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A boy who suffered "catastrophic brain injuries" when doctors failed to see he had a virus and sent him home after he had a seizure has been awarded £27m. The boy, who cannot be identified but is now 13, suffered seizures as a toddler more than a decade ago. Details of the settlement between the boy's father and Liverpool's Alder Hey Children's NHS Foundation Trust were published in a written ruling. High Court judge Mr Justice Fordham said it was a "sensible settlement". Trust bosses admitted "breach of duty" and "causation of loss and damage", the judge said. The judgment, from the hearing in Manchester, said the boy had suffered a seizure at 17 months old on 19 September 2009 and was taken to Alder Hey Children's Hospital. He suffered a second seizure in the accident and emergency department which was seen by medical staff. The boy was sent home and, despite going back to hospital, was not diagnosed with a virus until 24 September. Read full story Source: BBC News, 12 November 2021

Black women are more than four times more likely to die in pregnancy or childbirth than white women in the UK, a review of 2017-2019 deaths shows. The MBRRACE-UK report found women from Asian backgrounds are almost twice as likely to die as white women. Some 495 individuals died during pregnancy or up to a year after birth, out of 2,173,810 having a child. The charity Birthrights is concerned that overall "this bleak picture has not changed in over a decade". University of Oxford researchers say for the vast majority of people, pregnancy remains very safe in the UK. But despite slight decreases in the maternal death rate in recent years, there have been no significant improvements to these rates since the 2010 to 2012 period. Their current report shows heart disease, epilepsy and stroke continue to be the most common causes of death. And they say in some 37% of cases, improvements in care may have made a difference to the outcome. Lead researcher, Prof Marian Knight, said: "Pregnant women get inequitable care for several reasons. "Healthcare professionals often attribute their symptoms to pregnancy alone and they do not always end up getting the treatment they need because people can be incorrectly concerned about giving them medication. "On top of that is the unconscious bias that black and Asian women can experience. It all adds up. "We know from other studies that the disparity in death rates cannot be fully explained by socio-economic factors and other medical conditions for example. We need to look for other reasons." Read full story Source: BBC News, 11 November 2021

England has the highest death rates of frail and older hospitalised patients in the western world, a landmark global study has found. Harvard University, the London School of Economics (LSE) and the thinktank Health Foundation, all part of the International Collaborative on Costs, Outcomes and Needs in Care (Icconic), a global network of healthcare researchers, used thousands of official medical records to compare the cost and quality of care in 10 OECD (Organisation for Economic Co-operation and Development) countries. Patient deaths are commonly used measures of performance in healthcare systems but until now there have been few sources of comparable death rates across countries. In order to assess outcomes in frail and older patients, researchers focused on two groups that represent priority areas for the NHS and other healthcare systems: those in hospital with a hip fracture and those admitted with heart failure who have diabetes. On both measures, England had higher mortality rates than all the other countries, which included the US, Germany, France, Sweden and Spain. Dr Jennifer Dixon, the chief executive of the Health Foundation, said: “The findings of the Icconic study warrant urgent further investigation, particularly the finding of higher mortality among patients with hip fracture in the year after their admission for emergency treatment." “That patients in England with hip fracture spend far longer in hospital after surgery than they would in other countries also highlights an opportunity to improve efficiency by reducing the avoidable use of hospital care. Less avoidably long stays would mean existing capacity could be better used to address the backlogs in hospital care as a result of the pandemic. This could contribute to both better outcomes for patients and, as hip fracture is the most common reason for emergency surgery, significantly improved productivity for hospitals across the country.” Read full story Source: The Guardian, 10 November 2021

Campaigners have called for a change in how epilepsy services are delivered after "alarming" new research revealed that nearly 80% cent of deaths in young adults could have been avoided. It comes as researchers behind the first ever national review into deaths linked to the condition warned that "little has improved in epilepsy care" despite previous findings of premature mortality. They describe the situation as a "major public health problem in Scotland", adding that deaths "are not reducing, people are dying young, and many deaths are potentially avoidable”. In particular, the Edinburgh University team found that adults aged 16 to 24 were five times more likely to die compared to the general population, a problem they said may be linked to the "vulnerable period of transition from paediatric to adult care". Overall, for adults with epilepsy aged 16 to 54, the mortality rate was more than double that for the age group as a whole, with as many as 76% of these deaths potentially preventable and the majority occurring among patients from the most deprived areas. Read full story Source: The Herald, 11 November 2021

