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News Article
'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 -
News Article
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 -
News Article
‘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 -
News Article
Pregnant women should be asked how much they drink
Patient Safety Learning posted a news article in News
Pregnant women should be asked how much alcohol they are drinking and the answer recorded in their medical notes, new "priority advice" for the NHS says. The advice, from the National Institute for Health and Care Excellence (NICE), is designed to help spot problem drinking that can harm babies. Infants with foetal alcohol spectrum disorder (FASD) can be left with lifelong problems. The safest approach during pregnancy is to abstain from alcohol completely. The more someone drinks while pregnant, the higher the chance of FASD - and there is no proven "safe" level of alcohol. But the risk of harming the baby is "likely to be low if you have drunk only small amounts of alcohol before you knew you were pregnant or during pregnancy", the Department of Health says. An earlier draft of the recommendations for NHS staff in England and Wales suggested transferring data on a woman's alcohol intake to her child's medical notes - but this has now been dropped, following concern women who needed help might hide their drinking. The Royal College of Midwives spokeswoman Lia Brigante said: "As there is no known safe level of alcohol consumption during pregnancy, the RCM believes it is appropriate and important to advise women that the safest approach is to avoid drinking alcohol during pregnancy and advocates for this. "We are pleased to see that the recommendation to record alcohol consumption and to then transfer this to a child's record has been reconsidered. "This had the potential to disrupt or prevent the development of a trusting relationship between a woman and her midwife." Read full story Source: BBC News, 16 March 2022 -
News Article
Private hospital rated ‘inadequate’ again amid safety concerns
Patient Safety Learning posted a news article in News
A privately run mental health hospital put in special measures last year has been rated “inadequate” again following a fresh Care Quality Commission inspection. Inspectors raised serious concerns about unsafe ward environments and staff not managing patient risks at the Priory Hospital Arnold, which has beds commissioned by Nottinghamshire Healthcare Foundation Trust. Inspectors said that while the leadership team was experienced, the registered manager had been in post since April last year and the improvements they had made “had not been fully embedded”. The registered manager had changed after the service was placed in special measures. Ligature risks were found in patients’ bathrooms despite the provider making “some progress” and undertaking “substantial work” to remove them, the CQC said. And in one instance, a patient had tried to harm themselves with a plastic bag which was a restricted item on the ward. CQC head of hospital inspection for mental health and community services Craig Howarth said staff “had not followed the patient’s risk assessment” and had not searched the patient on their return from a visit off the ward. He added: “It was also concerning that despite rotas showing enough staff were available across the hospital, staff gave examples of when a lack of staffing had impacted on patient care and safety. “Despite the measures in place, the risks to patients were not reduced and there was evidence of incidents of harm to patients.” Read full story (paywalled) Source: HSJ, 15 March 2022 -
News ArticleSerious safety concerns have been raised about a children’s mental health hospital where staff lacked respect for patients, as the provider faces a police investigation into another one of its units. The Huntercombe Hospital in Stafford has been rated as “inadequate” by watchdog the Care Quality Commission (CQC) after inspectors found the safety of children within the hospital was at risk. The concerns about this hospital come as The Independent revealed police have launched an investigation into another mental health unit run by the provider in Maidenhead. Following an inspection in October inspectors sent an urgent warning notice to the provider, after it found there were not enough staff to keep patients safe. The hospital was described as relaying on agency workers who did not have knowledge of the patients. The CQC inspectors found children’s wards were dirty with poor hygiene measures in the hospital and patients at risk of infection. According to the report staff were found “sitting with their eyes closed for prolonged periods of time”, and that staff observations of at risk patients were “undermined by a blind spot where people could self-harm unseen.” Craig Howarth, CQC head of inspection for mental health and community health services, said: “Further to these issues, we saw that staff sometimes showed a lack of respect to patients and one ward was poorly furnished and maintained and there wasn’t always enough emphasis on some people’s individual requirements.” Read full story Source: The Independent, 11 March 2022
