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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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News Article
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 -
News Article
The NHS’s multimillion-pound blunders laid bare in new report
Patient Safety Learning posted a news article in News
The reasons behind the most catastrophic blunders in emergency departments have been laid bare in a NHS Resolution report highlighting some of the biggest pay outs for NHS A&E errors. NHS Resolution conducted a deep dive into compensation claims concerning emergency departments in England, including 16 cases which saw more than £1 million handed out after life-changing or deadly errors. The average “high-value claim” was £2,069,029, with many of them related to spinal cord injuries which, left undetected, can have a life-long impact on patients. The report detailed the case of a woman who suffered permanent neurological damage and now has bladder, bowel and sexual dysfunction symptoms, as well as loss of mobility, after a spinal condition was misdiagnosed as sciatica. The report also looked at 86 deaths which resulted in average pay outs of more than £45,000. After reviewing 220 claims between 2014 and 2018, the authors highlighted a number of “common themes”, including: diagnostic errors, including missing signs a patient was deteriorating a failure to recognise the significance of repeat attendance at A&E delays in care problems with communication, including problems with different hospital departments talking to each other. Read full story Source: In Your Area News, 29 March 2022 -
News Article
Baby deaths inquiry: Shrewsbury NHS trust condemned for ‘repeated failures’
Patient Safety Learning posted a news article in News
A damning report into hundreds of baby deaths has condemned the trust at the centre of the biggest maternity scandal in the history of the NHS for blaming mothers while repeatedly ignoring its own catastrophic blunders for decades. The independent inquiry into maternity practices at Shrewsbury and Telford hospital NHS trust uncovered hundreds of cases in which health officials failed to undertake serious incident investigations, while deaths were dismissed or not investigated appropriately. Instead, grieving families were denied access to reviews of their care and mothers were blamed when their babies died or suffered horrific injuries. A combination of an obsession with natural births over caesarean sections coupled with a shocking lack of staff, training and oversight of maternity wards resulted in a toxic culture in which mothers and babies died needlessly for 20 years while “repeated failures” were ignored again and again. Tragically, it meant some babies were stillborn, dying shortly after birth or being left severely brain damaged, while others suffered horrendous skull fractures or avoidable broken bones. Some babies developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries. The report, led by the maternity expert Donna Ockenden, examined cases involving 1,486 families between 2000 and 2019, and reviewed 1,592 clinical incidents. “Throughout our final report we have highlighted how failures in care were repeated from one incident to the next,” she said. “For example, ineffective monitoring of foetal growth and a culture of reluctance to perform caesarean sections resulted in many babies dying during birth or shortly after their birth. “In many cases, mother and babies were left with lifelong conditions as a result of their care and treatment. The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the trust and a culture of not listening to the families involved. “There was a tendency of the trust to blame mothers for their poor outcomes, in some cases even for their own deaths. What is astounding is that for more than two decades these issues have not been challenged internally and the trust was not held to account by external bodies. “This highlights that systemic change is needed locally, and nationally, to ensure that care provided to families is always professional and compassionate, and that teams from ward to board are aware of and accountable for the values and standards that they should be upholding. Going forward, there can be no excuses.” Read full story Source: The Guardian, 30 March 2022 -
News Article
Three hundred babies lost to a fixation on natural births
Patient Safety Learning posted a news article in News
When Debbie Greenaway was told by doctors that she should try to deliver her twin babies naturally, she was nervous. But the doctor was adamant, she recalls. “He said: ‘We’ve got the lowest caesarean rates in the country and we are proud of it and we plan to keep it that way'." For Greenaway, labour was seemingly endless. She was given repeated doses of syntocinon, a drug used to bring on contractions. By the second day, the midwife was worried for one of the babies, whom the couple had named John. “She was getting really concerned that they couldn’t find John’s heartbeat.” Her husband remembers “the midwife shaking her head”. “She said a number of times that we should be having a caesarean.” By the time doctors finally decided to perform an emergency C-section, it was too late. Starved of oxygen, baby John had suffered a catastrophic brain injury. When he was delivered at 3am, he had no pulse. Efforts to resuscitate him failed. Their son’s death was part of what is now recognised as the largest maternity scandal in NHS history. The five-year investigation will reveal that the experiences of 1,500 families at Shrewsbury and Telford Hospital Trust between 2000 and 2019 were examined. At least 12 mothers died while giving birth, and some families lost more than one child in separate incidents, the report is expected to show. The expert midwife Donna Ockenden and a team of more than 90 midwives and doctors will deliver a damning verdict on the Shrewsbury trust, its culture and leadership — and failure to learn from mistakes or listen to families. At its heart is how a toxic obsession with “normal birth” — fuelled by targets and pressure from the NHS to reduce caesarean rates — became so pervasive that life-or-death decisions on the maternity ward became dangerously distorted for nearly two decades. Read full story (paywalled) Source: The Times, 26 March 2022 -
