jabbed at an antenatal appointment. When the Covid vaccine programme began in the UK on 8 December 2020, pregnant women were told not to get vaccinated. But in October 2020, the Royal College of Obstetricians and Gynaecologists (RCOG) published guidance warning that “intensive care admission may be more common in pregnant women with Covid-19 than in non-pregnant women of the same age” and that pregnant women with Covid were three times more likely to have a preterm birth. Further evidence emerged in 2021 indicating that pregnant women were particularly vulnerable to Covid, especially in their final trimester. Research from the University of Washington, published in January, found that pregnant women were 13 times more likely to die from Covid than people of a similar age who were not pregnant. But throughout February and March, the JCVI’s scientists did not appear especially concerned about examining the case for vaccinating pregnant women. Priority in the early stages of the vaccine programme was being given to older people, so many pregnant women remained towards the back of the queue. The maternity campaign group Pregnant Then Screwed said: “If you look at who was on the Covid war cabinet and leading the daily briefing, it was nearly all men,” says Joeli Brearley, its founder. “Pregnant women were treated as if they were very similar to the general population, rather than being seen as a special cohort that needs special consideration. They were just not a priority.” Read full story Source: The Guardian, 23 November 2021 -
News Article
Trust focused on ‘reputation’ failed to address patient harms
Patient Safety Learning posted a news article in News
A focus on “reputation management” was a factor in how an acute trust failed to properly investigate serious safety concerns in a dysfunctional department where consultants were “divided along ethnic lines”. An external review into the urology services at University Hospitals of Morecambe Bay Foundation Trust has identified 520 cases where patients suffered “actual or potential harm”, including several cases where patients died. The review, commissioned by NHS England, has found there were “multiple individual, team, organisational, and regulatory shortfalls which have resulted in a systemic failure to deliver good urological care at all times”. Much of the report focuses on the trust’s failure to properly investigate concerns being raised, and to sort out poor relationships within the department which dated back 20 years. Read full story (paywalled) Source: HSJ, 24 November 2021 -
News Article
Change to sepsis advice after mums' herpes deaths
Patient Safety Learning posted a news article in News
Advice on how new mothers with sepsis should be treated is to change after two women died of a herpes infection. The Royal College of Obstetricians and Gynaecologists says viral sources of infections should be considered and appropriate treatment offered. This comes after the BBC revealed one surgeon might have infected the mothers while performing Caesareans on them. The East Kent Hospitals Trust said it had not been possible to identify the source of either infection. Kimberley Sampson, 29, and Samantha Mulcahy, 32, died of an infection caused by the herpes virus 44 days apart in 2018, shortly after giving birth by Caesarean section. Their families were told there was no link between the deaths but BBC News revealed on Monday that both operations had been carried out by the same surgeon. Documents we uncovered showed that the trust had been told two weeks after the second death that "it does look like surgical contamination". Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, which set standards in maternity care, said routine investigation and management of maternal sepsis "should always consider viral sources of infection, and appropriate changes should be instituted to support earlier diagnosis and treatment". Medics treating Ms Sampson and Mrs Mulcahy assumed they were suffering from a bacterial infection and didn't prescribe the anti-viral medication that may had saved their lives. The Royal College said the two deaths should be "fully investigated" as "surgical infection appears to be a significant possibility". But BBC News has learned that the East Kent Hospitals Trust, which treated both women, never told the coroner's office that the same surgeon had carried out both operations or that an investigation they had ordered had suggested the virus strains the two women had died from appeared to be "epidemiologically linked". Read full story Source: BBC News, 23 November 2021 -
