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News Article
Family hit a 'brick wall' seeking justice for baby
Patient Safety Learning posted a news article in News
The grandfather of a baby who died at a hospital that was fined over failings in the delivery has spoken of his five-year fight for justice. Derek Richford was speaking as an independent report into baby deaths at the East Kent Hospitals Trust will be released this week. He said he "came up against a brick wall" while searching for answers over the death of grandson Harry Richford. An inquest into Harry's death at Margate's Queen Elizabeth the Queen Mother Hospital in 2017 found it was wholly avoidable and contributed to by neglect. Coroner Christopher Sutton-Mattocks said the inquest, which was finally held in 2020, was only ordered due to the family's persistence. The following year the trust was fined £733,000 after admitting failing to provide safe care and treatment for mother Sarah Richford and her son following a prosecution by the Care Quality Commission (CQC). Mr Richford said: "To start with we felt fairly alone and we felt like we were coming up against a brick wall. "The trust were refusing at that time to call the coroner. They were reporting Harry's death as 'expected'. "We didn't contact anyone other than the CQC just to say 'look there's been a problem here'." He said at a meeting with the trust, more than five months later, "we suddenly realised that there were a huge [number] of errors". Mr Richford told the BBC: "It took me about a year to come up with all the detail I needed and to speak to all the right people." He said the family then spoke to the Health Safety Investigation Branch who found there were issues. Mr Richford also tracked down a "damming" report by the Royal College of Obstetricians and Gynaecologists (RCOG). "In the end it was like peeling back the layers of an onion, and the more you took off, the more you found," he said. Read full story Source: BBC News, 18 October 2022 -
News Article
'Speaking about the 22 babies I lost is seen as taboo'
Patient Safety Learning posted a news article in News
Imtiaz Fazil has been pregnant 24 times, but she only has two living children. She first fell pregnant in 1999 and, over the subsequent 23 years, has had 17 miscarriages and five babies die before their first birthdays due to a rare genetic condition. The 49-year-old, from Levenshulme in Manchester, told BBC North West Tonight her losses were not easy to talk about, but she was determined to do so, in part because such things remained a taboo subject among South Asian groups. She said she wanted to change that and break down the stigma surrounding baby loss. She said her own family "don't talk to me very much about the things" as they think "I might get hurt [by] bringing up memories". "It's too much sadness; that's why nobody approaches these sort of things," she said. Sarina Kaur Dosanjh and her husband Vik also have the hope of breaking the silence surrounding baby loss. The 29-year-olds, from Walsall in the West Midlands, have set up the Himmat Collective, a charity which offers a virtual space for South Asian women and men to share their experiences. The couple, who have had two miscarriages in the past two years, said the heartache was still not something that people easily speak about. "I think it's hidden," Sarina said. "It's really brushed under the carpet." Read full story Source: BBC News, 13 October 2022 -
News Article
Sudden unexplained death in childhood: Charity hails new NHS efforts
Patient Safety Learning posted a news article in News
NHS England has "never shown so much support" to stop children dying without explanation, a charity which works to prevent unexplained deaths has said. Sudden unexplained death in childhood (SUDC) is a rare category of death in which the cause remains unknown even after thorough investigation. Currently there is very little awareness or research into its causes. NHS England has said it will now begin a series of measures to change this, a move welcomed by the charity SUDC UK, including: Piloting systems to improve education of health professionals and gather data to help identify modifiable factors which will go on to establish processes to help manage the deterioration of children. Improve information given to families and professionals about SUDC. Separately, data from every child whose death has been put down as SUDC since 2019 will being reviewed by the National Child Mortality Database. Dr Nikki Speed, from the charity SUDC UK, described the plans as revolutionary. "This is such positive historic progress, a landmark moment. Never has the NHS shown such support to stop sudden unexplained death in childhood," she said. "Never has there been such a clear statement to review public information on SUDC, optimise data collection and learn how we could prevent future tragedies. "We finally have confidence that things will progress in our fight to stop SUDC." Read full story Source: BBC News, 15 October 2022 -
