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News Article
Deaths at home: More than 26,000 extra this year, ONS finds
Patient Safety Learning posted a news article in News
More men than normal are dying at home from heart disease in England and Wales and more women are dying from dementia and Alzheimer's disease, figures show. More than 26,000 extra deaths occurred in private homes this year, an analysis by the Office for National Statistics found. In contrast, deaths in hospitals from these causes have been lower than usual. The Covid epidemic may have led to fewer people being treated in hospital or it may be that people in older age groups, who make up the majority of these deaths, may be choosing to stay at home – but the underlying reasons for the figures are still not clear. Read full story Source: BBC News, 19 October 2020 -
News Article
Coronavirus: Survival rate of intensive care patients improving, data suggests
Patient Safety Learning posted a news article in News
As hospitalisations and intensive care admissions surge around the country, new figures indicate coronavirus patients in critical care have a better survival rate now than when the pandemic first began. The latest report from The Intensive Care National Audit and Research Centre (ICNARC) into critical care for England, Wales and Northern Ireland looks at patients admitted to intensive care up until 31 August and those admitted from 1 September. The data shows that on average, 39% of critical care coronavirus patients died up until the end of August while less than 12% have died since September. The proportion of patients who died after being admitted to critical care fell by almost a quarter from the peak and as much as half in hospitals overall. However, the Dean of the Faculty of Intensive Care Medicine, Dr Alison Pittard, told the BBC that the difference may be attributed to an insufficient amount of time having passed which impedes an accurate and longterm patient assessment, as some remain in hospital. Meanwhile, scientific advisors continue to warn that the next few weeks are critical for regulating hospital admissions. Read full story Source: The Independent, 18 October 2020 -
News ArticleThe parents of a three-year-old boy whose death was part of an alleged NHS cover-up have won a six year battle for the truth about how he died. Shropshire coroner John Ellery backed the parents of three-year-old Jonnie Meek in a second inquest into his death on Thursday and rejected evidence from nurses about what happened at Stafford Hospital in August 2014. Jonnie, who was born with rare congenital disability De Grouchy syndrome, died two hours after being admitted to hospital to trial a new feed which was being fed directly into his stomach. His parents, John Meek and April Keeling, from Cannock in Staffordshire, have always maintained their son died after a reaction to the milk feed caused him to vomit and suffocate. But they have been forced to battle what they believe was an attempt to hide what happened after they discovered attempts to alter their son’s medical history with claims he had experienced several cardiac arrests requiring resuscitation which never happened. In 2015, healthcare assistant Lauren Tew, who was with Jonnie and his mother when he died, told the HSJ that a statement in her name submitted to a child death overview panel stating Jonnie had died from a sudden cardiac arrest was false and she had never made such a statement. Another statement said Jonnie had been admitted to hospital for three weeks months before his death which also never happened. After his parents exposed the false statements an independent inquiry was launched, with three independent experts agreeing with Jonnie’s parents, and in April last year the High Court quashed the original inquest verdict that Jonnie died of natural causes and pneumonia. Speaking to The Independent Jonnie’s father said: “This does bring us some peace after six years. For the coroner to say he believes April over the nurses after all this time is a big weight lifted off her. “The hospital definitely decided to try and cover up what happened to Jonnie. We have always said we knew what happened and this has been a massive waste of resources. I am still very concerned about how these things can happen in the first place.” Read full story Source: The Independent, 15 October 2020
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News ArticleThe announcement on Friday by the Care Quality Commission (CQC) that it will bring criminal charges against an NHS trust for failing to provide safe care to a patient is a hugely significant milestone in efforts to bring about greater accountability and safer care in the health service. The CQC has had the power to bring such prosecutions against hospitals since April 2015 when it was given a suite of new legal powers to hold hospitals to account on the care they give to their patients. Bringing in the new laws, the so-called fundamental standards of care, was one of the most significant actions taken after the care disaster at the Mid Staffordshire NHS Trust, where hundreds of patients suffered shocking neglect, with some dying as a result. Prosecuting East Kent Hospitals University Trust over the tragic 2017 death of baby Harry Richford is a big step for the CQC and a consequence of the long-forgotten battles of many patients and families in Stafford who were told they were wrong in their complaints against the hospital. It will almost certainly lead to more calls for