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News Article
A women left in ‘hell’ for nine years after poor postnatal care
Patient Safety Learning posted a news article in News
It has been nine years living “like a prisoner” in “excruciating” pain and Kate is still facing a wait for surgery to tackle the horrifying mistakes in her postnatal care. Despite a difficult birth at Leeds General Hospital, Kate described the atmosphere at the trust’s labour ward as “lovely”. However, her experience quickly deteriorated into “hell” after she was told she had third-degree tears and was admitted to a postnatal ward, describing the care she received as “awful”. A few days following her discharge, which occurred before she’d had a bowel movement, Kate said she was left “screaming in pain” at home, “bleeding a lot from the back passage” and “incontinent”. Despite reporting these symptoms to the maternity department, Kate was told it was a “normal” experience. “I felt like nobody was listening to me,” Kate said. After six months, living in “intense pain”, with “flooding diarrhoea” and not able to leave the house, she was told by the NHS her symptoms were down to postnatal depression. She was referred to a colorectal surgeon, who found her anal sphincter was “fully open almost as if it wasn’t ever stitched”. Following an operation in 2015 to fix the issue, Kate developed sepsis, nearly losing her life and meaning it took 18 weeks for her wound to heal. However, her ordeal did not stop there. She had developed nerve damage, chronic pelvic pain, incontinence, coxalgia and a prolapse as a result of her problems being neglected for so long. By 2022, nine years later, she is now waiting for a colostomy bag operation – the only option to address her pain. Kate told The Independent: “Everywhere I go I have to plan the full day. I need to know where the toilets are. I don’t go out of the house. I’ve felt like a prisoner in my own home for nine years. “It makes me so emotional thinking about everything they have put me through. It hasn’t just affected my life, it’s also affected my partner and family. I have lost so much time that I’ll never get back. I couldn’t enjoy life and do the things that all mothers do with their babies. “There was no care, no sympathy, nothing. Nobody cared for me apart from my surgeon at Sheffield. I’ve forgotten what it feels like to feel normal. I can’t remember life without pain." Read full story Source: The Independent, 13 March 2022 -
News Article
Hospital patient sent 'whistleblower' letters
Patient Safety Learning posted a news article in News
A patient who spent months in hospital because of a medical error received anonymous letters alleging safety concerns at the unit that treated her. Marilyn Smith was diagnosed with tetanus after she was discharged following treatment for a leg injury at Hinchingbrooke Hospital in Huntingdon, Cambridgeshire. She said she was not asked about her tetanus immunisation status and was discharged from Hinchingbrooke without a booster shot. A few days later she woke up with trismus, commonly known as lockjaw, and was unable to open her mouth - a symptom of tetanus, which only a handful of people contract in the UK each year. She subsequently spent more than 120 days in hospital in Hinchingbrooke, and then Peterborough, when her condition worsened and she was moved to critical care, placed in an induced coma and needed intubation. She said she now struggled to walk. She received the first anonymous letter, claiming to be from "a group of current and previous A&E staff at Hinchingbrooke", in the post in January after she had been home from hospital for two weeks. "I wasn't a letter to me, but a letter about me," Ms Smith said. It described alleged shortcomings in her care. Two subsequent letters made similar claims and on the same day the third arrived at her house, on 24 February, the BBC also received one giving Ms Smith's name and address and describing the alleged failures in her initial care. This letter stated "the trust has been ignoring concerns about patient safety" and contained further allegations that related to an individual. She has since instructed a lawyer to look at her case because, she said, she did not want anybody else to suffer like she had. Read full story Source: BBC News, 8 March 2022 -
News ArticleVulnerable people released from immigration detention in the UK are too often left without crucial continuity of care, leading to quickly deteriorating health, concludes a report. The report comes from Medical Justice, a charity that sends independent volunteer clinicians into immigration removal centres across the UK to offer medical advice and assessments to immigration detainees. The charity said that between 1 October 2020 and 30 September 2021 a total of 21 362 people were detained in UK immigration centres and 17 283 were released into the community, having been granted bail or leave to enter the UK or remain. Of these, 2239 were considered to be “adults at risk.” One woman whose delay in treatment “could potentially have life or limb threatening consequences”, struggled to re-arrange an orthopaedic oncology appointment that she missed because she had been detained. One released Medical Justice client described how he ended up a number of times in Accident & Emergency, having been unable to secure a recommended cardiology appointment. The report found that release from detention is often unplanned, chaotic and medically unsafe. Medical Justice sees repeated cases of vulnerable people released into the community without adequate care plans, with little or no information and support about entitlement and how to access a GP, and rarely with referrals to community support services such as local mental health teams. This has included people who had very recently attempted suicide in detention. Read full story Source: BMJ, 4 March 2022