News Article
Staff at Kent NHS trust warned of 'harrowing report' into preventable baby deaths
Patient Safety Learning posted a news article in News
The chief executive of an NHS trust at the centre of a maternity scandal where there were at least seven preventable baby deaths has warned staff to prepare for a "harrowing report" into what happened. In an email seen by Sky News, East Kent Hospitals University NHS Foundation Trust chief executive Tracey Fletcher told her staff to expect a "harrowing report which will have a profound and significant impact on families and colleagues, particularly those working in maternity services". An independent investigation into the trust, stretching back over a decade, will be published this week and is expected to expose a catalogue of serious failings. It is also expected to say the avoidable baby deaths happened because recommendations that were made following reports into other NHS maternity scandals were not implemented. The East Kent review is led by obstetrician Dr Bill Kirkup, who also chaired the investigation into mother and baby deaths in Morecambe in 2015. Dawn Powell's newborn son Archie died in February 2019 aged four days. In an emotional interview, Mrs Powell told Sky News she will never get over the loss of her son, who would be alive today if she or Archie had been given a routine antibiotic. "For families like us, where your child has been taken away, you have forever got that hole in your life that you will never heal," Mrs Powell said. Read full story Source: Sky News, 16 October 2022 -
News Article
NHS logging baby deaths as stillbirths ‘to avoid scrutiny’
Patient Safety Learning posted a news article in News
NHS hospitals have claimed that babies born alive were stillborn, a Telegraph investigation has found, prompting accusations they were trying to avoid scrutiny. Six children who died before they left hospital were wrongly described as stillborn. Several of the children lived for minutes and one lived for five days. Coroners are not able to carry out inquests into stillbirths, leaving some families unable to get answers until the error was corrected. In one case, an obstetrician told a coroner in Stockport that he had been pressured by an NHS manager to say a baby he had delivered had definitely been stillborn, in order to be “loyal” to the trust. His comments are likely to raise fears that some NHS trusts in England have used the stillbirth label to avoid having coroners examine any errors that may have been made by staff. The revelations raise questions over transparency at some NHS trusts. The babies identified by The Telegraph should have been recorded as neonatal deaths, but staff claimed they were stillbirths – babies that never had any signs of life outside the mother’s body, even for a single moment. All the NHS trusts that wrongly classified neonatal deaths as stillbirths have apologised to the babies’ parents, and say they have changed their practices. Read full story (paywalled) Source: The Telegraph, 16 October 2022 -
News Article
‘Obfuscations and failures’ in trust’s handling of death, damning review finds
Patient Safety Learning posted a news article in News
There were ’obfuscations, difficulties and failures’ in a scandal-hit trust’s handling of a baby’s death, a damning review has found, although it cleared the organisation’s former chair of ’serious mismanagement’. A fit and proper person review into the conduct of former Shrewsbury and Telford Hospital Trust chair Ben Reid, who left in August 2020, has been published by the board. The report follows complaints about Mr Reid’s conduct from the family of baby Kate Stanton-Davies, who died in the trust’s care and whose case – alongside that of Pippa Griffiths – sparked the original Ockenden inquiry. In March 2022, the final Ockenden report into maternity services at Shrewsbury found poor maternity care had resulted in almost 300 avoidable baby deaths or brain damage cases in the most damning review of maternity services in the NHS’s history. Report author Fiona Scolding KC said she does not believe Mr Reid “lied” or acted unethically in his handling of complaints from the family and therefore this does not disqualify him from holding office within the terms of such a review. However, the report is highly critical of the trust, with Ms Scolding concluding it is “undoubtedly true” the provider had not dealt with Kate’s father Richard Stanton and her mother Rhiannon Davies in an “open and honest” way in respect of their daughter’s death. Read full story (paywalled) Source: HSJ, 13 October 2022 -
