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Content ArticleThis article outlines the results of a recent investigation by the Parliamentary and Health Service Ombudsman (PHSO) which found that a 65-year-old man died after doctors failed to notice serious abnormalities on his X-ray. The patient, known as Mr B, was admitted to University Hospitals Birmingham NHS Foundation Trust in May 2019 after being unwell for several days with abdominal pain and vomiting. An X-ray of his abdomen was taken, which two doctors said did not show any apparent abnormalities. The following day Mr B's condition deteriorated and he suffered a heart attack and died. The PHSO investigation found that the Trust failed to notice a blockage in his intestine on the X-ray. Because of this failure, Mr B did not receive treatment that could have saved his life.
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UK Infected Blood Inquiry website
Patient-Safety-Learning posted an article in Other reports and inquiries
This is the website of the independent public statutory Inquiry established to examine the circumstances in which patients in the UK were given infected blood and blood products, in particular since 1970. The Inquiry is Chaired by barrister Keith Langstaff, who has experience of health-related public inquiries. The website contains information on: public hearings and meetings evidence latest news on the Inquiry how to get support if you have been affected by infected blood products. The Inquiry team is also inviting patients and family members of patients who received infected blood or infected blood products to give evidence to the Inquiry, either as a written statement or by speaking to an intermediary. Evidence given to the Inquiry will contribute to its findings and recommendations. -
Content ArticleThis report draws on data from the National Child Mortality Database (NCMD) to investigate how illness around the time of birth affects the health of children up to the age of 10, and to draw out learning and recommendations for service providers and policymakers. This report aims to understand patterns and trends in child deaths where an event before, or around, the time of birth had a significant impact on life, and the risk of dying in childhood.
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UK Covid-19 Inquiry: Opening statement (21 July 2022)
Patient Safety Learning posted an article in Covid-19 Inquiry
In her opening statement, Baroness Heather Hallett, Chair of the UK Covid-19 Inquiry, has set out her approach to running it. The Inquiry will consider and report on the preparations and the response to the pandemic in England, Wales, Scotland and Northern Ireland. The Terms of Reference provide the broad outline of the issues the Inquiry will investigate. -
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Marie Curie - Better end of life report (April 2021)
Patient-Safety-Learning posted an article in End of life care
The Better End of Life programme is a collaboration between Marie Curie, King's College London Cicely Saunders Institute, Hull York Medical School, the University of Hull and the University of Cambridge. It's first research report outlines key findings of the programme relating to the experience of death and dying during 2020, at the height of the Covid-19 pandemic. This interactive webpage presents graphics which highlight the key findings of the research. -
Content ArticleKaren Lesley Starling died on 7 February 2020 aged 54 and Anne Edith Martinez died on 17 December 2020 aged 65. Both deceased underwent successful lung transplant procedures at the new Royal Papworth Hospital. However, both women became infected with a hospital acquired infection, namely Mycobacteria abscessus (M. abscessus), and died. M. abscessus is an environmental non-tuberculous mycobacterium (NTM). It can sometimes be found in soil, dust and water, including municipal water supplies. It is usually harmless for healthy people but may cause opportunistic infection in vulnerable individuals. Lung transplant patients and lung defence patients such as Mrs Starling and Mrs Martinez were at particular risk of infection from mycobacteria, including M. abscessus.
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Content ArticleOn 1 November 2022, Dr Bill Kirkup, HSIB's Clinical Director of Maternity Investigations, and lead investigator for the investigation into maternity and neonatal services at East Kent Hospitals University NHS Foundation Trust, presented the investigation report: 'Reading the signals' in a seminar delivered to HSIB staff.
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Content ArticleWomen are four times as likely to die after childbirth in Britain as in Scandinavian countries, a study published in the BMJ from Diguisto et al. has found. The authors compared maternal mortality in eight countries (France, Italy, UK, Denmark, Finland, the Netherlands, Norway, and Slovakia) with enhanced surveillance systems. They found that UK had the second-highest death rate, with one in 10,000 mothers dying within six weeks of giving birth, only slightly less than in Slovakia, the worst performing. Norway has the lowest maternal death rates in Europe, at one in 37,000. In Denmark, the second-best performing country, one in 29,000 died. In-depth analyses of differences in the quality of care and health system performance at national levels are needed to reduce maternal mortality further by learning from best practices and each other. Cardiovascular diseases and mental health in women during and after pregnancy must be prioritised in all countries.