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News Article
Ukraine’s hospitals ‘desperate’ for medical supplies as oxygen runs out
Patient Safety Learning posted a news article in News
Hospitals across Ukraine are “desperate” for medical supplies, doctors have warned, as oxygen stores are hit and other vital health supplies run low amid bombardment from Russian forces. UK-based Ukrainian doctors have issued an urgent appeal for donations of supplies as they travel to eastern Europe in response to reports of shortages of medical equipment and medicines. The World Health Organisation warned on Sunday evening that oxygen supplies in Ukraine were “dangerously low” as trucks were unable to transport oxygen supplies from plants to hospitals across the country. Dr Volodymyr Suskyi, an intensive care doctor at Feofaniya Clinical Hospital in Kyiv, told The Independent he had been forced to use an emergency back-up system to supply oxygen to a patient on life support after the area near plant which supplies his hospital was bombed. Dr Dennis Olugun, a UK-based doctor who is leading the group of medics from the Ukrainian Medical Association of the United Kingdom (UMAUK) to deliver medical supplies, said the situation was “desperate” in some areas. He said some hospitals did not have basic necessities such as rubber gloves. He told The Independent: “What they need in the hospitals is portable ultrasound machines, portable x-ray machines because they have so many patients they much rather walk around the wards and do whatever diagnostic work rather than transporting patients." The Association of the British Pharmaceutical Industry and European Federation of Pharmaceutical Industries and Associations have called for medicines, pharmaceutical ingredients and raw materials to be excluded from the scope of sanctions being levied against Russian trade. Read full story Source: The Independent, 1 March 2022 -
News Article
Patients will be endangered by flaws in health bill, says NHS ombudsman
Patient Safety Learning posted a news article in News
Patient safety will be harmed and victims of medical negligence denied justice because of flaws in the government’s health and care bill, the NHS ombudsman has told the Guardian. Rob Behrens, the parliamentary and health service ombudsman, fears he and his staff will not be able to get to the bottom of clinical blunders because under the bill he will be denied potentially vital information collected by the NHS’s Healthcare Safety Investigation Branch (HSIB). The ombudsman said the legislation would allow the HSIB to “operate behind a curtain of secrecy” and undermine his own investigations into lapses in patient safety and could deny grieving families the full truth about why a loved one died. Behrens has spoken out because he is concerned about government plans for NHS staff involved in an incident to give evidence about mistakes privately in a “safe space” to the HSIB, which cannot be shared with anyone else except coroners. His exclusion from seeing material gathered in that way could force him to take the agency to the high court to access it, he said. “If the ‘safe space’ provisions become law as drafted there is a real risk to patient safety and to justice for those who deserve it. This is a crisis of accountability and scrutiny,” he said. Julia Neuberger, a crossbench peer who chairs University College hospitals NHS trust, has tabled an amendment to the bill in the House of Lords seeking to give the ombudsman access to information obtained via “safe space” processes. Unless ministers rethink the plan “there could be serious consequences for members of the public who use the ombudsman service”, she recently told a Lords debate. “If the ombudsman is unable to investigate robustly all aspects of complaints about the NHS, except with the permission of the high court, patients may find it harder to get access to justice. The NHS may well become less accountable for its system failings,” she said. Peter Walsh, chief executive of patient safety charity Action Against Medical Accidents, backed Behrens. “The so-called safe space is a red herring with serious unintended consequences. There is no evidence staff do not take part in investigations for fear of information being known. It is bullying employers and over-zealous regulators that staff fear. Denying people their right to have the ombudsman investigate properly does nothing to address that.” Read full story Source: The Guardian, 28 February 2022 -