News ArticleThe mother of a bullied 12-year-old girl has said her daughter struggled to get mental health support on the NHS in the months before she killed herself, and accused her school of failing to deal with inappropriate messages circulating among pupils. The mother of Charley-Ann Patterson, Jamie, told a hearing that despite being seen by three medical professionals, Charley-Ann had been unable to get mental health support in the months before her death. In a statement read at an inquest at Northumberland coroner’s court on 12 October, Jamie said her daughter had changed halfway through her first year of secondary school, when she was sent “inappropriate” and “shocking” messages by other pupils. The inquest heard that Jamie first took her daughter to a GP over self-harm concerns in June 2019, but she said she “did not believe that the GP took Charley-Ann’s self-harm seriously, potentially due to her age”. She took Charley-Ann to A&E in May 2020 after a second episode of self-harm, where she was referred to a psychiatric team and given a telephone appointment in which she was told Charley-Ann would be referred to child and adolescent mental health services (CAMHS), but that “it was likely that she would not be seen for three years”. In an appointment with a nurse she was told that she would be referred to the Northumberland mental health hub for low mood and anxiety, but later learned “that this referral was never made”. Read full story Source: The Guardian, 12 October 2022
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News Article
Deaths inquiry will exclude dozens of concerning cases, says whistleblower
Patient Safety Learning posted a news article in News
An inquiry into alleged efforts to cover up care failings at an ambulance trust has been criticised by a key whistleblower for being too limited in scope. NHS England recently commissioned the inquiry into North East Ambulance Service, which has been accused of withholding key details from coroners in a number of deaths. Whistleblowers have raised concerns about disclosure in more than 90 cases. Draft terms of reference for the review, seen by HSJ, say it will examine cases which occurred over a 12-month period up until December 2019. Paul Calvert, a coroners’ officer at NEAS who raised concerns about the issues, said this effectively means only five cases will be scrutinised. He added: “The terms of reference are clearly designed to not include the ongoing malpractice, only focusing on a limited time period and limited cases." “The fact that the [inquiry] has chosen such a narrow time window and a handful of cases, is designed to perpetuate that after 2018 and 2019, the mistakes of the past were remedied. This is simply incorrect, misleading and dishonest to suggest.” He said concerns about information being withheld continued “well into 2021” and the terms of reference risked “continuing the cover up of univestigated deaths”. Read full story (paywalled) Source: HSJ, 13 October 2022 -
News Article
Lucy Letby was ‘constant malevolent’ presence on neonatal ward, court hears
Patient Safety Learning posted a news article in News
A nurse murdered seven babies and attempted to kill 10 others by poisoning them on a hospital neonatal unit where she was a “constant malevolent presence”, a court has heard. Lucy Letby, 32, fatally injected newborns with insulin, air or milk during night shifts when she knew their parents would not be present, a jury was told. One of the babies was just 24 hours old when Letby allegedly injected him with air, killing him just 90 minutes after she came on shift. The nurse tried to kill his twin sister the next day, it is alleged. The court was told that Letby, who was trained to care for the most seriously ill babies, developed an “unusual interest” in the parents of some of her 17 alleged victims and in some cases tracked them on Facebook. Jurors were told that she was the only “common denominator” that connected the deaths of seven infants and the “catastrophic” collapses of 10 others at the Countess of Chester hospital between June 2015 and June 2016. She allegedly tried to kill some babies more than once – in one case, three times – using various methods. Nick Johnson KC, prosecuting, told the jury: “We say the collapses and deaths of the 17 children named on the indictment were not normally occurring tragedies. They were all the work, we say, of the woman in the dock who we say was a constant malevolent presence when things took a turn for the worse for these children.” Read full story Source: The Guardian, 10 October 2022 -
News Article
We must challenge 'doctor knows best' attitude, bereaved mother says
Patient Safety Learning posted a news article in News
Merope Mills, an editor at the Guardian, has questioned doctors' attitudes after her 13-year-old daughter Martha's preventable death in hospital. Martha had sustained a rare pancreatic trauma after falling off a bike on a family holiday, and spent weeks in a specialist unit where she developed sepsis. An inquest concluded that her death was preventable, and the hospital apologised. Ms Mills said her daughter would be alive today if doctors had not kept information from the parents about her condition, because they would have demanded a second opinion. She added that doctors' attitudes "reeked of misogyny", citing a moment when her "anxiety" was used as an argument to not send critical care to Martha. In a statement, Prof Clive Kay, chief executive of King’s College Hospital NHS Foundation Trust said he was "deeply sorry that we failed Martha when she needed us most". "Our focus now is on ensuring the specific learnings from her case are used to improve the care our teams provide - and that is what we are committed to doing." Watch video Source: BBC News, 6 October 2022 Further reading on the hub ‘We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death (The Guardian) “Are you questioning my clinical judgement?” Suppressing parents’ concerns is a serious patient safety risk -
