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News Article
Ambulance trust covered up paramedics’ fatal errors like a ‘criminal gang’
Patient Safety Learning posted a news article in News
An ambulance trust has been accused of acting like a “criminal gang” and lying to dead patients’ families by an employee who repeatedly warned about paramedics’ mistakes being covered up. Paul Calvert, a coroner’s officer whose job was to produce reports on deaths, tried to raise concerns about managers at the North East Ambulance Service (NEAS) for three years before walking out last year on the verge of a breakdown. “My life was being made a misery,” said Calvert, who was previously a detective with Northumbria police. “They were basically like a criminal gang. I had tried everything I could to warn the proper authorities about how the service was destroying and concealing evidence meant for the coroner. I spoke to my managers, to human resources, to external auditors. I even made disclosures to the Care Quality Commission and Northumbria police. Nothing was done about it.” Despite their denials of a large-scale cover-up of mistakes, the NEAS this year offered Calvert £41,000 as part of a non-disclosure agreement it asked him to sign. One of the clauses meant destroying all the evidence he had collected. Another tried to stop him making any further disclosures to police. Reports and witness statements from ambulance staff were not being disclosed to the coroner “on a daily basis”, according to Calvert, amounting to key pieces of evidence relating to deaths being hidden from the public. Read full story (paywalled) Source: The Times, 29 May 2022 -
News ArticleDonna Ockenden, the midwife who investigated the Shopshire maternity scandal, has been appointed to lead a review into failings in Nottingham following a dogged campaign by families. The current review will be wound up by 10 June after concerns from NHS England and families that it is not fit for purpose. It was commissioned after revelations from The Independent and Channel Four News that dozens of babies had died or been brain-damaged following care at Nottingham University Hospitals Foundation Trust. In a letter to families on Thursday, NHS England chief operating officer David Sloman said: “I want to begin by apologising for the distress caused by the delay in our announcing a new chair and to take this opportunity to update you on how the work to replace the existing Review has been developing as we have taken on board various views that you have shared with us.” “After careful consideration and in light of the concerns from some families, our own concerns, and those of stakeholders including in the wider NHS that the current Review is not fit for purpose, we have taken the decision to ask the current Review team to conclude all of their work by Friday 10 June.” “We will be asking the new national Review team to begin afresh, drawing a line under the work undertaken to date by the current local Review team, and we are using this opportunity to communicate that to you clearly.” Ms Ockenden said: “Having a baby is one of the most important times for a family and when women and their babies come into contact with NHS maternity services they should receive the very best and safest care." “I am delighted to have been asked by Sir David Sloman to take up the role of Chair of this Review and will be engaging with families shortly as my first priority. I look forward to working with and listening to families and staff, and working with NHS England and NHS Improvement to deliver a Review and recommendations that lead to real change and safer care for women, babies and families in Nottingham as soon as possible.” Read full story Source: BBC News, 26 May 2022
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News Article
Bristol surgeon ‘harmed’ 203 women with unnecessary operations
Patient Safety Learning posted a news article in News
More than 200 women were harmed when a rogue surgeon carried out operations on them unnecessarily, an NHS inquiry has found. Some of the women were left with life-changing physical problems or unable to work, while many also suffered trauma and serious psychological harm as a result. Overall, 203 women on whom Anthony Dixon performed procedures between 2007 and 2017 came to harm, according to a review by the North Bristol NHS trust (NBT). Dixon, who for years was Britain’s most influential pelvic surgeon, worked for both the trust and the private Spire hospital in the city. In 2017, NBT launched a review of Dixon’s performance and suspended him after dozens of women he had performed procedures on complained that they had experienced appalling consequences, including unmanageable pain and incontinence. The Guardian revealed in late 2017 that 100 women were suing him for medical negligence. Some cases have since been settled, but dozens are ongoing. NBT sacked Dixon in 2019 and he is currently banned from practising in the UK. During the review, 378 women were recalled and asked to set out their dealings with Dixon. All had undergone a procedure called laparoscopic ventral mesh rectopexy (LVMR), in which plastic mesh is inserted to repair weakened tissue in the pelvic floor. In papers presented to NBT’s board on Thursday, board members were told that the inquiry had concluded. “The trust has notified 203 NHS patients that, although their LVMR operation was carried out satisfactorily, they should have been offered alternative treatments before proceeding to surgery. We have defined these patients as suffering ‘harm’ as a result,” it said. Read full story Source: The Guardian, 26 May 2022 -