criminal charges against hospitals from families who have been failed. There are countless examples of NHS trusts not acting on safety warnings and patients coming to harm as a result. Just this week an inquest into the case of baby Wynter Andrews at Nottingham University Trust revealed fears over safety had been highlighted to the trust board 10 months before her death. At Shrewsbury and Telford Hospitals Trust there are hundreds of families asking the same questions as more evidence emerges of long-standing failures to learn from its mistakes. CQC's chief executive, Ian Trenholm, has provoked anger among NHS leaders and clinicians when he advocated taking a tougher line when trusts break the law. But it is unlikely the CQC will launch a slew of prosecutions. It has said it will bring cases only where it sees patterns of behaviour and systemic failings. That is the correct approach as healthcare is complex and single errors will sadly happen despite everyone doing their best. Read full story Source: The Independent, 10 October 2020
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News ArticleA number of patients in a cancer ward have died in hospital after a coronavirus outbreak and more have tested positive for the virus. NHS Lothian have not confirmed how many died but said it was fewer than five and a ‘very small number’ of patients. The health board is investigating the Western General Hospital in Edinburgh which has had to put measures in place to further contain the outbreak. Another six patients have tested positive for the virus so the hospital has closed the oncology ward to new patients being admitted. The hospital has also asked patients, who would usually be allowed to go home over the weekend and return to hospital on Monday, to stay in hospital the whole week. Dr Donald Inverarity, consultant microbiologist at NHS Lothian, said: ‘Our thoughts are with the family of the deceased and I would like to express our sincere condolences." "A multidisciplinary Incident Management Team was immediately established and all necessary infection control measures are in place. The situation will continue to be reviewed and monitored very closely." The health board’s Health Protection Team and the nationwide Test and Protect teams are carrying out contact tracing of visitors and outpatients where necessary. Routine coronavirus screening of staff and patients is also taking place as part of an enhanced regime. Read full story Source: Metro, 10 October 2020
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News ArticleAn anaesthetist who had been drinking before an emergency caesarean that led to the death of a British woman should serve the maximum three years in jail if convicted and should be banned from working as a doctor, a French prosecutor has demanded. Helga Wauters is on trial in Pau, south-west France, for the manslaughter of Xynthia Hawke in 2014. She is accused of starving Hawke of oxygen for up to an hour after pushing a ventilation tube into the wrong passageway. Orlane Yaouang, prosecuting, described the scene in the operating theatre when Hawke turned blue as “carnage” and spoke of the “surreal situation” in which the panicked hospital staff called the emergency services. Read full story Source: The Guardian, 9 October 2020
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News ArticleThe Care Quality Commission (CQC) has launched the first prosecution of an acute trust for failing to meet fundamental standards of care. East Kent Hospitals University Foundation Trust faces two charges relating to the death of Harry Richford and the risks posed to his mother during his birth. Both charges are under regulation 12 of the Health and Social Care Act 2008. The trust is accused of failing to discharge its duty under regulation 12 in that it failed to provide safe care and treatment exposing Harry and his mother Sarah to a significant risk of avoidable harm. It is only the fourth prosecution of a trust over the “fundamental standards” which were brought in following the Mid Staffordshire care scandal and are meant to be enforced by the CQC. It is also thought to be the first related to the safety of clinical care. Read full story (paywalled) Source: HSJ, 9 October 2020
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News Article
Baby died on maternity unit months after staff warned it was unsafe
Patient Safety Learning posted a news article in News
A baby died during birth because of systemic errors in one of Britain's largest NHS hospitals, months after staff had warned hospital chiefs that the maternity unit was “unsafe”, an inquest has found. A coroner ruled that neglect by staff at Nottingham University Hospitals Trust contributed to the death of baby Wynter Andrews last year. She was delivered by caesarean section on 15 September after significant delays. Her umbilical cord was wrapped around her neck and leg, resulting in her being starved of oxygen. In a verdict on Wednesday, assistant coroner Laurinda Bower said Wynter would have survived if action had been taken sooner, criticising the units “unsafe culture” and warning that her death was not an isolated incident. Wynter’s mother, Sarah Andrews, called on the health secretary, Matt Hancock, to investigate the trust’s maternity unit. She said: “We know Wynter isn’t an isolated incident; there have been other baby deaths arising because of the trust’s systemic failings. She was a victim of the trust’s unsafe culture and practices.” Read full story Source: The Independent, 7 October 2020 -