News Article
Coroner warns of lack of change since man's death
Patient Safety Learning posted a news article in News
A coroner has raised concerns about a mental heath trust where staff falsified records made on the night a man died. Eliot Harris, 48, died in the Northgate Hospital in Great Yarmouth, run by the Norfolk and Suffolk Foundation Trust (NSFT), in April 2020. Norfolk coroner Jacqueline Lake said that, two years on, staff were still not recording observations properly. The 48-year-old, who had schizophrenia, had been sectioned under the Mental Health Act after he became agitated at his care home and refused to take medication. He was taken to Northgate Hospital and, after a period in a seclusion room, was transferred to a private room on the ward. Mr Harris was discovered unresponsive in bed during the early hours of 10 April and pronounced dead half an hour later. In a Prevention of Future Deaths Report (PFDR), Ms Lake said: "Quality audits undertaken following Eliot Harris's death, show that observations are still not being carried out and recorded in accordance with NSFT's most recent policy - more than two years following Eliot's death." She said that on the night Mr Harris died there was no nurse in charge and instead of being allocated specific tasks, staff were told to "muck in", causing confusion about job responsibilities. These issues were not resolved at the time of the inquest, she said, with no evidence provided about whether specific tasks were allocated on the night shift. Not all staff had been trained in recording observations, there was a lack of evidence about procedures for entering a patient's room over concerns for their welfare, and there was "still some way to go to make sure care plans are completed", Ms Lake said. Read full story Source: BBC News, 6 October 2022 -
News Article
WHO alert over India-made cough syrups after deaths in The Gambia
Patient Safety Learning posted a news article in News
A global alert has been issued over four cough syrups after the World Health Organization (WHO) warned they could be linked to the deaths of 66 children in The Gambia. The syrups have been "potentially linked with acute kidney injuries and 66 deaths among children", it said. The products were manufactured by an Indian company, Maiden Pharmaceuticals, which had failed to provide guarantees about their safety, the WHO added. The WHO identified the medicines as Promethazine Oral Solution, Kofexmalin Baby Cough Syrup, Makoff Baby Cough Syrup and Magrip N Cold Syrup. The four products had been identified in The Gambia, but "may have been distributed, through informal markets, to other countries or regions", the WHO added, in the alert published on its website. It warned that their use may result in serious injury or death, especially among children. Read full story Source: BBC News, 6 October 2022 -
News Article
How 175 British children were infected with HIV
Patient Safety Learning posted a news article in News
At least 175 children with the blood disorder haemophilia were infected with HIV in the 1980s, according to documents from the national archives seen by BBC News. Some of the families affected are giving evidence at a public inquiry into what has been called the worst treatment disaster in the history of the NHS. It was almost 36 years ago - in late October 1986 - but Linda will never forget the day she was told her son had been infected. She had been called into a consulting room in Birmingham Children's Hospital, with 16-year-old Michael. As a toddler, he had been diagnosed with haemophilia, a genetic disorder that stopped his blood clotting properly. Linda assumed the meeting was to discuss moving his care to the main Queen Elizabeth Hospital in the city. "It was so routine that my husband stayed in the car outside," she says. "Then, all of a sudden, the doctor said, 'Of course, Michael is HIV positive,' and he came out with it like he was talking about the weather outside. My stomach just fell." Between 1970 and 1991, 1,250 people with blood disorders were infected with HIV in the UK after taking Factor VIII - a new treatment that replaced the clotting protein missing from their blood. About half of those infected with HIV died of an Aids-related illness before life-saving antiretroviral drugs became available. Almost three decades later, Linda is giving evidence to the long-running public inquiry into the treatment disaster. She will appear alongside other parents, in a special session about the experiences of families whose children were infected in the 1970s and 80s. "I felt as though I needed to do it because I want to help get to the bottom of it," she says. "We all want to know why it was allowed to happen and to keep on happening as well." Read full story Source: BBC News, 6 October 2022 -