News ArticleA London mum says she has been left in "agony" and only able to walk 10 minutes at a time after a transvaginal mesh implant perforated her organs. Anna Collyer, 53, had a transvaginal mesh fitted in 2015 at St. Helier hospital in Sutton. The mesh is a net-like implant and aims to give permanent support to the weakened organs and to repair damaged tissue. The mesh implants are designed to be permanent, but last April, Anna started to experience severe pain when the mesh cut into her organs leaving her "unable to live any sort of life anymore," she said. Even when doctors partially removed the mesh last June - her symptoms persisted. Anna, who lives in Morden, told MyLondon: "I could feel something sharp inside me. The pain relief tablets were not touching it. I was in agony. "It's got to the stage now where 10 minutes is all I can walk, because the pain is excruciating. I have pain in pelvis, groin, hips, back and shooting pains in legs. The level is horrendous. I have to lie down all the time. The vaginal mesh procedure was once common place in the UK, with more than 92,000 women receiving one between April 2007 and March 2015 in England alone. But the treatment was “paused” and The Independent Medicines and Medical Devices Safety Review was ordered by the then health secretary, Jeremy Hunt, in 2018 amid mounting safety concerns. Women told the review team of “excruciating chronic pain feeling like razors inside their body" and felt dismissed when reporting complications including “unacceptable labelling of so many symptoms as ‘normal’ and attributable to ‘women’s problems’”, the report says. The new review accuses medial professionals of displaying “an institutional and professional resistance” to changing practice. The report concluded that “those harmed are due not only an apology, but better care and support through specialist centres”. Read full story Source: MyLondon. 22 February 2022
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News Article
Mothers who helped uncover the biggest NHS maternity scandal
Patient Safety Learning posted a news article in News
Next month, a report will be published into one of the biggest scandals in the history of the NHS, the failures of maternity care at the Shrewsbury and Telford Hospital NHS Trust. The BBC's Michael Buchanan who helped uncover the problems examines why so many failures were allowed to happen for so long. Kayleigh Griffiths' baby, Pippa, died at 31 hours old. The cause of death, the couple were later told, was an infection - Group B Strep. The Shrewsbury and Telford Hospital NHS Trust told the family they would carry out an investigation. But after several weeks of silence, Kayleigh contacted the trust to be told it was an internal investigation and the couple's input wouldn't be required. Kayleigh, an NHS auditor at a different trust, feared the truth was being hidden from her. That's when she decided to send the email to Rhiannon Davies, whose baby, Kate, also died at the Shrewsbury and Telford Hospital NHS Trust As the bond between the mothers deepened, their conversations morphed into something else. Armed with little more than a gnawing suspicion, they started to scour the internet, coroner's records and death notices to see if any other families had received poor maternity care at the Shropshire trust. They collated 23 cases dating back to 2000 - including stillbirths, neonatal deaths, maternal deaths and babies born with brain injuries. Appalled by what they had found, they wrote to the then health secretary Jeremy Hunt in December 2016, asking him to order an investigation. He agreed and in May 2017, senior midwife Donna Ockenden was appointed to lead the review. One of the themes the inquiry has already noted, in an interim report published in December 2020, is that in many cases the trust failed to investigate after something went wrong, or simply carried out its own inquiry. Panorama has discovered the trust even developed its own investigation system, what they called a High Risk Case Review. It was outside any national framework that has been used to help learn lessons from incidents and doesn't appear to be a system that's used in any other NHS organisation. Another consequence of the unorthodox system was that fewer incidents were reported to NHS regulators, limiting the opportunity to learn lessons. One of the earliest cases on the original list of 23 compiled by the two couples was the death of Kathryn Leigh in 2000. Panorama has investigated the case and discovered that a theme identified almost two decades ago was to come up repeatedly in subsequent incidents. The publication of the final report by Donna Ockenden next month will be a watershed moment in the history of the NHS - the revelation of multiple instances of maternity failures in a rural corner of England. Pippa Griffiths and Kate Stanton-Davies lived fewer than 40 hours between them, but their legacy, in terms of improved maternity care, could last decades. Read full story Source: BBC News, 23 February 2022 Source: -