A woman took her own life on a ward after her move to a mental health hospital was not facilitated. Anne Clelland was found unconscious in the toilet of her room in Glasgow's Queen Elizabeth University Hospital and later died of a brain injury. Anne - who had a history of self-harm - was admitted following an overdose. She was due to be moved to a psychiatric hospital three days before her death but this did not take place because of a "failure of communication." NHS Greater Glasgow and Clyde pled guilty today to failing to conduct their undertaking in a way that a person would not be exposed to risks to their health and safety. Glasgow Sheriff Court heard Anne was admitted to Ward 5A at the hospital after overdosing on 7 May 2015. A specialist met with Ann on 11 and 12 May with a plan put in place for her to be transferred to Leverndale hospital once she was medically fit. A psychiatry team was to be contacted at that time for a further review to facilitate the transfer. Prosecutor Catriona Dow said: “There was no suggestion at this time that despite her ongoing treatment following her suicide attempt, that she was at risk of suicide and required special requirements such as the removal of her possessions and enhanced observations such as constant observations.” “There appears there was a breakdown in communication regarding the intention of the psychiatrist that Anne would be transferred that evening due to her assessed risk of self-harm.” Other witnesses recalled a plan for a transfer to Leverndale but it was understood that until a bed was to become available, she would be able to remain at Ward 5A. Other staff appeared not to have been aware of the assessed risk of self-harm and her transfer to Leverndale that evening. Read full story Source: Glasgow Live, 8 November 2021

More than 11,000 people who died from Covid probably caught the deadly virus while in hospital for other reasons, it has emerged. Freedom of information requests to NHS trusts across England has revealed as many as one in eight people who have died in hospital from coronavirus during the pandemic actually arrived free of the virus. An investigation by the Daily Telegraph has revealed 11,688 people are listed by the NHS as either probably or definitely catching the virus which killed them while in hospital. Probable cases are those who tested positive at least eight days after admission, while definite cases require the patient to not have tested positive until they had been on the wards for at least 15 days. The figures emerged as the government was expected to announce it will be mandatory for all NHS staff to be vaccinated against Covid by next spring. Read full story Source: The Independent, 9 November 2021

Saiqa Parveen was eight months pregnant and weeks from welcoming her fifth daughter to the world, but died of Covid after putting off getting the coronavirus jab. Her family have now issued an emotional plea for pregnant women to get vaccinated. Parveen, 37, had planned to delay having the jab until her baby was born, her family said, but she was admitted to hospital with breathing difficulties in September and put on a ventilator. A decision was taken by medical staff at Good Hope hospital in Sutton Coldfield, Birmingham, to deliver the baby by emergency caesarean section. Parveen died on 1 November after spending five weeks in intensive care. Asked what her last words were, her husband Gahfur said: “She couldn’t even talk. She couldn’t breathe properly … She couldn’t talk.” He added: “I’m going to pass this message to the whole world, I just beg all people to get the vaccine, otherwise it’s very hard for them. It’s a very deadly disease, you know. She planned so many things, and this disease didn’t give her a chance.” Covid vaccines are recommended for pregnant women. In a letter to midwives, obstetricians and GP practices in July, the chief midwife for England, Jacqueline Dunkley-Bent, said all healthcare professionals had “a responsibility to proactively encourage pregnant women” to get vaccinated. Parveen chose not to have the vaccine, but concerns have been raised that pregnant women are being turned away from vaccine clinics despite clinical advice. Members of the Joint Committee on Vaccination and Immunisation told the Guardian that they were urging ministers to focus more on pregnant women because only about 15% in the UK have been fully vaccinated. Read full story Source: The Guardian, 7 November 2021

There have been more than 30 serious security breaches at NHS hospital mortuaries in the past five years, The Independent can reveal. The figures come as local MPs demand a public inquiry into the crimes of NHS electrician David Fuller who sexually abused 100 corpses, including three children, over a period of 12 years. The calls for a full inquiry have also been backed by Labour’s shadow health secretary Jonathan Ashworth who said on Friday: “It is important the secretary of state listens to the concerns of the local MP and the families of those who have been involved, and establishes a full, swift public inquiry, so that lessons can be learned from this appalling incident and ensure this is never repeated.” Fuller, aged 67, pleaded guilty on Thursday to the murders of two women, Wendy Knell, 25, and Caroline Pierce, 20, in two separate attacks in Tunbridge Wells, Kent, in 1987. Detectives searching Fuller’s home found four million images of sexual abuse he had downloaded from the internet on computer hard drives. They also found footage he had filmed of himself carrying out attacks on the bodies of women at the now-closed Kent and Sussex Hospital and the Tunbridge Wells Hospital, where he had worked since 1989. Read full story Source: The Independent, 5 November 2021