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Published on 19 October 2022, the report of the investigation into maternity and neonatal services at East Kent Hospitals NHS Foundation Trust revealed a series of serious patient safety failings between 2009 and 2020, which resulted in avoidable harm to patients and deaths. The investigation found that if nationally recognised standards had been followed, the outcome could have been different in 97 of the 202 cases reviewed. In this article, Patient Safety Learning analyses the findings of this report from a broad patient safety perspective, focusing on five key themes that are consistent with many other serious patient safety inquiries and reports in recent years. It sets these in their wider context and highlights the need for a fundamental transformation in our approach to patient safety if similar scandals are to be prevented in the future.- Posted
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Content ArticleDrugwatch is a US consumer advocacy organisation that works with certified medical and legal experts to educate the public on dangerous drugs and medical devices and to empower consumers to assert their legal rights. In this article, Terry Turner, writer for Drugwatch, examines the history of the medical tech company C.R. Bard, which specialises in vascular, urology, surgery and oncology devices. Bard manufactures thousands of medical devices and sells them worldwide. The article looks at how the company was established and then examines several legal issues Bard has faced, including criminal charges stemming from medical fraud and accusations of selling defective devices that have killed patients or caused serious complications. The author looks at criminal charges concerning heart catheters to which Bard pleaded guilty. They also highlight problems with Bard's transvaginal and hernia mesh products and inferior vena cava (IVC) filters—devices designed to catch blood clots before they reach the lungs or the heart.
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Content ArticleThe MBRRACE-UK collaboration, led from Oxford Population Health's National Perinatal Epidemiology Unit (NPEU), has published the results of their latest UK Confidential Enquiry into Maternal Deaths and Morbidity. These annual rigorous reports are recognised as a gold standard in identifying key improvements needed for maternity services. The latest Saving Lives, Improving Mothers' Care analysis examines in detail the care of all women who died during, or up to one year after, pregnancy between 2018 and 2020 in the UK. This is the first report to include data that demonstrates the impact of the COVID-19 pandemic on maternal deaths.
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Content ArticleThis webpage outlines the role of Medical Examiner Officers (MEOs), who provide the continuity and oversight that the medical examiner service requires to have the maximum benefit. It includes information on training, induction and recruitment, as well as a model job description for an MEO.
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RCPath - Medical examiners good practice series
Patient-Safety-Learning posted an article in Processes
This Good Practice Series published by The Royal College of Pathologists is a topical collection of focused summary documents, designed to be easily read and digested by busy front-line staff. The documents contain links to further reading, guidance and support, and cover the following topics: Supporting people of Black, Asian and minority ethnic heritage Urgent release of a body Learning disability and autism Organ and tissue donation Post-mortem examinations Child deaths Mental health and eating disorders Out-of-hours arrangements -
Content ArticleWhen a loved one dies, any delay in the registration or release of a deceased patient’s body can be distressing for the bereaved. The medical examiner system is being introduced in England and Wales to provide bereaved families with greater transparency and opportunities to raise concerns, improve the quality and accuracy of medical certification of cause of death, and ensure referrals to coroners are appropriate. These good practice guidelines set out how the National Medical Examiner expects medical examiner offices to operate during the non-statutory phase of the programme.
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Content ArticleIn 1999, the pivotal report “To Err is Human” by the Institute of Medicine led to sweeping changes in healthcare. This report outlined how blaming individuals does not change the underlying factors that contribute to medical errors. It also stated that blaming an individual does little to make the system safer – or prevent someone else from similar errors. It is unusual for a nurse to be charged criminally, when there is no intent to harm a patient. However, the recent trial in America of nurse RaDonda Vaught could set a precedent for future medical errors to be treated as criminal cases. The case may ensure that for every step that has been taken forward in patient safety, we have now taken two steps backwards. This article from Human Factors 101 looks at the case of RaDonda Vaught, the criminal trial and conviction, and discusses the impact this will have on healthcare.
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Content ArticleIn this debate the Parliamentary Under-Secretary of State for Health and Social Care, Maria Caulfield MP, responds to an Urgent Question asking for a statement on abuse and deaths in secure mental health units. The Minister discusses the recent findings from investigations into the deaths of Christie Harnett, Nadia Sharif and Emily Moore who were in the care of the Tees, Esk & Wear Valleys NHS Foundation Trust, reflecting on these in the context of broader concerns highlighted by other recent patient safety scandals concerning NHS mental health services. This is followed by questions from MPs in the chamber and the Minister’s responses.