News Article
Ambulance service will collapse by August, predicts its nursing director
Patient Safety Learning posted a news article in News
A struggling ambulance trust could face a ‘Titanic moment’ and collapse entirely this summer if the region’s worsening problems with hospital handover delays are not taken more seriously, its nursing director has told HSJ. Mark Docherty, of West Midlands Ambulance Service (WMAS), said patients were “dying every day” from avoidable causes created by ambulance delays and that he could not understand why NHS England and the Care Quality Commission were “not all over” the issue. He revealed that handover delays at the region’s hospitals were the worst ever recorded, that rising numbers of people were waiting in the back of ambulances for 24 hours, and that serious incidents have quadrupled in the past year, largely due to severe delays. More than 100 serious incidents recorded at WMAS relate to patient deaths where the service has been unable to respond because its ambulances are held outside hospitals, according to the minutes of the trust’s March quality and safety committee. "Around 17 August is the day I think it will all fail,” he said. “I’ve been asked how I can be so specific, but that date is when a third of our resource [will be] lost to delays, and that will mean we just can’t respond. Mathematically it will be a bit like a Titanic moment. ”It will be a mathematical certain that this thing is sinking, and it will be pretty much beyond the tipping point by then.” Read full story (paywalled) Source: HSJ, 25 May 2022 -
News Article
North East Ambulance Service: Cover-up claims to be probed by government
Patient Safety Learning posted a news article in News
The government is to investigate claims an ambulance service covered up details of the deaths of patients following mistakes by paramedics. It follows the Sunday Times report that North East Ambulance Service (NEAS) withheld information from coroners. Labour's shadow health secretary Wes Streeting described the alleged cover-up as "a national disgrace". Health minister Maria Caulfield said she was "horrified" and there would be a further investigation. The newspaper reported that concerns were raised about more than 90 cases and whistleblowers believed NEAS had prevented full disclosure to relatives of people who died in 2018 and 2019. Speaking in the House of Commons, Mr Streeting asked why the regulator - the Care Quality Commission (CQC) - had failed to take action. Ms Caulfield said that while both the NEAS and the CQC had both reviewed the allegations, further investigation was required. The minister said non-disclosure agreements have "no place in the NHS", adding: "Reputation management is never more important than patient safety." Read full story Source: BBC News, 23 May 2022 -
News Article
Shrewsbury and Telford NHS Trust admits failures after two patients die
Patient Safety Learning posted a news article in News
A hospital trust has pleaded guilty to failures in care that contributed to the deaths of two patients. One of the charges related to the death of patient Mohammed Ismael Zaman in 2019 at the Royal Shrewsbury Hospital. The 31-year-old died of severe blood loss while undergoing dialysis, Telford Magistrates' Court heard. Max Dingle, in his 80s, died after his head became trapped between a mattress and bed rail while he was being treated at the Royal Shrewsbury Hospital. Shrewsbury and Telford Hospital NHS Trust (SaTH) admitted three counts of failing to provide treatment and care in a safe way, resulting in harm or loss, between October 2019 and May 2020. Representing the CQC, Ryan Donoghue said the failures in Mr Zaman's care "were the legal cause of his death, for which the trust is responsible". He said Mr Dingle, who had been admitted with chronic lung disease, died from a cardiac arrest after he was freed. "The basis [of the guilty plea] is that the failures exposed him to a significant risk of avoidable harm," Mr Donoghue said. As well as the two deaths, the CQC accused the trust of exposing other patients to significant risk of avoidable harm. Read full story Source: BBC News, 18 May 2022 -
News Article
Patient waited 24 hours in ambulance for A&E
Patient Safety Learning posted a news article in News
Nearly 600 patients waited 10 hours or more in the back of an ambulance to be transferred into emergency departments last month – with one taking 24 hours, HSJ can reveal. The 24-hour wait was the longest handover delay recorded in the past year, and probably ever, according to information released by ambulance trust chief executives. In May last year the longest recorded rate was seven hours. This has risen steadily during the year to hit 24 hours in April. In March a patient in the West Midlands had to wait 23 hours. The figures also show 11,000 patients waited more than three hours for handover last month, with 7,000 of them taking more than four hours and 4,000 over five hours. Some 599 waited more than 10 hours. The Association of Ambulance Chief Executives estimates 35,000 patients were potentially at risk of harm from delayed handovers last month, with just under 4,000 of those risking severe harm. This is based on work it did looking at patients waiting more than 60 minutes in 2021 and was a slight fall on March. They are based only on handover delays and do not include harm from patients left waiting for an ambulance response. Hours lost to ambulance handover delays restrict ambulance trusts’ ability to reach other patients waiting for an ambulance in the community. Read full story (paywalled) Source: HSJ, 16 May 2022 -