News Article
NHS compensation payouts have doubled in six years, figures show
Patient Safety Learning posted a news article in News
NHS Payouts linked to medication blunders have doubled in six years, fuelling record spending, official figures show. The NHS figures show that in 2019/20, the health service spent £24.3 million on negligence claims relating to medication errors - up from £12.8 million in 2013/14. The statistics show that in the past 15 years, almost £220 million has been spent on claims relating to the blunders. Previous research has suggested that medication errors may be killing up to 22,000 patients in England every year. Errors occur when patients are given the wrong drugs, doses which are too high or low, or medicines which cause dangerous reactions. In some cases, patients have been given medication which was intended for another person entirely, sometimes with fatal consequences. Other studies suggest that 1 in 12 prescriptions dispensed by the NHS involve a mistake in medication, dose or length of course. In some cases, patients have died after being given a dose of morphine ten times that which should have been administered, with other fatalities involving fatal reactions. Confusion often occurs when drugs are not labelled clearly, or when packaging of different medications looks similar. Jeremy Hunt, now chairman of the Commons Health and Social Care Committee, said the NHS needed to make far more progress preventing harms, instead of seeing an ever increasing negligence bill. He said: “It is nothing short of immoral that we often spend more cleaning up the mess of numerous tragedies in the courts, than we actually do on the doctors and nurses who could prevent them." Read full story (paywalled) Source: The Telegraph, 3 October 2020 -
News ArticleAs she lay dying in a Joliette, Que., hospital bed, an Atikamekw woman clicked her phone on and broadcast a Facebook Live video appearing to show her being insulted and sworn at by hospital staff. Joyce Echaquan's death on Monday prompted an immediate outcry from her home community of Manawan, about 250 kilometres north of Montreal, and has spurred unusually quick and decisive action on the part of the provincial government. The mother of seven's death will be the subject of a coroner's inquiry and an administrative probe, the Quebec government said today. A nurse who was involved in her treatment has been dismissed. But that dismissal doesn't ease the pain of Echaquan's husband, Carol Dubé, whose voice trembled with emotion as he told Radio-Canada his wife went to the hospital with a stomach ache on Saturday and "two days later, she died." Echaquan's relatives told Radio-Canada she had a history of heart problems and felt she was being given too much morphine. In the video viewed by CBC News, the 37-year-old is heard screaming in distress and repeatedly calling for help. Eventually, her video picks up the voices of staff members. One hospital staff member tells her, "You're stupid as hell." Another is heard saying Echaquan made bad life choices and asking her what her children would say if they saw her in that state. Dubé said it's clear hospital staff were degrading his wife and he doesn't understand how something like this could happen in 2020. Read full story Source: CBC News, 29 September 2020
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News ArticleToo many English hospitals risk repeating maternity scandals involving avoidable baby deaths and brain injury because staff are too frightened to raise concerns, the chief inspector of hospitals has warned. Speaking at the opening session of an inquiry into the safety of maternity units by the health select committee, Prof Ted Baker, chief inspector of hospitals for the Care Quality Commission, said: “There are too many cases when tragedy strikes because services are not not doing their job well enough.” Baker admitted that 38% of such services were deemed to require improvement for patient safety and some could get even worse. “There is a significant number of services that are not achieving the level of safety they should,” he said. He said many NHS maternity units were in danger of repeating fatal mistakes made at what became the University Hospitals of Morecambe Bay NHS foundation trust (UHMBT), despite a high profile 2015 report finding that a “lethal mix” of failings at almost every level led to the unnecessary deaths of one mother and 11 babies. “Five years on from Morecombe Bay we have still not learned all the lessons,” Baker said. “[The] Morecombe Bay [report] did talk about about dysfunctional teams and midwives and obstetricians not working effectively together, and poor investigations without learning taking place. And I think those elements are what we are still finding in other services.” Baker urged hospital managers to encourage staff to whistleblow about problems without fear of recrimination. He said: “The reason why people are frightened to raise concerns is because of the culture in the units in which they work. A healthy culture would mean that people routinely raise concerns. But raising concerns is regarded as being a difficult member of the team.” Read full story Source: The Guardian, 29 September 2020