A man who murdered two women 34 years ago went on to sexually abuse 100 female corpses in hospital mortuaries, taking videos and images of his crimes, HSJ can reveal. David Fuller was employed as an electrician and later a maintenance supervisor at the now closed Kent and Sussex Hospital, in Tunbridge Wells, and later the Tunbridge Wells hospital in Kent. Over a period of 12 years from 2008 to 2020 he used his access to the hospital mortuaries to sexually abuse the bodies of women and girls. HSJ first learned of David Fuller’s crimes in June this year, but agreed to a request by Kent police not to publish before his trial concluded. They can now reveal all that they discovered. Police have identified 80 victims – from mortuary records and name tags visible in some of the photos and videos Mr Fuller took of the abuse – but 20 are currently unidentified. Mr Fuller’s mortuary offences – which he admitted at a court hearing last month – only came to light when he was arrested for the 1987 murders of Caroline Pierce and Wendy Knell. Police searching his home in Heathfield, East Sussex, discovered millions of videos and photographs, some clearly showing him abusing the bodies. To many of his colleagues at Tunbridge Wells Hospital, David Fuller was an affable and helpful maintenance supervisor who was always willing to carry out small tasks and was the “go to” man if a problem needed sorting. His arrest on murder charges last December was greeted with shock and disbelief by those who knew him. Both the families of the women violated by Mr Fuller and some staff at Maidstone and Tunbridge Wells are expected to need psychological help to deal with the enormity and nature of Fuller’s crimes. Families will be offered a range of support, including psychiatric counselling, and will also be given a letter from Mr Scott, with a personal apology and containing an invitation for them to contact the trust if they want to. Read full story (paywalled) Source: HSJ, 4 November 2021

A special Crown Office unit set up to probe Covid-linked deaths is considering 827 cases in Scotland's hospitals, latest figures show. The unit was set up to consider the circumstances of Covid-linked deaths such as those in care homes. But the prosecution service has also received reports of hundreds of hospital-related virus deaths. Prosecutors will eventually decide if these deaths should be the subject of a fatal accident inquiry or prosecution. As of 7 October, Crown Office figures show Scotland's biggest hospital, the Queen Elizabeth University Hospital in Glasgow, has the highest number of reported Covid-linked deaths at 113. This was followed by the Royal Alexandra Hospital in Paisley and Glasgow Royal Infirmary which both had 71 Covid-related deaths referred to the Crown Office. The figures do not include deaths at home addresses or hospices, or where a care home resident died in hospital after contracting COVID-19 in a home. Read full story Source: BBC News, 4 November 2021

People are dying at home without the correct nursing support or pain relief because of staff shortages, according to the end-of-life charity Marie Curie. One in three nurses, responding to a survey by the charity and Nursing Standard, say a lack of staff is the main challenge providing quality care to dying people. More than half of the nurses said they feel the standard of care has deteriorated during the coronavirus pandemic. Some 548 nursing staff across acute and community settings in the UK completed the survey in September. They raise concerns about the increased number of people dying at home and insufficient numbers of community nurses to support these people and their families. One nurse who responded to the survey said: "If more [people] are dying at home then there is a huge pressure on local district nursing teams which struggle with staffing as it is." Julie Pearce, chief nurse and executive director of quality and caring services at Marie Curie, said: "The pandemic has accelerated change across many care settings. "More people are dying at home and staffing to support this shift isn't there. "The data shows a hidden crisis happening behind closed doors and people dying without access to pain relief or the dignity they deserve." Read full story Source: The Independent, 27 October 2021

A mental health trust ‘scapegoated’ a psychiatrist over the death of a patient amid systemic issues, an employment tribunal has found. Judges called the conduct of two senior directors — one of whom is a current NHS trust medical director — into question after ruling they had colluded to scapegoat Bernadette McInerney for issues that would have damaged the trust’s reputation. Nottinghamshire Healthcare Foundation Trust was found unanimously to have unfairly sacked and victimised Dr McInerney, a former consultant forensic psychiatrist at Rampton secure hospital, in a decision published last week. The judgement was critical of both Chris Packham, a GP at Rampton hospital, and NHFT’s then-executive medical director Julie Hankin, but it also strongly condemned the trust’s former executive director for forensic services Peter Wright. Dr Hankin is now medical director at Cambridgeshire and Peterborough FT. Read full article here (paywalled) Original source: Health Service Journal