News ArticleOne in four older Americans covered by Medicare had some type of temporary or lasting harm during hospital stays before the COVID-19 pandemic, government investigators said in an oversight report published Thursday. The report from the U.S. Department of Health and Human Services Office of Inspector General said 12% of patients had “adverse events” that mainly led to longer hospital stays but also permanent harm, death or required life-saving intervention. Another 13% had temporary issues that could have caused further complications had hospital staff not acted. Investigators reviewed the medical records of 770 Medicare patients discharged from 629 hospitals in 2018 to formulate a national rate on how often patients were harmed, whether preventable or not. An earlier Inspector General review found 27% of patients experienced some type of harm – an investigation that led to new patient safety efforts and incentives. The incremental improvement follows intense focus on patient safety since at least 1999 when the then-Institute of Medicine published To Err is Human, a landmark report that estimated up to 98,000 deaths per year could be due to medical errors. Initiatives have since sought to improve patient safety by limiting medical errors, reducing medication mix-ups and holding hospitals with a poor record of patient safety accountable through Medicare's program to dock the pay of the worst performers on a list of safety measures. While Inspector General investigators noted improvements in certain safety measures, officials said the 25% harm rate is concerning and deserves renewed attention from hospitals and two federal agencies that oversee patient safety: the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality. "We still have a significant way to go in terms of improving patient safety," said Amy Ashcraft, a deputy regional inspector general. Read full story Source: USA Today News, 12 May 2022
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News Article
Nurse who filmed unconscious patients at hospital jailed for 12 years
Patient Safety Learning posted a news article in News
A nurse who filmed up the gowns of unconscious women patients and recorded staff using the toilet at a large teaching hospital has been jailed for 12 years by a judge who said he had "brought shame on an honourable profession". Paul Grayson, 51, was also told by the judge he must serve an extended licence period of 4 years when he is eventually released. The judge described how four patients were targeted as they recovered from surgery at Sheffield's Royal Hallamshire Hospital – one of whom has never been identified from the footage. Sentencing Grayson on Tuesday, Judge Jeremy Richardson QC said: "You have betrayed every ounce of trust reposed in you. Earlier this week, the court heard one victim, who was secretly filmed in the shower by Grayson over a number of years, face him directly in court as she told him his "sick and disgusting perversions" and "evil actions" were crimes that "have torn me into pieces". The court heard that one victim was unconscious after an eye operation when Grayson filmed her up her gown, and could be seen moving her underwear. The woman told police she had "put her trust in staff at the hospital to keep her safe". The victim said that she has since been due to have an operation at another hospital but she "can't bring myself to go". Read full story Source: Medscape UK, 11 May 2022 -
News Article
Hospital staff charged over patient mistreatment
Patient Safety Learning posted a news article in News
Five healthcare staff have been charged with criminal offences as part of a major investigation into the ill-treatment of hospital patients. Concerns had been raised over the welfare of some patients on the stroke unit at Blackpool Victoria Hospital. Three nurses and two healthcare assistants will appear at court for offences including unlawful sedation of patients and theft, police said. The charges relate to a period between August 2014 and November 2018. Those charged are Catherine Hudson, 52, of Coriander Close, Blackpool; Charlotte Wilmot, 47, of Bowland Crescent, Blackpool; Matthew Pover, 39, of Bearwood Road in Smethwick; Victoria Holehouse, 31, of Riverside Drive, Hambleton, and Marek Grabianowski, 45, of Montpelier Avenue, Bispham. They face charges including ill-treatment or wilful neglect, encouraging a nurse to sedate a patient, theft, supplying drugs and perverting the course of justice. Read full story Source: BBC News, 6 May 2022 -
News Article
Maternity scandal review chair resigns after pressure from families
Patient Safety Learning posted a news article in News
The newly appointed chair of a major review into poor maternity care in Nottingham has resigned following mounting pressure from families. Julie Dent was appointed by the NHS just two weeks ago to lead a review into hundreds of cases of alleged poor care at Nottingham University Hospitals NHS Trust. On 7 April, more than 100 families called for Ms Dent to decline the offer after they had previously urged NHS England to appoint Donna Ockenden, who chaired the Shrewsbury and Telford maternity inquiry. In a letter to families on Wednesday, the chief operating officer of NHS England and NHS Improvement, David Sloman, said: “After careful consideration and further conversations with her family, Julie Dent has, for personal reasons, decided not to proceed as chair of the independent review of maternity services at Nottingham University Hospitals NHS Trust.” The letter said that NHS England and NHS Improvement would still have “oversight” of the independent review, and that a new review process was being established. Mr Sloman said he would write to families to inform them of the next stage in the review “shortly”. The Nottingham independent maternity review was launched in July last year, and since then more than 500 families have come forward, the majority in the last two months. Read full story Source: The Independent, 4 May 2022 -