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News ArticleDelays at the Great Ormond Street Hospital led to a boy dying an agonising death, a health watchdog has found. Arvind Jain, 13, who had Duchenne Muscular Dystrophy, died in August 2009 after waiting months for an operation. The ombudsman's report found he had "suffered considerable distress" and criticised referral procedures as "chaotic and substandard". The Great Ormond Street Hospital said there were "failings in clinical care". Arvind's sister Shushma said: "To read that he was suffering all the time, that was disgusting. He had been asking us repeatedly if he would get the operation and we would be constantly reassuring him that he would not die." The degenerative disease Arvind, who lived in Cricklewood, north London, suffered from was not immediately life threatening but in January 2009 his condition had become acute enough for him to struggle with swallowing and feeding. He had a temporary medical solution where a tube was inserted through his nose to help him get the required nutrition. He also experienced a number of other medical complications although none of these was considered life-threatening. The permanent solution recommended by his consultant paediatric neurologist was a gastrostomy insertion which would allow Arvind to feed through his stomach. The Great Ormond Street Hospital Trust (GOSH) excels in such procedures, however, a series of communication errors meant despite repeated and urgent requests from his neurological consultant, proper investigations were not carried out into Arvind's suitability for the operation. After five months of delays he and his family were reassured that as soon as he got the operation he would be much more comfortable. Another hospital also offered to carry out the operation in the event that the delays continued. But the surgical team that was due to carry out the operation never managed to assess Arvind. His condition deteriorated to the point where he was not well enough to be operated on and Arvind died on 9 August 2009. The Parliamentary and Health Service Ombudsman's report said he "suffered considerable distress and discomfort". It also describes a series of basic shortcomings in Arvind's care. The report said: "The standard of care provided for Arvind fell so far below the applicable standards as to amount to service failure." Read full story Source: BBC News, 23 September 2020
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News Article
10,000 more deaths than usual occurred in UK homes since June
Patient Safety Learning posted a news article in News
Some 10,000 more deaths than usual have occurred in peoples’ private homes since mid June, long after the peak in Covid deaths, prompting fears that people may still be avoiding health services and delaying sending their loved ones to care homes. It brings to more than 30,000 the total number of excess deaths happening in people’s homes across the UK since the start of the pandemic. Excess deaths are a count of those deaths which are over and above a “normal” year, based on the average number of deaths that occurred in the past five years. In the past three months the number of excess deaths across all settings, has, in the main been lower than that of previous years. However, deaths in private homes buck the trend with an average of 824 excess deaths per week in people’s homes in the 13 weeks to mid-September. Experts are citing resistance from the public to enter hospitals or home care settings and “deconditioning” caused by decreased physical activity among older people shielding at home, for example not walking around a supermarket or garden centre as they might normally. Read full story Source: The Guardian, 24 September 2020 -
News ArticleA third of coronavirus patients in intensive care are from black, Asian and minority ethnic backgrounds, prompting the head of the British Medical Association to warn that government inaction will be responsible for further disproportionate deaths. Chaand Nagpaul, the BMA Council chair, was the first public figure to call for an inquiry into whether and why there was a disparity between BAME and white people in Britain in terms of how they were being affected by the pandemic, in April. Subsequent studies, including a Public Health England (PHE) analysis in early June, confirmed people of certain ethnicities were at greater risk but Nagpaul said no remedial action had been taken by the government. Nagpaul told the Guardian: “We are continuing to see BAME people suffering disproportionately in terms of intensive care admissions so not acting means that we’re not protecting our vulnerable communities. Action was needed back in July and it’s certainly needed now more than ever. “As the infection rate rises, there’s no reason to believe that the BAME population will not suffer again because no action has been taken to protect them. They are still at higher risk of serious ill health and dying.” Read full story Source: The Guardian, 20 September 2020
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News ArticleA decision not to "urgently" refer an anorexic woman whose condition had significantly deteriorated contributed to her death, a coroner said. Amanda Bowles, 45, was found at her Cambridge home in September 2017. An eating disorder psychiatrist who assessed her on 24 August apologised to Ms Bowles' family for not organising an admission under the Mental Health Act. Assistant coroner Sean Horstead said the decision not to arrange an assessment "contributed to her death". Mr Horstead told an inquest at Huntingdon Racecourse that also on the balance of probabilities the "decision not to significantly increase the level of in-person monitoring" following 24 August "contributed to the death". In his narrative conclusion, Mr Horstead said it was "possible... that had a robust system for monitoring Ms Bowles in the months preceding her death been in place, then the deterioration in her physical and mental health may have been detected earlier" and led to an earlier referral to the Adult Eating Disorder Service. He said this absence "was the direct consequence of the lack of formally commissioned monitoring in either primary or secondary care for eating disorder patients". Read full story Source: BBC News, 17 September 2020