News Article
Residents 'not safe' at four-inquest care home
Patient Safety Learning posted a news article in News
A care home that will close after admitting "shortcomings in care" and failures in leadership has been labelled "not safe" by inspectors. The Elms in Whittlesey, Cambridgeshire will shut later this month, and the Care Quality Commission (CQC) has found the service to be inadequate. In May, the BBC first reported the concerns of relatives about The Elms after their loved ones died in 2019, weeks after a meeting in which worries were raised about "poor care". Inquests into the deaths of the residents - George Lowlett, Margaret Canham and David Poole - remain ongoing. HC-One also apologised to the family of Joyce Parrott, who died in April 2020. Inspectors found "people were not safe and were at risk of avoidable harm" and described multiple occasions when people had "not received their medicines as prescribed". Other findings included: Staff had not referred all potential safeguarding events to the local authority A failure to "establish systems to ensure people were effectively safeguarded from abuse" The provider had failed to learn when things went wrong "Widespread and significant shortfalls" in leadership No reliable record of the staff that had worked at the home and a reliance upon agency staff, which "resulted in people not receiving consistent care" Read full story Source: BBC News, 5 October 2022 -
News Article
Covid inquiry ‘marginalising’ bereaved on first day of hearing
Patient Safety Learning posted a news article in News
Bereaved families fear their experiences will be “diluted” in the UK Covid-19 Inquiry after it was confirmed their evidence would be submitted to a third-party company. Instead of the usual “pen portraits” heard in the inquiry, families will submit their evidence to a private research company as part of a parallel listening exercise that will analyse the responses and feed back the findings to the inquiry chaired by Baroness Heather Hallett. Matt Fowler, co-founder of the Covid-19 Bereaved Families for Justice campaign, said while families believe the start of the inquiry is a step in the right direction after campaigning for two years, they fear being excluded from the inquiry because of the listening exercise. “All bereaved families want from the inquiry is the same outcome that anyone should, for lessons to be learnt from our loss that can stop the monumental scale of death that took place from happening again,” Matt said following the preliminary hearing. “As Baroness Hallett herself has acknowledged, for that to happen the experiences of the bereaved must be learnt from, so why is she leaving us out in the cold instead of working with us?” A&E doctor Saleyah Ahsan, from east London, worked in intensive care units during the pandemic. She said she remembers holding hands with people and telling them they needed to be incubated as they desperately called their families – some died in intensive care. “It is very important that stories jump off the page and are real because they are real,” She added: “If we really want to make sure we get this right there is only this inquiry, it has to be right. I am a medic, I see the numbers are rising, it’s autumn. Thankfully we’ve got a booster but hospitals are getting busy – I’m worried.” Read full story Source: The Independent, 4 October 2022 -
News Article
Hospital merger confusion blamed for cancer deaths
Patient Safety Learning posted a news article in News
A ‘leading’ cancer service has reported a series of safety incidents which contributed to patients being severely harmed or dying, HSJ has reported. An internal report at Liverpool University Hospitals Foundation Trust suggests the incidents within the pancreatic cancer specialty were partly linked to patient pathways being ill-defined following the merger of its two major hospitals. The report lists seven incidents involving severe harm or death, and five involving moderate harm. It is not clear how many of the patients died. The trust was formed in 2019 through the merger of the Royal Liverpool and Aintree acute sites, with the consolidation of clinical services an integral part of the plans. However, there were no formal plans to change the configuration of pancreatic cancer services, which already operated under a “hub and spoke” model. In one finding relevant to all 12 incidents, the report said: “Patient ownership and clinician accountability (local vs specialist) have not been defined following the merger of the legacy trusts and subsequent service reconfigurations. “This has contributed to system failures in the provision of timely quality care, particularly in patients with time-critical clinical uncertainty.” Read full story (paywalled) Source: HSJ, 5 October 2022 -