Five serious incidents, including the deaths of two children, spark “urgent” investigations at specialist trust Great Ormond Street Hospital FT has linked the incidents partly to what it described as a “faulty” batch of a type of glue used to close wounds during surgery Supplier says it followed the correct recall processes for the product Five serious incidents, including the deaths of two children, have sparked ‘urgent’ investigations into the processes through which clinicians are alerted to potential safety concerns over medical products used on patients. Great Ormond Street Hospital Foundation Trust has been investigating the incidents which happened between December 2020 and April 2021. The trust has linked the incidents partly to what it described as a “faulty” batch of a type of glue used to close wounds during surgery. The glue, called Histoacryl, is produced by B. Braun Medical Ltd, and the company issued three separate “field safety notices”, relating to different batches of the product, in March and April this year. The company has stressed that it followed the correct recall processes throughout. According to a report to GOSH’s public board meeting on 29 September, Histoacryl has been used for the endovascular treatment of brain arteriovenous malformations for more than 30 years, but earlier this year batches of the product were identified as hardening less rapidly than expected. The trust told HSJ in a statement: “A comprehensive serious incident investigation has been carried out to determine the impact of the faulty glue on all patients treated with it. “The investigation found that whilst the passage of glue through the intended vessel may have been contributory in some instances of harm, it was unlikely to be the sole or main factor. “Both patients who died had serious and complex medical conditions and the procedure to correct these always carries a high degree of risk which is discussed extensively with the families before any treatment takes place.” Read full article here (paywalled) Original source: Health Service Journal

Tens of thousands of defibrillators across the UK risk being unusable because 999 call handlers do not know about them. When someone has a cardiac arrest, ambulance staff can only direct bystanders to the nearest defibrillator if it is on a central register. "That could be the difference between life and death," said Adam Fletcher, head of British Heart Foundation Cymru. A campaign to register defibrillators on The Circuit has now been launched. Survival rates are low in the more than 30,000 out-of-hospital cardiac arrests each year in the UK, according to the British Heart Foundation (BHF) - with fewer than one in 10 people surviving. BHF said early CPR and defibrillation could double the chances of surviving and it was often down to 999 call handlers being aware that a defibrillator was nearby. "If we don't know a defibrillator is there, we can't send somebody to get it, to potentially save somebody's life," said Carl Powell, the clinical support lead for cardiac care with the Welsh Ambulance Service. Read full story Source: BBC News, 22 October 2021

Failings by NHS 111 contributed to the death of an autistic teenager, a coroner has ruled. Hannah Royle, 16, suffered a cardiac arrest as she was driven to hospital by her parents after a 111 algorithm failed to notice she was seriously ill. A coroner said her death had exposed a risk people were being misled about the capability of the system and its staff. An NHS spokesperson said it would act on the findings and learnings "where necessary". Hannah's father Jeff Royle said he regretted dialling 111 and wished he had taken his daughter straight to hospital. "I feel so dreadful, that I have let her down and she has been let down by the NHS," he said. Read full story Source: BBC News, 20 October 2021

On Tuesday, there were 356 COVID-19 patients being treated in intensive care wards throughout Australia. Of those, 25 were fully vaccinated. While the data points to the extraordinary efficacy of COVID-19 vaccines in preventing people from becoming severely unwell, being hospitalised and dying, it does raise the question: why do a small number of people become seriously ill and, in rare cases, die, despite being fully vaccinated? An intensive care unit staff specialist at Nepean hospital in Sydney, Dr Nhi Nguyen, said those who are fully vaccinated and die tend to have significant underlying health conditions. Being treated in intensive care, where people may be on a ventilator and unable to move, added to any existing frailty, especially in elderly people, she said. “If we think about intensive care patients in general, whether they are there due to COVID-19, pneumonia or any other infection, we know that those who have underlying disorders, those who are frail, and those with co-morbidities will have a higher risk of dying from whatever the cause of being in intensive care is,” she said. “Being fully vaccinated against Covid protects you from getting severe disease, yes, but it doesn’t completely protect you from getting Covid. So if you are someone with chronic health conditions, what might be a mild disease or mild infection in a young person or a person who is in good health, will have a greater impact on you.” She said this was why the Australian Technical Advisory Group for Immunisation (Atagi) had recommended boosters for those people who are severely immunocompromised. On Wednesday the government said it intended booster shots to be rolled out to the aged care sector within weeks, and to be available to the whole population by the end of the year. Read full story Source: The Guardian, 20 October 2021