News Article
‘40,000 put at risk last month’ while waiting in ambulance
Patient Safety Learning posted a news article in News
More than 38,000 patients were put at risk of harm during March – more than 4,000 of them seriously – while they waited in an ambulance outside hospital, according to estimates shared with HSJ. The number of hour-plus delays to handing over patients from ambulances to emergency departments in March was the highest ever recorded, following steep increases since last summer. Figures collected by the Association of Ambulance Chief Executives (AACE), and shared with HSJ, reveal that one trust recorded a delay of 23 hours during March. Based on its detailed information about the length of handover delays, AACE has produced an estimate of the likely number of patients harmed while waiting to he handed over, using a model initially developed in research published last year. This found 85 per cent of those who waited more than an hour could have suffered potential harm. The AACE report said that patients who waited the longest were at greatest risk of some level of harm and the risk of severe harm tripled for those waiting for more than four hours compared with waiting for 60 to 90 minutes. AACE managing director Martin Flaherty told HSJ: “We expect the situation to be no better when we collate our figures for April. “The most significant problem remains hospital handover delays which continue to increase exponentially, with tens of thousands of ambulance hours being lost due to hospital handover delays, causing enormous knock-on effects out in the community, where delays in people receiving the ambulance resource they need are the obvious result. “However, the human cost, in terms of direct harm that is being caused to patients through these combined delays at hospitals and in the community, as well as to the health and wellbeing of our ambulance crews, is substantial." Read full story (paywalled) Source: HSJ, 29 April 2022 -
News Article
When the NHS spends billions on personal injury cases, it’s the public that loses
Patient Safety Learning posted a news article in News
Hunt’s radical plan to reform compensation for clinical negligence is “completely unacceptable” says the Association of Personal Injury Lawyers, which includes some of the kinds of firms that urge people to sue the NHS, soliciting online, in TV ads or posters in waiting rooms. Damages paid by the NHS as a result of medical negligence claims have soared exponentially over the last decade, up from £900m to £2.2bn now. Yet despite horror stories of deaths and life-changing damage in badly run maternity wards, the National Audit Office (NAO) finds no evidence of more injuries, only that the number of claims and sums awarded by courts are shooting up. The NAO found that “the claimant’s legal costs exceeded the damages awarded in 61% of claims settled”. Though the lawyers in the clinical compensation business protest vigorously that they defend patients’ rights, the Hunt committee demolishes any justification for the present system. The report quotes Sir Ian Kennedy QC, the chair of many inquiries and emeritus professor of health law and ethics at University College London, who wrote in 2021 that clinical negligence was an “outdated, arbitrary and scandalously expensive system” with a “stranglehold that lawyers exert over a system that should be putting the interests and needs of patients first”. What injured patients need is an independent authority to conduct a speedy and transparent investigation of what went wrong, with everyone free to speak openly, ending in reasonable compensation and a pledge to prevent anyone else being put at risk by the same error. Peter Walsh, the chief executive of Action Against Medical Accidents, told the committee that litigation was often “a last-gasp attempt to get a sense of justice and to get to the bottom of what has actually happened after people have experienced denial after denial”. Instead of a system of delays and denials that frustrates grieving families and terrorises doctors as lawyers seek to pin personal blame on someone, the committee proposes a system closer to those used in New Zealand and Scandinavia. An independent administrative body would investigate a patient’s case to see if the harm done was avoidable and if so, to fix fair compensation briskly within six months. The priority would be openness and learning from mistakes to protect future patients. Not needing to find a person to blame makes it easier for patients to get compensation – but the payout would be far lower. Some warn this lower burden of proof would encourage a flood of claims, but New Zealand found a similar system ended up halving the sums paid out. Read full story Source: The Guardian, 3 May 2022 -
News Article
‘Lives at risk’ in Britain’s crumbling hospitals
Patient Safety Learning posted a news article in News