News ArticleTina Hughes, 59, died from sepsis after doctors allegedly delayed treating the condition for 12 hours while they argued over which ward to treat her on. Ms Hughes was rushed to A&E after developing symptoms of the life-threatening illness on September 8 last year. Despite paramedics flagging to staff they suspected sepsis, it was not mentioned on her initial assessment at Sandwell General Hospital, in West Bromwich. A second assessment six hours later also failed to mention sepsis while medics disagreed over whether to treat her on a surgical ward or a high dependency unit. The grandmother-of-five was eventually transferred to the acute medical unit at 3am the next morning where sepsis was finally diagnosed, but she continued to deteriorate and was admitted to intensive care four hours later and put on a ventilator. She died the following morning. A serious incident investigation report by Sandwell and West Birmingham Hospitals NHS Trust has since found there was "a delay in explicit recognition of sepsis". Read full story (paywalled) Source: The Telegraph, 4 October 2022
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News Article
Tribunal told of 'failure' over girl's blood tests
Patient Safety Learning posted a news article in News
If doctors had tested a nine-year-old girl's blood sooner they may have changed the treatment she received before her death, an expert witness has confirmed to a medical tribunal. The hearing was told this was a "significant failure" in the care of Claire Roberts. Claire died at the Royal Belfast Hospital for Sick Children in 1996. In 2018 a public inquiry concluded she died from an overdose of fluids and medication caused by negligent care. At the time, her parents were told a viral infection had spread from her stomach to her brain. The General Medical Council (GMC) said one of the doctors involved in Claire's care, Dr Heather Steen, acted dishonestly in trying to conceal the circumstances of her death. Dr Steen denied allegations that she acted dishonestly and engaged in a cover-up. The Medical Practitioners Tribunal Service (MPTS) heard from a defence expert witness on Monday who said doctors not checking the sodium levels in Claire's blood earlier was a "significant failure" in her care. Dr Nicholas Mann told the tribunal he would have ordered more blood tests on Claire on the morning after she was admitted to hospital but he said he did not know if this would have prevented her death. "There should have been more attention to her fluids and electrolytes on the day after admission. Whether that would have altered the final outcome I don't know but certainly it would have been sensible to do that," he said. The tribunal also heard that Claire's death was not referred to a coroner, despite this being something all of the doctors caring for her would have had a duty to do. It was also told that a letter sent to Claire's parents from the hospital in 2005 contained inaccuracies. During questioning of Dr Mann, a barrister for the GMC highlighted the involvement of Dr Steen in compiling the letter which was signed by another doctor. Tom Forster KC said it was the GMC's case that Claire's family were given incorrect information about potential causes of her death despite these not being definitively diagnosed. Read full story Source: BBC News, 3 October 2022 -
News Article
Covid inquiry first preliminary hearing to begin
Patient Safety Learning posted a news article in News
The first preliminary hearing of the UK Covid public inquiry will begin today. The session, in London, will focus on the UK's pandemic preparedness before 2020. It will be largely procedural, involving lawyers and an announcement about who will be giving evidence. Public hearings where witnesses are called will not start until the spring. The inquiry formally started in the summer, with a listening exercise. But this first preliminary hearing is still being seen as an important milestone for the families who lost loved ones. Lindsay Jackson's mother, Sylvia, 87, died from Covid during the first lockdown, after contracting it at a care home. Ms Jackson, of the Covid-19 Bereaved Families for Justice campaign group, said it was essential lessons were learned. She was "really pleased" the inquiry was finally starting but it had taken too long to reach this stage. "It's two-and-a-half years since the pandemic started," she said. "We lost so many people. If people have done things wrong, they need to be held accountable. "For me, my family and the others who lost loved ones, it's important that answers are found to the questions that we have." Read full story Source: BBC News, 4 October 2022 -