Stillbirth rates remain "exceptionally high" for black and Asian babies in the UK, a report examining baby loss in 2019 has found. The figures come despite improving numbers overall, with some 610 fewer stillbirths in 2019 than in 2013. The MBBRACE-UK report found babies of mothers living in deprived areas are at higher risk of stillbirths and neonatal deaths than those in other places. Charities say there is an urgent need to tackle inequalities around birth. There were some 2,399 stillbirths (a death occurring before or during birth once a pregnancy has reached 24 weeks) and 1,158 neonatal deaths (babies who die in the first 28 days of life) in the UK in 2019. The report, by the Universities of Leicester and Oxford, found: Overall stillbirth rates fell from 4.2 per 1,000 births in 2013 to 3.35 per 1,000 births in 2019 For babies of black and black British ethnicity, stillbirth rates were 7.23 per 1,000 births For babies of Asian and Asian British ethnicity, stillbirth rates were 5.05 per 1,000 births For babies of white ethnicity, stillbirth rates were 3.22 per 1,000 births. Read full story Source: BBC News, 15 October 2021

Austerity measures introduced by David Cameron’s coalition government after 2010 can be linked to tens of thousands of additional deaths, according to a damning new study. A paper published by researchers at the University of York concluded that reductions in funding to health can be linked to an extra 57,550 fatalities. Researchers looked at the healthcare spending of the Conservative and Liberal Democrat government after 2010. The researchers said the results of their paper confirmed what had been reported in previous studies. But the conclusions of causal impact of social care, public health and healthcare expenditure on mortality in England, published in the BMJ Open journal, make “a major contribution by additionally estimating the effect of social care expenditure,” its authors said. Read full story Source: The Independent, 15 October 2021

Hundreds of people a day across London are waiting hours for an emergency ambulance to get to them, as paramedics warn that patients are dying as a result of delays. Patients in emergency calls classified as category two, such as those involving a suspected stroke or chest pains, should be seen by paramedics within an average of 18 minutes but are being forced in some cases to wait up to 10 hours. Even life-threatening calls where patients are in cardiac arrest and should be reached within seven minutes have experienced delays, with data suggesting one such call was waiting 20 minutes on Monday. Internal data shared with The Independent shows that London Ambulance Service is holding hundreds of open 999 calls for hours at a time with the service’s boss acknowledging in an email to staff that the service is struggling to maintain standards. Experts warned that the problems in the capital were reflected in ambulance services across the country. One paramedic told The Independent: “Patients desperately requiring ambulances aren’t getting them and, anecdotally, people are deteriorating and dying whilst waiting. Our poor dispatchers have to stare at screens of held calls, working out who gets the next available resource and who waits, suffers or dies.” Read full story Source: The Independent, 5 January 2021

All NHS trusts in England have been given a deadline of Monday to enact safety improvements in maternity care amid Shropshire's baby deaths scandal. Heath chiefs have told hospitals they must have the 12 "urgent clinical priorities" in place by 17:00 GMT. The move is to address "too much variation" in outcomes for families. It comes during a probe into the maternity care of more than 1,800 families in Shropshire. The inquiry, launched amid concerns of repeated failings at Shrewsbury and Telford Hospital NHS Trust (SaTH), focuses on the experience of 1,862 in total, and includes instances of infant fatality. An interim report published last week found poor care over nearly two decades had harmed dozens of women and their babies. The report called for seven "essential actions" to be implemented at maternity units across England. But that has since been transformed into 12 clinical tasks, including giving women with complex pregnancies a named consultant, ensuring regular training of fetal heart rate monitoring, and developing a proper process to gather the views of families. The directions are revealed in a letter in which NHS England says there is "too much variation in experience and outcomes for women and their families". Read full story Source: BBC News, 15 December 2020