Patients’ lives are at risk because NHS hospitals have been allowed to crumble into disrepair, with ceilings collapsing and power cuts disrupting surgery. The number of clinical incidents linked to the failure to repair old buildings and faulty equipment has tripled in the past five years, an investigation by The Times found. Hundreds of vital NHS operations and appointments are being cancelled as a result of outdated infrastructure, undermining attempts by doctors to tackle record waiting lists. Recent incidents include an unconscious patient on a ventilator being trapped in a broken lift for 35 minutes and power running out as a patient lay in an operating theatre. On Saturday, April 23, a five-hour power cut at the Royal London Hospital in east London led to the cancellation of operations including two lifesaving kidney transplants, and meant women giving birth had to be transferred to different maternity units in the backs of taxis. Hospitals have also recorded hundreds of rat and pest infestations, and some rooms containing patients have been left “overflowing with raw sewage”. Read full story (paywalled) Source: The Times, 2 May 2022 -
News Article
Maternity scandal families slam NHS over no confidence vote ‘silence’
Patient Safety Learning posted a news article in News
Families impacted by the Nottingham maternity scandal say they have been left in “limbo” following silence from NHS England in response to their concerns over a major review, as 50 more come forward. The review into failures in maternity services at Nottingham University Hospitals Foundation Trust has now had 512 families come forward with concerns, up from 460 last month, and has spoken to 71 members of staff. The update comes as families told The Independent they were yet to receive a direct acknowledgement or response to their warning on Monday that they had no confidence in newly appointed review chairwoman Julie Dent. In response to a letter outlining her appointment, the families asked for Ms Dent to decline the offer and instead pushed for NHS England to ask Donna Ockenden, who is chairing a similar inquiry into Shrewsbury maternity care. Former health secretary and health committee chairman, Jeremy Hunt, has now also challenged the NHS on Ms Dent’s appointment, and echoed the families’ call to ask Ms Ockenden. Read full story Source: The Independent, 29 April 2022 -
News Article
Fear over high rates of diabetes foot amputations
Patient Safety Learning posted a news article in News
Major differences in the rate of foot amputations for people with diabetes in England are incredibly concerning, patient groups say. Such amputations are a sign patients have not received adequate care, as poorly controlled diabetes increases the risk of foot ulcers and infections. One in 10 areas had "significantly higher rates", government data shows. There was nearly a five-fold difference between the best and worst when taking into account risk factors such as age. The government data - published by the Office for Health Improvement and Disparities - looked at the three years leading up to the pandemic. It is believed up to 80% of foot amputations could be avoided with better care. Diabetes UK said the figures "shined a light on the scale of the crisis facing diabetes care" and it warned access to support was likely to have become worse during the pandemic. A report produced by the charity earlier this month said lives would be needlessly lost because of disruption to services over the past two years. Diabetes UK chief executive Chris Askew said the latest figures were "incredibly concerning". "The majority of these major amputations are preventable, but many people living with diabetes are struggling to access the care they need - and in areas of higher deprivation, people are experiencing worse outcomes. These inequalities must be addressed." Read full story Source: BBC News, 27 April 2022 -
News Article
NHS orders new chair of review into baby deaths
Patient Safety Learning posted a news article in News
The NHS has ordered a new chair for the Nottingham maternity scandal review which is looking into hundreds of cases of alleged poor care. In a letter published late on Friday the NHS said there needed to be “urgent” changes to the way the review was being carried out and this included appointing a former NHS trust chair Julie Dent to lead the review. More than 100 bereaved families wrote to the health secretary Sajid Javid on 7 April calling for the review, to be overhauled and the chair Cathy Purt, to be replaced by Donna Ockenden who chaired the Shrewsbury maternity scandal inquiry. The Nottingham review, dubbed an “independent thematic review”, was launched in July 2021 and is being led by local NHS commissioners and NHS England. It was announced after The Independent and Channel 4 revealed millions had been paid out by the trust over 30 baby deaths and 46 incidents of babies left permanently brain damaged by Nottingham University Hospitals Foundation Trust. Sir David Sloman, the NHS chief operating officer, said in his letter on Friday: “Following discussions at both a regional and national level, it is clear that urgent changes to how the review is being delivered need to be made. A new chair needs to lead this review with sufficient senior experience to address the concerns and challenges faced at Nottingham University Hospitals, to speed up the process and to deliver a review that can bring about real change for women and babies in Nottingham. “It has therefore been agreed that the review will now have enhanced national oversight by NHS England and NHS Improvement and I am pleased to announce that Julie Dent CBE has agreed to take on the role of chair for this review and she will begin this work with immediate effect.” Read full story Source: The Independent, 23 April 2022 -