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News ArticleYesterday marked the second World Patient Safety Day, and this year’s theme shined a light on health worker safety – those on the frontline of the pandemic have been selfless in their sacrifices to care for an ailing global population. What has become ever clearer is that a health system is nothing without those who work within it and that we must prioritise the safety and wellbeing of health workers, because without safe health workers we cannot have safe patients. Improving maternity safety has been a priority for some time – although rare, when things go wrong the consequences are unthinkable for families and the professionals caring for them. Maternity negligence makes up 50% of the total value of negligence claims across all NHS sectors, according to the latest NHS Resolution annual report and accounts. It states there were claims of around £2.4 billion in 2019/20, which is in the region of £6.5 million a day. This cost says nothing of the suffering families and professionals associated. However, without investing in the maternity frontline we cannot hope to make integral systemic changes to improve maternity safety and save mothers’ and babies’ lives, writes Sara Ledger, head of research and development at Baby Lifeline in the Independent. "We owe it to every mother and baby to rigorously and transparently scrutinise the safety of maternity services, which will be in no small way linked to the support staff receive." Read full story Source: The Independent, 17 September 2020
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News ArticleAccidents on maternity wards cost the NHS nearly £1 billion last year, Jeremy Hunt, the chairman of the Commons health committee, has revealed. The former health secretary said the bill for maternity legal action was nearly twice the amount spent on maternity doctors in England. It was part of the NHS’s £2.4 billion total legal fees and compensation bill, up £137 million on the previous year. Mr Hunt has also told the Daily Mail there is evidence that hospitals are failing to provide details of avoidable deaths despite being ordered to do so three years ago as he highlighted “appalling high” figures which showed that up to 150 lives are being lost needlessly every week in public hospitals. Responding to the figures, Mr Hunt said: "Something has gone badly wrong." In 2017, he told trusts to publish data on the number of avoidable deaths among patients in their care. But freedom of information responses from 59 hospital trusts, about half the total, found less than a quarter gave meaningful data on avoidable deaths. Mr Hunt cited “major cultural challenges” which he blamed for preventing doctors and nurses from accepting any blame. He blamed lawyers who get involved “almost immediately” once something goes wrong with a patient’s care. “Doctors, nurses and midwives worry they could lose their licence if they are found to have made a mistake. Hospital managers worry about the reputation of their organisation,” he added. Mr Hunt said: “We have appallingly high levels of avoidable harm and death in our healthcare system. We seem to just accept it as inevitable.” An NHS spokesman said: “Delivering the safest possible health service for patients is a priority, and the national policy on learning from deaths is clear that hospitals must publish this information every three months, as well as an annual summary, so that they are clear about any problems that have been identified and how they are being addressed. Read full story Source: The Telegraph, 18 September 2020
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News ArticleAn investigation into the outbreak of a bacterial infection that killed 15 people has found there were several “missed opportunities” in their care. Mid Essex Clinical Commissioning Group has released the outcome of a 10-month investigation into a Strep A outbreak in 2019, which killed 15 people and affected a further 24. The final report was critical of Provide, a community interest company based in Colchester, as well as the former Mid Essex Hospital Services Trust (now part of Mid and South Essex Foundation Trust). It said: “This investigation has identified that in some cases there were missed opportunities where treatment should have been more proactive, holistic and timely. These do not definitively indicate that their outcomes would have been different.” Investigators found that 13 of the 15 people that died had received poor wound care from Provide CIC. They reported that inappropriate wound dressings were used and record keeping was so poor that deterioration of wounds was not recognised. Even wounds that had not improved over 22 days were not escalated to senior team members for help or referred to the tissue viability service for specialist advice, with investigators told this was often due to concerns over team capacity. The report, commissioned by the CCG and conducted by consultancy firm