News ArticleThe family of a woman who died after being repeatedly overdosed with paracetamol in an NHS hospital have demanded action over her death amid allegations of an NHS cover up. Laura Higginson, a trainee solicitor and mum of two, died after seeking medical help for sickness and pneumonia. She died two weeks later from multi-organ failure and sepsis. Whiston Hospital, in Merseyside, has admitted to the overdose but denied it caused her death and rejects any suggestion of wrong doing. But expert reports, seen by The Independent, including from a liver specialist, questions the trust’s account of what happened, the quality of its post-mortem and concludes the mother-of-two – who only weighed 36kg – suffered liver failure after too much paracetamol in April 2017. The overdose mistake was recognised by staff on the third day but Laura’s family were never told. The trust did not record the error as an incident and only started an investigation 14 months later when concerns were raised by Laura’s family. Her husband Antony Higginson says the subsequent investigation report is “littered with inaccuracies.” He told The Independent: “We just want justice; we don’t care about money. Laura died needlessly and all these institutions charged with ensuring safe care and accountability have point blank failed and have rendered Laura’s life as essentially worthless and that she didn’t matter, when she did matter.” Read full story Source: The Independent, 21 November 2021
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News Article
Trust fined £2.5m after deaths of two patients
Patient Safety Learning posted a news article in News
An acute trust has been fined £2.5m after pleading guilty to charges of failing to provide safe care after the deaths of two patients. The Care Quality Commission brought charges against The Dudley Group Foundation Trust earlier this year over care failings in two separate cases which the regulator said exposed two patients to “significant risk of avoidable harm”. The trust pleaded guilty to the charges in July and was fined during a sentencing hearing today. The cases, involving 33-year-old mother of six Natalie Billingham, and 14-year-old Kaysie-Jane Bland [also known as Kaysie-Jayne Robinson], were both in 2018 and related to care at the trust’s Russells Hall Hospital in Dudley. Ms Billingham was admitted to Dudley’s Russells Hall Hospital with numbness in her right foot on 28 February 2018 and died on 2 March of organ failure caused by a “time critical” infection. The court was told she was initially thought to have a deep vein thrombosis after a three-minute triage that failed to identify "disordered" observations. The hospital then had multiple reasons to reconsider the initial diagnosis, but opportunities for review were "missed or ignored". In the case of Kaysie-Jane, who had cerebral palsy, an "early warning score" was inaccurate, meaning a sepsis screening tool was not triggered. The CQC said the care both patients received at Russells Hall Hospital was undermined by the Dudley Group’s failure to address known safety failings which the regulator repeatedly raised with the trust in the months before their deaths. The CQC said the trust did not take all reasonable steps to make improvements, despite its intervention. The trust has denied it did not react to the concerns raised. Failings included errors in the hospital’s initial assessments and monitoring of both patients, which hindered the timely escalation of concerns. A lawyer acting on behalf of the Dudley Group NHS Foundation Trust had admitted the trust failed to provide treatment in a safe way, resulting in harm, in February and March 2018. Read full story (paywalled) Source: HSJ, 19 November 2021 -
News ArticleThe increased risk of black and minority ethnic women dying during pregnancy needs to be seen as a whole system problem and not limited to just maternity departments, according to experts on an exclusive panel hosted by The Independent. Professor Marian Knight, from Oxford University told the virtual event on Wednesday night that the health service needed to change its approach to caring for ethnic minority women in a wider context. Campaigners Tinuke Awe and Clotilde Rebecca Abe, from the Fivexmore campaign, called for changes to the way midwives were trained and demanded it was time to “decolonise the curriculum” so it recognised the physiological differences between some ethnic minority women and white women. Dr Mary Ross-Davie, from the Royal College of Midwives, said work was underway to ensure the voices of black women and other minorities were represented in its work and it was examining how it could deliver better training to midwives. The data on maternity deaths in the UK show black women are four times more likely to die during pregnancy in the UK than white women. For Asian women, they are twice as likely to die. Read full story and watch video of event Source: The Independent, 18 November 2021
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News Article
A&E overcrowding in UK ‘killing thousands a year’, say doctors
Patient Safety Learning posted a news article in News