News Article
Mums-to-be still being given unsafe epilepsy drug
Patient Safety Learning posted a news article in News
The moment her newborn son Sebastian was handed to her, Catherine McNamara knew something was terribly wrong. His tiny hands were deformed, unnaturally twisted and facing in the wrong direction. One was missing a thumb. A few days later, the couple were devastated as doctors told them Sebastian’s deformities were permanent — and had been caused by the drug McNamara had been taking to control her epilepsy. Like thousands of women, McNamara had been told her epilepsy medicine, sodium valproate, was safe to take during pregnancy. “They told me everything would be fine,” she said. Sodium valproate, which was given to women with epilepsy for decades without proper warnings, has caused autism, learning difficulties and physical deformities in up to 20,000 babies in Britain. Yet despite a 2020 report that criticised the failure over four decades to inform women about the dangers, doctors are still not properly warning women of the risks. According to the latest data, published in March, sodium valproate was prescribed to 247 pregnant women between April 2018 and September 2021. An investigation by The Sunday Times has found that the drug is still being handed out to women in plain packets with the information leaflets missing, or with stickers over the warnings. The government is refusing to offer any compensation to those affected by sodium valproate, despite an independent review by Baroness Cumberlege concluding in 2020 that families should be given financial redress. The former health secretary Jeremy Hunt says doctors should now be banned from prescribing the drug to pregnant women — and that the families affected by it must be properly compensated. He has compared the case to the scandal of the anti-morning-sickness drug thalidomide, which caused deformities in thousands of babies after it was licensed in the UK in the 1950s. Read full story (paywalled) Source: The Sunday Times, 16 April 2022 -
News Article
A&E patients waiting more than two days for a bed, warns leaked letter
Patient Safety Learning posted a news article in News
A clinical director and several senior managers have written to a trust CEO warning that patients are routinely waiting more than 60 hours to be admitted to a ward from accident and emergency, leaving staff “crying with frustration and anger”. In a letter to executives at Lancashire Teaching Hospitals Foundation Trust, seen by HSJ, the managers say they lack support from the rest of the trust, and claim the emergency department at Royal Preston Hospital has a “never-ending elasticity in the eyes of others”. The letter, dated 30 March, is signed by clinical director Graham Ellis, two unit managers, the specialty business manager, and the matron. It says: “Whilst we have documented our concerns previously the current situation is worse than it has ever been…Our situation is increasingly precarious… “For the past few months we have on a regular basis had more than 50 patients waiting for a bed and that wait being in excess of 60 hours. “This means that at most times there is limited or no space to accommodate newly acutely ill patients causing ambulance handover delays of over four hours and delay in treatment.” Clinicians at Preston have been raising safety concerns about the ED for several years, but the letter is the first time concerns of senior managers have been made public. The letter references research which suggests patients die as a “direct result from long waits in ED”, and says there has been an increase in clinical incidents, pressure sores, detrimental outcomes, and occasions where patients “die without the dignity of privacy”. Read full story (paywalled) Source: HSJ, 4 April 2022 -
News ArticlePatients continue to experience avoidable harms from unsafe care because the NHS fails to learn from its mistakes, a report that tracked what actions the NHS took following safety reviews over several decades has found. Patient Safety Learning looked at the findings of a variety of investigations, including widespread public inquiries, Healthcare Safety Investigation Branch (HSIB) reports, Prevention of Future Deaths reports, incident reports, and complaints and legal action by patients and their families. It found an “implementation gap” in learning lessons and taking action to prevent future harms. It highlighted an absence of a systemic and joined up approach to safety; poor systems for sharing learning and acting on that learning; lack of system oversight, monitoring, and evaluation; and unclear patient safety leadership. Helen Hughes, chief executive of Patient Safety Learning, said, “Time and time again there is a lack of action and coordination in responding to recommendations, an absence of systems to share learning, and a lack of commitment to evaluate and monitor the effectiveness of safety recommendations. “This is a shocking conclusion that is an affront to all those patients and families who have been assured that ‘lessons have been learnt’ and ‘action will be taken to prevent future avoidable harm to others.’ The healthcare system needs to understand and tackle the barriers for implementing recommendations, not just continually repeat them.” The report calls for “systemwide commitment and resources, with effective and transparent performance monitoring” for patient safety inquiries and reviews and HSIB reports to ensure that the accepted recommendations translate into action and improvement. Read full story Source: BMJ, 8 April 2022