Pre-existing social inequalities contributed to the UK recording the highest death rates from Covid in Europe, a leading authority on public health has said, warning that many children’s lives would be permanently blighted if the problem is not tackled. Sir Michael Marmot, known for his landmark work on the social determinants of health, argued in a new report that families at the bottom of the social and economic scale were missing out before the pandemic, and were now suffering even more, losing health, jobs, lives and educational opportunities. In the report, Build Back Fairer, Marmot said these social inequalities must be addressed whatever the cost and it was not enough to revert to how things before the pandemic. “We can’t afford not to do it,” he said. Read full story Source: The Guardian, 15 December 2020

Strong leadership, challenging poor workplace culture, and ringfencing maternity funding are key to improving safety. That’s the message from two leading Royal Colleges as they respond to the independent review of maternity services at Shrewsbury and Telford NHS Trust led by Donna Ockenden. The RCOG and the Royal College of Midwives (RCM) have today welcomed the Ockenden Review and its recognition of the need to challenge poor working relationships, improve funding and access to multidisciplinary training and crucially to listen to women and their families to improve learning and to ensure tragedies such as those that have happened at Shrewsbury and Telford NHS Trust never occur again. The Colleges have said that the local actions for learning and the immediate and essential actions laid out in this report must be read and acted upon immediately in all Trusts and Health Boards delivering maternity services across the UK. Commenting, Dr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, said: “This report makes difficult reading for all of us working in maternity services and should be a watershed moment for the system. Reducing risk needs a holistic approach that targets the specific challenges of fetal monitoring interpretation and strengthens organisational functioning, culture and behaviour." Read press release Source: RCOG, 10 December 2020

Patient Safety Learning Press Release 10th December 2020 Today the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust published its first report on its findings.[1] The report made recommendations for actions to be implemented by the Trust and “immediate and essential actions” for both the Trust and the wider NHS. The Review was formally commissioned in 2017 to assess “the quality of investigations relating to new-born, infant and maternal harm at The Shrewsbury and Telford Hospital NHS Trust”.[2] Initially it was focused on 23 cases but has been significantly expanded as families have subsequently contacted the review team with their concerns about maternity care and treatment at the Trust. The total number of families to be included in the final report is 1,862. These initial findings are drawn from 250 cases reviewed to date. This is another shocking report into avoidable harm. We welcome the publication of these interim findings and the sharing of early actions that have been identified to make improvements to patient safety in NHS maternity services. We commend the ambition for immediate responses and action. Reflecting on the report, there are a number of broad patient safety themes, many of which have been made time and time again in other reports and inquiries. A failure to listen to patients The report outlines serious concerns about how the Trust engaged and involved women both in their care and after harm had occurred. This was particularly notable in the example of the option of having a caesarean section, where there was an impression that the Trust had a culture of wanting to keep the numbers of these low, regardless of patients’ wishes. They commented: “The Review Team observed that women who accessed the Trust’s maternity service appeared to have little or no freedom to express a preference for caesarean section or exercise any choice on their mode of deliver.” It also noted a theme in common with both Paterson Inquiry and Cumberlege Review relating to the Trusts’ poor response to patients raising concerns.[3] The report noted that “there have also been cases where women and their families raised concerns about their care and were dismissed or not listened to at all”. The need for better investigations Concerns about the quality of investigations into patient safety incidents at the Trust is another theme that emerges. The review reflected that in some cases no investigation happened at all, while in others these did take place but “no learning appears to have been identified and the cases were subsequently closed with it deemed that no further action was required”. One of the most valuable sources for learning is the investigation of serious incidents and near misses. If these processes are absent or inadequate, then organisations will be unable to learn lessons and prevent future harm reoccurring. Patient Safety Learning believes it is vital that Trusts have the commitment, resources, and frameworks in place to support investigations and that the investigators themselves have the right skills and training so that these are done well and to a consistently high standard. This has not formed part of the Report’s recommendations and we hope that this is included in their final report. Lack of leadership for patient safety Another key issue highlighted by the report is the failure at a leadership level to identify and tackle the patient safety issues. Related to this one issue it notes is high levels of turnover in the roles of Chief Executive, executive directors and non-executive directors. As part of its wider recommendations, the Report suggests trust boards should identify a non-executive director who has oversight of maternity services. Good leadership plays a key role in shaping an organisations culture. Patient Safety Leadership believes that leaders need to drive patient safety performance, support learning from unsafe care and put in place clear governance processes to enable this. Leaders need to be accountable for patient safety. There are questions we hope will be answered in the final report that relate to whether leaders knew about patients’ safety concerns and the avoidable harm to women and their babies. If they did not know, why not? If they did know but did not act, why not? Informed Consent and shared decision-making The NHS defines informed consent as “the person must be given all of the information about what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment does not go ahead”.[4] The report highlights concerns around the absence of this, particularly on the issue of where women choose as a place of birth, noting: “In many cases reviewed there appears to have been little or no discussion and limited evidence of joint decision making and informed consent concerning place of birth. There is evidence from interviews with women and their families, that it was not explained to them in case of a complication during childbirth, what the anticipated transfer time to the obstetric-led unit might be.” Again this is another area of common ground with other recent patient safety reports such as the Cumberlege Review.[5] Patient Safety Learning believes it is important that patients are not simply treated as passive participants in the process of their care. Informed consent and shared decision making are vital to respecting the rights of patients, maintaining trust in the patient-clinician relationship, and ensuring safe care. Implementation for action and improved patient safety In its introduction, the report states: “Having listened to families we state that there must be an end to investigations, reviews and reports that do not lead to lasting meaningful change. This is our call to action.” Responding with an official statement in the House of Commons today, Nadine Dorries MP, Minister for Mental Health, Suicide Prevention and Patient Safety, did not outline a timetable for the implementation of this report’s recommendations. In 2020 we have seen significant patient safety reports whose findings have been welcomed by the Department of Health and Social Care but where there has subsequently been no formal response nor clear timetable for the implementation of recommendations, most notably the Paterson Inquiry and Cumberlege Review. Patient Safety Learning believes there is an urgent need to set out a plan for implementing the recommendations of the Ockenden Report and these other patient safety reports. Patients must be listened to and action taken to ensure patient safety. [1] Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Emerging findings and recommendations form the independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, 10 December 2020. https://www.ockendenmaternityreview.org.uk/wp-content/uploads/2020/12/ockenden-report.pdf [2] Ibid. [3] The Right Reverend Graham Jones, Report of the Independent Inquiry into the Issues raised by Paterson, 2020. https://assets.publishing.serv...; The Independent Medicines and Medical Devices Safety Review, First Do No Harm, 8 July 2020. https://www.immdsreview.org.uk/downloads/IMMDSReview_Web.pdf [4] NHS England, Consent to treatment, Last Accessed 16 July 2020. https://www.nhs.uk/conditions/consent-to-treatment/ [5] Patient Safety Learning, Findings of the Cumberlege Review: informed consent, Patient Safety Learning’s the hub, 24 July 2020. https://www.pslhub.org/learn/patient-engagement/consent-and-privacy/consent-issues/findings-of-the-cumberlege-review-informed-consent-july-2020-r2683/