Thousands of patients a year are dying because of overcrowding in A&E units in Britain, and more fatalities will follow this winter, emergency care doctors claim. An estimated 4,519 people in England died in 2020-21 as a direct result of people receiving less than ideal care while delayed in A&E waiting to start treatment in the hospital. “To say this figure is shocking is an understatement. Quite simply, crowding kills,” said Dr Adrian Boyle, a vice-president of the Royal College of Emergency Medicine (RCEM). There have also been 709 deaths in Wales and 303 in Scotland so far this year for the same reason, according to a report by the college. Another 566 excess deaths caused by overcrowding occurred in Northern Ireland in 2020-21. The 4,519 in England “may be an underestimate”, it adds. The four figures taken together mean the college has identified at least 6,097 deaths across the four home nations that it believes occurred because overcrowding hampered the person’s treatment. “There’s a lot of human misery behind these figures. It’s uncomfortable and unbearable that people are being put through this. It’s impossible not to feel upset and angry about this,” Boyle said. Read full story Source: The Guardian, 18 November 2021 -
News Article
Widow demands answers over Covid official's death
Patient Safety Learning posted a news article in News
The widow of a top Scottish government official, who died after contracting Covid, believes the full details of his illness were concealed to protect the reputation of a troubled hospital. Andrew Slorance, Scottish government's head of response and communication unit, in charge of its handling of the Covid pandemic, went into Glasgow's Queen Elizabeth University Hospital for cancer treatment a year ago. His wife Louise believes he caught Covid there as well as another life-threatening infection. Andrew went in to the £850m flagship Queen Elizabeth University Hospital (QUEH) at the end of October 2020 for a stem cell transplant and chemotherapy as part of treatment for Mantle Cell Lymphoma (MCL). He died nearly six weeks into his stay, with the cause of his death listed as Covid pneumonia. But after requesting a copy of his medical notes, Mrs Slorance discovered her husband had also been treated for an infection caused by a fungus called aspergillus, which had not been discussed with either of them during his hospital stay. The infection is common in the environment but can be extremely dangerous for people with weak immune systems. Mrs Slorance questions whether it may have played a part in her husband's death, and if so, why she was not told? She told the BBC: "I think somebody and probably a number of people have made an active decision not to inform his family of that infection, either during his admission or post-death." Mrs Slorance believes that officials wanted to protect the hospital, which is already the subject of a public inquiry, and its reputation, "no matter what the cost". Mrs Slorance says a full investigation should take place into incidences of aspergillus at the hospital campus. In response, NHS Greater Glasgow and Clyde said: "We are sorry that the family are unhappy with aspects of Mr Slorance's treatment, details of which were discussed with the family at the time. "While we cannot comment on individual patients, we do not recognise the claims being made. We are confident that the appropriate care was provided. There has been a clinical review of this case and we would like to reassure the family that we have been open and honest and there has been no attempt to conceal any information from them." Read full story Source: BBC News, 18 November 2021 -
News Article
Bereaved left in limbo by report delays, says mum
Patient Safety Learning posted a news article in News
The mother of a man who took his own life said bereaved families would be left "in limbo" by a mental health trust's serious incident report delays. Local health officials have raised concerns over the "timeliness" of Cambridgeshire and Peterborough NHS Foundation Trust's (CPFT) reports. Maria Nowshadi, whose son James died in 2020, said they should be done quickly "so there's answers for families". Ms Nowshadi said: "These investigations should happen in a timely, quick manner so there's answers for families, but also in case there's any learning to be had... to make sure there's no further deaths that happen in the same way, because of any errors within the system." She said when the original date the report was due to be completed passed, she "reached the stage where I was looking at the mailbox every day". She said she told a patient liaison officer: "This is actually starting to affect my mental health. The chief nurse at Cambridgeshire and Peterborough's Clinical Commissioning Group (CCG), Carol Anderson, said there were "concerns... [around] serious incident processes and reporting" at CPFT. A CCG spokeswoman added they had agreed an extension with CPFT "for the completion of serious incident reports due to additional pressures due to the pandemic and staff redeployment". "Our overall concern is the timeliness of serious incident reporting, so that we can ensure that learning is put in place as soon as possible," she added. Read full story Source: BBC News, 17 November 2021