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News Article
Nurse suspended after forcing medication into patient’s mouth
Patient Safety Learning posted a news article in News
A nurse has been suspended for three months by the Nursing and Midwifery Council (NMC) after forcing medication into a person with dementia's mouth. An NMC Fitness to Practise (FtP) panel found Reni Kirilova had forced medicine into the patient’s mouth, held her mouth closed and shouted ‘take your tablets’ while working at the Chocolate Quarter Care Home in Bristol, run by the St Monica Trust. Patient was reportedly distressed, waving her hands and shouting The incident occurred on 30 May 2019, seven days after Ms Kirilova began working at the care home on 23 May. She was suspended on 7 June pending a police investigation and she resigned the same day. One witness told the NMC hearing that they saw the nurse’s fingers go over the patient’s mouth for around 30 seconds while the patient was ‘flapping her hands’ and ‘trying to spit them out’. They added the patient was distressed and was ‘waving her hands everywhere’ and shouting ‘no, no, no’. Ms Kirilova denied the allegations and said that she had given the patient some water and then tilted the patient’s chin to help her swallow. The panel found that the allegation she held her hand over the patient’s mouth was not true but that she had held it closed in some way, after three witnesses corroborated this. The panel said they were not satisfied that she had considered how she would cope with stressful situations in the future and there was a risk it could happen again. Read full story Source: Nursing Standard, 7 April 2022 -
News Article
Patients continue to die and be harmed by the failure to learn from unsafe care
Patient Safety Learning posted a news article in News
Press release: 7 April 2022 Today the charity Patient Safety Learning has published a new report, ‘Mind the implementation gap: The persistence of avoidable harm in the NHS'. The report is an evidence-based summary of the failures over decades to translate learning into action and safety improvement. It highlights that avoidable unsafe care kills and harms thousands of people each year in the UK and costs the NHS billions of pounds for additional treatment, support, and compensatory costs. The report highlights how we fail to learn lessons from incidents of unsafe care and are not taking the action needed to prevent harm recurring. The report focuses on six sources of patient safety insights and recommendations, ranging from inquiry reports into patient safety scandals, such as the recent Ockenden report into maternal and neonatal harm at Shrewsbury and Telford Hospital, to the findings of Coroner’s Prevention of Future Deaths reports. It calls on the Government, parliamentarians, and NHS leaders to take action to address the underlying causes of avoidable harm in healthcare and proposes recommendations in each policy area. Patient Safety Learning is calling for system-wide action in healthcare to transform our approach to learning and safety improvement. Helen Hughes, Chief Executive of Patient Safety Learning, said: “Today’s report highlights the all too frequent examples of where healthcare organisations fail to learn lessons from incidents of unsafe care and not taking the action needed to prevent future harm. Time and time again there is a lack of action and coordination in responding to recommendations, an absence of systems to share learning and a lack of commitment to evaluate and monitor the effectiveness of safety recommendations.” “This is a shocking conclusion that is an affront to all those patients and families who have been assured that ‘lessons have been learned’ and ‘action will be taken to prevent future avoidable harm to others’. The healthcare system needs to understand and address the barriers for implementing recommendations, not just continually repeat them. Hope is not a strategy.” This report has been published as part of the Safety for All Campaign, which calls for improvements in, and between, patient and healthcare worker safety to prevent safety incidents and deliver better outcomes for all. The campaign is supported by Patient Safety Learning and the Safer Healthcare and Biosafety Network. Notes to editors: Patient Safety Learning is a charity and independent voice for improving patient safety. We harness the knowledge, insights, enthusiasm and commitment of health and social care organisations, professionals and patients for system-wide change and the reduction of avoidable harm. Safer Healthcare and Biosafety Network an independent forum focused on improving healthcare worker and patient safety and has been in existence more than 20 years. It is made up of clinicians, professional associations, trades unions and employers, manufacturers and government agencies with the shared objective to improve occupational health and safety and patient safety in healthcare. COVID-19 pandemic has provided a stark reminder of the vital role healthcare professionals play in providing care to those in our society who need it most and this was recognized in the WHO Patient Safety Day in September 2020: only when healthcare workers are safe can patients be safe. In 2020, the Network launched a campaign called ‘Safety for All’ to improve practice in, and between, patient and healthcare worker safety to prevent safety incidents and deliver better outcomes for all. -