Health chiefs are designing an “early warning” system to detect and prevent future maternity care scandals before they happen, a health minister has said. Patient safety minister Nadine Dorries said she hoped the system would highlight hospitals and maternity units where mistakes were being made earlier. The former nurse also revealed the Department of Health and Social Care was drawing up a plan for a joint national curriculum for both midwives and obstetricians to make sure they had the skills to look after women safely. During a Parliamentary debate following the publication of a report into the Shrewsbury and Telford Hospital care scandal, the minister was challenged by MPs to take action to prevent future scandals. The former health secretary, Jeremy Hunt, warned the failings at the Shropshire trust, where dozens of babies died or were left with permanent brain damage, could be repeated elsewhere. He said: “The biggest mistake in interpreting this report would be to think that what happened at Shrewsbury and Telford is a one-off — it may well not be, and we mustn't assume that it is.” Ms Dorries said: “Every woman should own her birth plan, be in control of what is happening to her during her delivery and I really hope ... this report is fundamental in how it's going to reform the maternity services across the UK going forward. Read full story Source: The Independent, 11 December 2020

Great Ormond Street Hospital may have broken the law by failing to share information with parents that showed its errors had contributed to their son’s death, The Independent understands. The care watchdog is speaking to Great Ormond Street about its handling of an expert report into five-year-old Walif Yafi in 2017. It showed that the hospital’s failure to share results that showed a deadly infection had played a role in Walif’s death. But the boy’s parents were only told about the findings after inquiries by The Independent – months after settling a lawsuit with Great Ormond Street in which the trust denied responsibility. The Care Quality Commission is looking at concerns relating to duty of candour regulations, which require hospitals to be open and honest with families about mistakes made that result in serious harm to patients. Breaching the regulations is a criminal offence and can lead to prosecution. Read full story Source: The Independent, 7 December 2020