News ArticleHospital authorities in Wales have been accused of attempting to cover up failings in the delivery of a baby born with significant brain damage. Gethin Channon, who was born on 25 March 2019 at Singleton Hospital, in Swansea, suffers from quadriplegic cerebral palsy, a severe disability that requires 24/7 care. There were complications during his birth, due to him being in an abnormal position that prevented normal delivery, and he was eventually born via caesarean section. An independent review commissioned by Swansea Bay University Health Board (SBUHB), which manages Singleton Hospital, found “several adverse features” surrounding Gethin’s delivery that were omitted from or “inaccurately specified” in the hospital’s internal report. The investigation, carried out by obstetrician Dr Bill Kirkup, said SBUHB had “significantly” downplayed the “suboptimal” care received by Gethin and his mother, Sian, and had erroneously attributed his condition to a blocked windpipe. It also suggests that amendments were retrospectively made to examination notes taken by staff during the course of Ms Channon’s labour. The family said that SBUHB, which was flagged by national inspectors in the months after Gethin’s birth due to “concerns” over its ability to deliver “safe and effective” maternity care, had “covered up” the failings in their case. SBUHB said it had been “working tirelessly” with the family to investigate and address their concerns, and that it would be inappropriate to comment on specific allegations as the process was ongoing. Read full story Source: The Independent, 2 September 2022
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News Article
Scottish Government orders review as neonatal deaths higher than expected
Patient Safety Learning posted a news article in News
Healthcare Improvement Scotland have been commissioned to lead a review into the neonatal death rates. It follows the higher than expected deaths in both March 2022 and September last year, as published by Public Health Scotland. At least 18 babies under four weeks old died in March – a rate of 4.6 per 1,000 births. The wider inquiry is understood to have been triggered because the mortality rate passed an "upper control" threshold of 4.4 per 1,000 births. The average mortality rate among newborns is just over 2 per 1,000 births. The Scottish Government said the investigation is expected to take no longer than six to nine months once the review team is formed. Public health minister Maree Todd said: “Every death is a tragedy for the families involved. That is why earlier this year I committed to this review to find out if there is a reason for the increase. “I appreciate how difficult this time is for anyone affected and I would encourage them to access support if they wish to do so. There is information about organisations and help available on the National Bereavement Care Pathways Scotland as well as the Scottish Government website.” Read full story Source: The Scotsman, 30 September 2022 -
News Article
Mother given substantial damages over baby's care
Patient Safety Learning posted a news article in News
A mother from County Down will receive "substantial" undisclosed damages over alleged hospital treatment failures and care given to her daughter. Christina Campbell from Ballygowan brought medical negligence lawsuits over treatment she received at the Ulster Hospital in Dundonald after her daughter, Jessica, died in 2017 with a rare genetic disorder. The claim said that failure to test Ms Campbell during her pregnancy meant the condition went undetected. Damages were also sought for an alleged "ineffective" end of life care plan for the four month old. Jessica was diagnosed with trisomy 13 shortly after her birth in December 2016. She experienced feeding and respiratory difficulties, as well as a congenital heart defect and a bilateral cleft lip and palate. She was discharged from hospital with a home-based end-of-life care plan, including community and respite referral to the hospice, but a few months later. The claims said a failure to provide Ms Campbell with a amniocentesis test, which checks for genetic or chromosomal conditions, meant Jessica's condition was not discovered sooner. The lawsuit also highlighted concerns about Jessica's hospice treatment. It includes alleged uncertainty about the provision of humidified oxygen, a defective feeding pump and delays in a specific feeding plan and saline nebuliser being provided for the family. The family's solicitor said the awarding of damages "signifies the importance of lessons learned" as a result of Ms Campbell's campaign. "It is hoped that lessons can now be learned to ensure no other family has to go through a similar experience," he said. Read full story Source: BBC News, 29 September 2022 -
News Article
NHS 111 failures led to early Covid deaths, investigation finds
Patient Safety Learning posted a news article in News