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Content ArticleOn 19 October 2022, the long-awaited findings of Dr Bill Kirkup’s independent investigation into maternity services at East Kent were published. This blog outlines the response of the charity Birthrights to the investigation. It focuses on how breaches of mothers' human rights contributed to negative experiences of care and affected outcomes. Lack of informed consent, the use of disrespectful and discriminatory language and a failure to listen to mothers' concerns all contributed to many cases of avoidable harm. It argues that there is a desperate need for proper funding and real commitment to improving staff recruitment and retention, coupled with a culture shift in maternity care that embeds human rights at the centre of care.
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Content ArticleThese reports outline the findings of separate investigations into the deaths of three teenage girls who were detained mental health patients in the care of Tees, Esk & Wear Valleys NHS Foundation Trust (TEWV). The reports uncover many systemic failings at West Lane Hospital in Middlesbrough, the secure mental health unit for children where Christie Harnett and Nadia Sharif, both 17 years old, died and where Emily Moore, 18, was placed prior to her death in Lanchester Road Hospital, Durham. The girls had been friends and spent time together at West Lane, and all three deaths were self-inflicted. The reports highlight a total of 119 care and service delivery problems at West Lane including ineffective management, reduced staffing, lack of leadership, aggressive handling of disciplinary problems, issues with succession of crisis management and failures to respond to concerns from patients and staff. Although West Lane was closed in 2019, it was reopened in May 2021 under the new name of Acklam Road Hospital. Subsequent Care Quality Commission (CQC) inspections and further deaths demonstrate that dangerous cultures and practices are still operating in the Trust's inpatient mental health units. In June, the Care Quality Commission (CQC) announced that they will be bringing criminal charges against TEWV in relation to Christie’s death. This document contains three separate investigation reports relating to Christie Harnett, Nadia Sharif and Emily Moore's individual cases.
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Content ArticleThe Hyponatraemia Inquiry is the longest-running public inquiry in recent history: its report was delivered in January 2018, without fanfare. Yet its very existence has gone unnoticed. Marcus Shepheard argues that there are important lessons to be learned for other public inquiries – and for government.
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Content ArticleIn this blog, The Patients Association's Chief Executive Rachel Power argues that the findings of the independent investigation into maternity and neonatal services at East Kent Hospitals NHS Foundation Trust demonstrate the repeated failure of maternity services in England to offer safe and compassionate care to families. She outlines the key findings of the report, including catastrophic failures in the organisation's culture, team working and professionalism, and failure to listen to patients. She highlights that the lack of honesty shown by the Trust to individuals and families harmed by the hospitals' failures is shocking, and compounded the suffering felt by each family.
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Content ArticleThis debate begins with a statement by the Parliamentary Under-Secretary of State for Health and Social Care, Dr Caroline Johnson MP, regarding the publication of the report of the independent investigation into maternity and neonatal services in East Kent Hospitals NHS Foundation Trust. It is followed by questions from MPs in the chamber and the Minister's responses.
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Content ArticleThis is a written statement to the House of Commons by the Parliamentary Under-Secretary of State for Health and Social Care, Dr Caroline Johnson MP, on behalf of the UK Government. It regards the publication of the report of the independent investigation into maternity and neonatal services in East Kent Hospitals NHS Foundation Trust.
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In this short blog, Patient Safety Learning sets out its initial response to the publication of the report of the independent investigation into maternity and neonatal services at the East Kent Hospitals NHS Foundation Trust.- Posted
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Content ArticleIn February 2020 the UK Government commissioned Dr Bill Kirkup to undertake a review into maternity and neonatal care services between 2009 and 2020 in two hospitals, the Queen Elizabeth The Queen Mother Hospital (QEQM) at Margate and the William Harvey Hospital (WHH) in Ashford. Both these services fall under the East Kent Hospitals NHS Foundation Trust. The report found that over this period those responsible for these services too often provided clinical care that was suboptimal and led to significant harm, failed to listen to the families involved, and acted in ways which made the experience of families unacceptably and distressingly poor. It identifies four key areas for action which must be addressed to improve patient safety in maternity and neonatal care services.
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Content ArticleHarry Richford was born at the Queen Elizabeth the Queen Mother Hospital (QEQM), Margate, Kent on 2/11/17. He died on 9/11/17 at the William Harvey Hospital, Ashford to where he had been transferred. The cause of death was 1a Hypoxic Ischaemic Brain Encephalopathy. There was a narrative conclusion setting out some seven failures in the care of Harry Richford together with a conclusion that his death was contributed to by neglect.