Facere Melius, said: “[Some] individuals became increasingly unwell over a period of time in the community, yet their deterioration either went unnoticed or was not acted upon promptly. Sometimes their condition had become so serious that they were very ill before acute medical intervention was sought”. Other findings included delays in the community in the taking of wound swabs to determine if the wound was infected and by which bacteria. It said in one case nine days elapsed before the requested swab took place. Even after Public Health England asked for all wounds to be swabbed following the initial outbreak, this was only conducted on a single patient. In other cases there were delays in patients being given antibiotics and this “could have had an adverse impact on the treatment for infection”. It also found that sepsis guidelines were not accurately followed, wounds were not uncovered for inspection in A&E, and some patients were given penicillin-based antibiotics despite penicillin allergies being listed in their health records. Read full story (paywalled) Source: HSJ, 17 September 2020
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News ArticleToday, the nonpartisan nonprofit Patient Safety Movement Foundation will lead a demonstration in the nation’s capital to raise awareness for the patient safety crisis that claims more than 200,000 lives annually in the U.S. due to preventable medical harm. The demonstration begins from Freedom Plaza and participants will walk down Pennsylvania Avenue to the Capitol Lawn, where they will hold a remembrance of loved ones lost needlessly to preventable medical errors. The demonstrators will also demand the creation of a National Patient Safety Board to implement data-driven standards, transparency, accountability, and aligned incentives. “COVID-19 has exposed the safety gaps in our healthcare system that already cause 200,000 deaths a year,” said Dr. David B. Mayer, CEO of the Patient Safety Movement Foundation. “Many of us also have very personal stories of loss and tragedy related to preventable medical harm. Now is the time for change and improvement as we work toward zero preventable patient deaths by 2030.” Read full story Source: Patient Safety Movement
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News ArticleA damning report into Devon’s NHS 111 and out of hours GP service has revealed shocking stories of patients who have either had their health put at risk or tragically died due to the service being in need of urgent improvement. Devon Doctors Limited, which provides an Urgent Integrated Care Service (UICS) across Devon and Somerset, was inspected by independent health and social care regulator the Care Quality Commission (CQC) in July, after concerns were raised about the service. They included the care and treatment of patients, deaths and serious incidents, call waits, staff shortages, and low morale. Inspectors found 'deep rooted issues'. The CQC concluded it was not assured that patients were being treated promptly enough and, in some cases, they had not received safe care or treatment. It is calling for the service to make urgent improvements which will be closely monitored. Since August 2019, the report stated Devon Doctors had received 179 complaints. Nine had been identified by the service as incidents of high risk of harm and six had been identified by the service as incidents of moderate risk of harm. These had been recorded on the service’s significant event log. However, on review, the CQC identified an additional 30 events from the complaints log which could also have been classed as either moderate or high risk of harm. Read full story Source: Devon Live, 15 September 2020
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News ArticleA third of those who died with diagnosed or suspected COVID-19 in English hospitals did so at Tameside and Glossop Integrated Care Foundation Trust in the seven days to 10 September. The Greater Manchester Trust has seen a significant rise in COVID-19 deaths, from a weekly total of five on 4 September to 18 six days later. The total number of COVID-19 hospital deaths in the seven days to 10 September across England was 54. COVID-19 deaths at Tameside and Glossop had fallen to a weekly total of zero on 23 July, before beginning to climb steadily from 20 August. The last time the trust recorded 18 deaths in a seven-day period was in late April when the pandemic was still close to its first peak. The highest seven day figure recorded by the trust was 28, meaning the 10 September figure is equivalent to 64% of its peak covid-19 mortality. Nationally, hospital deaths with the virus are running at less than 1 per cent of the early-April peak. No other trust recorded more than three covid-19 deaths during the seven days to 10 September. Read full story (paywalled) Source: HSJ, 13 September 2020
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News ArticleA trust which accounted for one in eight of covid deaths in hospital during part of the summer has been criticised by the Care Quality Commission for its infection control. Staff did not follow social distancing rules in a staff room at East Kent Hospitals University Foundation Trust, did not always practise hand hygiene, and the trust had used incorrect PPE, the CQC said. In addition, two hourly cleans were not always carried out, soap and hand sanitiser were missing, and the emergency department at the William Harvey Hospital in Ashford did not have enough sinks for staff and visitors to wash their hands in. There was also a lack of hand hygiene guidance on display. Inspectors added that not all staff understood what needed to be done when a walk-in patient presented with covid symptoms, and the emergency department did not have an escalation plan if areas were crowded and patients could not socially distance. The CQC inspected the William Harvey Hospital on 11 August and took enforcement action after the visit. It has yet to publish the report but the initial feedback was summarised in the trust’s latest board papers, together with the trust’s response. Read full story (paywalled) Source: HSJ, 14 September 2020