Multiple failures by the NHS 111 telephone advice service early in the pandemic left Covid patients struggling to get care and led directly to some people dying, an investigation has found. The Healthcare Safety Investigation Branch (HSIB) looked into the help that NHS 111 gave people with Covid in the weeks before and after the UK entered its first lockdown on 23 March 2020. It identified a series of weaknesses with the helpline, including misjudgment of how seriously ill some people with Covid were, a failure to tell some people to seek urgent help, and a lack of capacity to deal with a sudden spike in calls. It also raised concerns that the government’s advice to citizens to “stay at home” to protect NHS services deterred people who needed immediate medical attention from seeking it from GPs and hospitals, sometimes with fatal consequences. Mistakes identified by HSIB included that: The CRS algorithm did not allow for the assessment of any life-threatening illness a caller had – such as obesity, cancer or lung disease – to establish whether they should undergo a clinical assessment. When many callers reached the core 111 service, there was no way to divert them as intended to the CRS, which was operationally independent of 111. Although patients who had Covid-19 symptoms as well as underlying health conditions, such as diabetes, were meant to be assessed when they spoke to the core 111 service, some were not. The number of extra calls to 111 in March 2020 meant that only half were answered. Read full story Source: The Guardian, 29 September 2022 -
News Article
Coroner criticises NHS trust’s treatment of family of woman who killed herself
Patient Safety Learning posted a news article in News
An NHS trust has “not covered itself in glory” in its dealings with the family of a vulnerable young woman who killed herself after being refused admission to hospital, a coroner has found. The three-day hearing looked at evidence withheld from the original inquest into the death of Sally Mays, who killed herself in 2014 after being turned away from a mental health unit. Mays was failed by staff “neglect” at Miranda House in Hull, a 2015 inquest ruled, after a 14-minute assessment led to her being refused a place, despite being a suicide risk. Her parents, Angela and Andy Mays, won a high court battle in December to hear details of an informal chat outside the building between Laura Elliot, a community mental health nurse who was supporting Mays, and the consultant psychiatrist Dr Kwame Fofie, which only later came to light. This was ruled to be “neither a clinical conversation nor an attempt to escalate her care” by senior coroner Prof Paul Marks on Wednesday. He said: “It was a conversation between colleagues in which the frustrations of the working day were vented.” But, he said: “The trust has not covered itself in glory with regard to its dealings with the family and the disclosing of documents.” The Mays have spent the last seven years fighting to hear details of the car park conversation, which could have changed their understanding of what happened before their daughter died. Angela Mays added: “I never considered myself to be a campaigner. I have only considered myself to be a mother who actually wants the truth about the facts relating to her daughter’s death.” Read full story Source: The Guardian, 28 September 2022 -
News Article
Dying patient should have been seen in person
Patient Safety Learning posted a news article in News
NHS officials ruled a man who died after his ear infection was not picked up in GP telephone consultations should have been seen face to face, a BBC Newsnight investigation has found. David Nash, 26, had four remote consultations over three weeks during Covid restrictions but was never offered an in-person appointment. His infection led to a fatal abscess on his brainstem. David first spoke to the practice on 14 October 2020, after finding lumps on his neck. He sent a photograph but was never examined. With David worried the lumps might be cancerous, the GP asked a series of questions about his health and reassured him that while she could not rule it out completely, she was not worried about cancer. She suggested he booked a blood test for two to three weeks' time. In those three weeks, David would go on to speak to another GP and two advanced nurse practitioners but never face to face or via video call. He was actually due to be seen in person at the GP surgery that day, for the blood tests booked some 19 days earlier, when he had presented with neck lumps. But - fearing he could have coronavirus, despite a negative PCR test - the nurse cancelled the bloods and asked David to retest for Covid. In its investigation, NHS England found "the overarching benefit [of this decision] was less than the risk with going ahead with blood tests". After five calls to NHS 111, David was taken to hospital in an ambulance that day but died two days later. NHS England, in a finding seen by Newsnight, said: "A face-to-face assessment should have been offered or organised to confirm the diagnosis and initiate definitive management." Read full story Source: BBC News, 29 September 2022