News Article
Acute trust to be prosecuted by CQC
Patient Safety Learning posted a news article in News
The Care Quality Commission is to prosecute an acute trust after a patient was injured when allegedly exposed to “avoidable harm”. United Lincolnshire Hospitals Trust is due to appear tomorrow afternoon at Boston Magistrates’ Court. The alleged incident took place at Lincoln County Hospital, the CQC said. Although the CQC declined to comment further, Lincolnshire Live reported the alleged incident involved 91-year-old Iris Longmate and relates to a failure to provide safe care and treatment on or before 3 March 2019. The local publication added court papers claimed “at the same time ULHT also failed to give safe care and treatment to patients on Greetwell Ward, who were ‘being exposed to a significant risk of avoidable harm occurring’”. Proceedings are being brought under sections 22 and 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These rules require providers to take reasonable steps to minimise risks to people’s health and safety during treatment, and make it a criminal offence if a provider fails to comply and a patient suffers avoidable harm or is exposed to a risk of this happening. Read full story (paywalled) Source: HSJ, 24 March 2022 -
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'My husband cried on the phone, begging for help'
Patient Safety Learning posted a news article in News
A man who experiences regular mental health crises says an NHS scheme designed to offer support during emergency episodes has become broken. The trust running the service says a crisis team offers immediate support in an emergency, and a 24-hour helpline. But when Mark Doody, who has bipolar disorder, cried "down the phone, begging the team for help", he was told to call an ambulance, his wife said. The trust said a 999 call could sometimes be the appropriate action. Trish Doody cited a "dreadful" deterioration in mental healthcare where the couple lived in Redditch, Worcestershire. She said while her husband was able to get support if an emergency happened "between 9am and 5pm", assistance became difficult outside of those hours. Mr Doody said his condition meant he experienced a mental health crisis every three months. He has also made suicide attempts. Mental healthcare provision in the county had gone downhill over the last 20 years, Mrs Doody said, with her husband adding: "The system is just broken really." Healthwatch Worcestershire, which helps hold the NHS to account locally, said it was "exploring" whether there was a problem with the crisis helpline, and was also aware of delays for those seeking one-to-one counselling, which it said the trust was tackling. Read full story Source: BBC News, 22 March 2022 -
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Nurse who mistreated patient with dementia asks to be removed from register
Patient Safety Learning posted a news article in News
A nurse who admitted she was unfit to practise after dragging a patient with dementia to her room and forcefully attempting to administer a sedative has been suspended for a year by the nursing regulator. Carol Picton was working in the stroke unit at the Western General Hospital in Edinburgh in November 2017 when colleagues raised concerns about her treatment of a vulnerable older woman. Witnesses who gave evidence to an NMC fitness to practice (FtP) panel said they heard the patient screaming in distress after being roughly dragged by her arm back to her room by Ms Picton. The nurse then attempted to forcefully administer the anti-psychotic drug Haloperidol without checking the correct dosage, the hearing was told. She tried to give the drug orally using a 2ml injection syringe rather than an oral syringe. Ms Picton denied forceful mistreatment and panel found no evidence she had shown insight into her misconduct When the patient spat out the drug Ms Picton gave her more without knowing how much she had ingested, risking an overdose, the panel heard. Ms Picton, who was referred to the NMC by her employer following an internal investigation, was also said to have tilted the patient’s bed to prevent her getting out and leaving her room. The panel, which found five charges proven, concluded that Ms Picton’s actions were ‘deplorable’ and amounted to harassment and abuse. Read full story Source: Nursing Standard, 21 March 2022 -
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‘Cinderella’ postnatal care leaves women ‘forgotten’ after birth
Patient Safety Learning posted a news article in News
Women and NHS staff have warned that mothers are being “forgotten” after giving birth, with a staff crisis only making matters worse. Kate, a 32-year-old from Leeds, says she has been left in “excruciating” pain for nine years after horrifying postnatal care. Other women have told The Independent stories of care ranging from “disjointed” to “disastrous”. It comes as midwives warn there are “horrendous” shortages in community services, which have prevented women from accessing adequate antenatal and postnatal care. Mary Ross-Davie, the Royal College of Midwives’ director for professional midwifery, said that with each Covid wave midwifery staffing has been hit worse than the last. To provide safe care during labour, antenatal and postnatal care, teams are sent into wards putting “huge pressure on care”. She said this could mean clinicians end up “missing things”, such as women struggling emotionally after birth. The warnings over poor antenatal and postnatal care come after experts at the University of Oxford said in November there were “stark” gaps in postnatal care, despite the highest number of deaths being recorded in the postnatal period. Dr Sunita Sharma, lead consultant for postnatal care at Chelsea and Westminster Trust, said that when NHS maternity inpatient staffing overall is in crisis “often the first place staff are moved from is the postnatal ward, which is clinically very appropriate, but it can come at a cost of putting more pressure on postnatal care for other mothers”. Dr Sharma said postnatal teams were doing their best to improve services but need national drivers and funding to sustain improvement. Read full story Source: The Independent, 16 March 2022