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News ArticleCOVID-19 may have contributed to the deaths of 18 people who contracted the infection while being treated at Weston general hospital in Somerset, an investigation has found. The layout of the hospital and the proximity of staff and other patients who had Covid but were asymptomatic may have been among the reasons for the 18 people acquiring the virus. The hospital temporarily stopped accepting new patients, including into its A&E department, on Monday 25 May following a Covid outbreak among patients. It fully reopened on 18 June. As part of its investigation, University Hospitals Bristol and Weston NHS foundation trust identified 31 patients who died after contracting Covid while they were in-patients from 5-24 May. A detailed review of each of the cases was undertaken and it concluded that in 18 patients, the infection may have contributed to their death. Dr William Oldfield, the trust’s medical director, said: “We are deeply sorry for this. We are already in contact with the families of these patients and have informed them of the outcome of the review. We have apologised unreservedly and have offered them support." “For each family concerned, we will undertake an investigation into the specific circumstances that led to the death of their loved one. We will invite them to help inform the investigation to ensure that any questions they have are addressed. We recognise that other patients and families may have concerns and we would like to provide reassurance to everyone that the safety of our patients and staff continues to be our main priority.” Read full story Source: The Guardian, 10 September 2020
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News ArticleA risk calculator that takes seconds to produce a score indicating a COVD-19 patient’s risk of death could help clinicians make care decisions soon after patients arrive in hospital, according to a large study conducted by a consortium of researchers across the UK. As UK COVID-19 cases rise, schools reopen and the weather gets colder, doctors at UK hospitals are expected to see an influx of coronavirus patients. Patients with COVID-19 behave very differently to patients with other conditions such as flu and bacterial pneumonia, said Dr Antonia Ho of the University of Glasgow, one of the study’s authors, and it is very challenging for doctors managing this unfamiliar disease to accurately identify those who are at high risk of deterioration or who can ride out their illness at home. “So having a tool that … can help clinicians at the front door to accurately group patients who are coming in with COVID-19 into four distinct risk categories – low, intermediate, high and very high risk – is hugely valuable,” she added. “Having an accompanying low-risk score will provide that doctor with increased confidence that the vast majority of people, patients with that low-risk score, will come to no real harm.” Read full story Source: The Guardian, 9 September 2020
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News Article
Parents seek second inquest into baby's hospital death
Patient Safety Learning posted a news article in News
The parents of a baby who died after medical errors are to push for a new inquest into his death, after they say a "cruel" inquest denied them justice. Hayden Nguyen died in 2016 after medics failed to treat an infection properly. However, despite the NHS trust admitting mistakes, coroner Shirley Radcliffe concluded the infant died of natural causes, after raising concerns about the hospital's initial investigation. Hayden was six days old when his parents took him to the Chelsea and Westminster hospital in west London in August 2016. He initially had a fever but rapidly deteriorated; he had a cardiac arrest and died within 12 hours of arriving there. An internal NHS investigation concluded eight errors were made in Hayden's care, and the root causes of his death were failure to identify the signs of shock and failure to act on abnormal test results. "When they had completed the investigation, they sat us down and took us through it line by line," says Alex Nguyen, Hayden's mother. "Although the content was incredibly disturbing, it was in a way healing and it helped a little bit with the grieving process." An inquest at Westminster Coroner's Court, conducted by Dr Radcliffe, followed. However, the coroner was not happy with the hospital's investigation. The hospital to issue a second report into Hayden's care, which halved the number of errors, and said the root cause of his death was the infection "which is known to have a high mortality". Armed with this second report, the coroner concluded that Hayden had died of natural causes. "What the coroner did was kill Hayden a second time," Hayden's father, Tum, told the BBC. Read full story Source: BBC News, 14 May 2021