News Article
Lincolnshire Trust fined after patient suffered serious avoidable harm
Patient Safety Learning posted a news article in News
United Lincolnshire Hospitals NHS Trust has been ordered to pay a total of £111,204 in fines and legal costs after pleading guilty to failing to provide safe care and treatment to an elderly patient, causing them avoidable harm, following a sentencing hearing on Friday, 25 March at Boston Magistrates’ Court. The case was taken by the Care Quality Commission (CQC) under regulations 12 and 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The case against United Lincolnshire Hospitals NHS Trust involved the care of an elderly patient, Iris Longmate, who was admitted to the Greetwell Ward at Lincoln County Hospital on 20 February 2019. On March 3, 2019 Iris fainted and fell unsupervised from a commode, and was found face down on the floor in her room. Iris sustained spinal injuries and a cut to the head as a result of the fall, but then also suffered significant burns to her thigh and left arm as a result of being pressed against a radiator whilst being assessed by staff following the fall. Iris was subsequently transferred to Queens Medical Centre for assessment and treatment. She sadly contracted pneumonia in hospital and died on March 14, 2019. United Lincolnshire Hospitals NHS Trust pleaded guilty to a single offence of failure to provide safe care and treatment causing avoidable harm to Iris, for which the trust was fined £100,000. The court also ordered the trust to pay £170 victim surcharge and £11,034 costs to the CQC. The trust was found to not have taken all reasonable steps to ensure that safe care and treatment was provided, resulting in avoidable harm to Iris. In pleading guilty to the offence of causing avoidable harm to Iris, the trust also acknowledged that other patients on the Greetwell Ward had also been exposed to a significant risk of avoidable harm. Fiona Allinson, CQC’s deputy chief inspector of hospitals, said: "This death is a tragedy. My thoughts are with the family and others grieving for their loss." "People have the right to safe care and treatment, so it’s unacceptable that patient safety was not well managed by United Lincolnshire Hospitals NHS Trust," she said. "Had the trust addressed the issues with the exposed heating pipes before Iris fell, she wouldn’t have suffered such awful burns injuries." Read full story Source: Medscape, 2 April 2022 -
News ArticleHospital inspectors have uncovered repeated maternity failings and expressed serious concern about the safety of mothers and babies in Sheffield just days after a damning report warned there had been hundreds of avoidable baby deaths in Shrewsbury. The Care Quality Commission (CQC) found Sheffield teaching hospitals NHS foundation trust, one of the largest NHS trusts in England, had failed to make the required improvements to services when it visited in October and November, despite receiving previous warnings from the watchdog. As well as concerns across the wider trust, a focused inspection on maternity raised significant issues about the way its service is run. When it came to medical staff at the Sheffield trust, the “service did not have enough medical staff with the right qualifications, skills, and experience to keep women and babies safe from avoidable harm and to provide the right care and treatment”, the report said. Inspectors found that staff were not interpreting, classifying or escalating measures of a baby’s heart rate properly, an issue that was raised by Donna Ockenden in her review of the Shrewsbury scandal. Despite fetal monitoring being highlighted as an area needing attention in 2015 and 2021, the most recent inspection “highlighted that the service continued to lack urgency and pace in implementing actions and recommendations to mitigate these risks, therefore exposing patients to risk of harm”. Read full story Source: The Guardian, 5 April 2022
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Shrewsbury maternity scandal: Sajid Javid’s statement to the Commons
Patient Safety Learning posted a news article in News
Sajid Javid has issued an apology for the maternity service failings reported at Shrewsbury and Telford Hospital NHS Trust. The health secretary spoke in the Commons on Wednesday after an independent inquiry into the UK’s biggest maternity scandal found that 201 babies and nine mothers could have - or would have - survived if the NHS trust had provided better care. Speaking in the Commons, the health secretary said Donna Ockenden - a maternity expert who led the report - told him about “basic oversights” at “every level of patient care” at the trust. He said the report “has given a voice at last to those families who were ignored and so grievously wronged”. Javid said the report painted a tragic and harrowing picture of repeated failures in care over two decades which led to unimaginable trauma for so many people. Rather than moments of joy and happiness for these families their experience of maternity care was one of tragedy and distress and the effects of these failures were felt across families, communities and generations. The cases in this report are stark and deeply upsetting. Mr Javid offered reassurances that the individuals who are responsible for the “serious and repeated failures” will be held to account. Read full story and Sajid Javid's statement Source: The Independent, 30 March 2022