News ArticleThe government of Mexico City handed out nearly 200 000 “ivermectin based kits” last year to people who had tested positive for Covid-19, without telling them they were subjects in an experiment on the drug’s effectiveness. The results of that experiment were then written up by public officials in an article placed on popular US preprint server SocArXiv. It became one of site’s most viewed articles, claiming that ivermectin had reduced hospital admissions by 52-76%. But those officials have been under fire at home since SocArXiv withdrew the paper earlier this month, calling it “either very poor quality or else deliberately false and misleading.” Opposition deputies in Mexico City’s Congress demanded hearings and said they would bring legal action against the paper’s lead author, José Merino, head of the city’s Digital Agency for Public Innovation. Explaining the decision to withdraw the article—the first to be taken down by SocArXiv—the site’s steering committee wrote that it had responded “to a community groundswell beseeching us to act” in order “to prevent the paper from causing additional harm.” The committee wrote, “The paper is spreading misinformation, promoting an unproved medical treatment in the midst of a global pandemic. The paper is part of, and justification for, a government programme that unethically dispenses (or did dispense) unproven medication apparently without proper consent or appropriate ethical protections.” Read full story Source: BMJ, 22 February 2022
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News Article
Baby deaths force end to NHS targets for natural births
Patient Safety Learning posted a news article in News
The NHS has abandoned targets that encouraged hospitals to pursue “normal births”, over fears for the safety of mothers and babies. Maternity units were told in a letter to stop using caesarean section rates to assess their performance. It comes after repeated scandals in maternity units, blamed in part on a focus on pursuing natural births at the expense of safety. The letter from Jacqueline Dunkley-Bent, NHS England’s chief midwife, and Dr Matthew Jolly, the national clinical director for maternity, instructed “all maternity services to stop using total caesarean section rates as a means of performance management”. It added: “We are concerned by the potential for services to pursue targets that may be clinically inappropriate and unsafe in individual cases." A final report into the deaths of dozens of babies at the Shrewsbury and Telford Hospital NHS Trust will be published next month. It is expected to be highly critical. The midwife leading the inquiry, Donna Ockenden, has said women “felt pressured to have a normal birth” at the trust, adding: “There was a multi-professional, not midwife-led, focus on normal birth pretty much at any cost.” Hayley Coates, 29, lost her son Kaylan after staff at Nottingham University Hospitals NHS Trust ignored her pleas for a caesarean section in March 2018. A coroner ruled that neglect contributed to Kaylan’s death. He suffered a fractured skull when he was delivered with forceps and was starved of oxygen. Coates, a mother of three, said she welcomed the NHS England letter, adding: “I was just ignored when I asked multiple times for a caesarean section. I was told repeatedly: ‘You will have this baby naturally, you don’t want to go to theatre.’ If I had gone to theatre many hours before, my baby wouldn’t have died. They have a duty of care, and the mother’s wishes are supposed to be priority.” Read full story (paywalled) Source: The Times, 20 February 2022 -
News ArticleCampaigners found to have been harmed by medical products have written to the health secretary warning that government inaction is "causing pain and destroying lives" by ignoring review recommendations. Some 18 months ago, an independent review recommended financial help for people damaged by some products and drugs that had been prescribed by UK doctors. The government - which set up the Independent Medicines and Medical Devices Safety Review in the first place - has chosen to ignore several of its recommendations. Alleged victims of vaginal mesh, and the drugs valproate and Primodos, have written to Health Secretary Sajid Javid and Maria Caulfield to say they feel ignored. The letter states: "Our members gave evidence to the two-year-long review, sometimes travelling long distances, often with disabilities." "Families shared intimate details of their medical problems, their daily struggles, their difficulties parenting, sometimes even their sex lives. The panel, led by Baroness Cumberlege, was set up by the government to listen, assess and direct policy towards the best course of action. "What was the point of this exercise and the hard work of the panel, if their key recommendations are then ignored by the government?" In the letter, campaigners say: "The decision not to offer an agency for redress (Cumberlege recommendation 3) means that the review has lost its teeth." "Still, no one is facing consequences of medical failures other than the patients. At a time when the public is being asked to put its faith in vaccines, this is a bad look for the government." Kath Sansom, of the campaign group Sling the Mesh, said: "Women must dutifully accept their health has been irreversibly shattered by a medical product they were told was safe, some now needing a disabled blue badge, and they must put up and shut up." Read full story Source: Sky News, 17 February 2022 MeshPrimodosSodiumValproate_LettertoMariaCaulfield_170222.pdf
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News ArticleTonjanic Hill was overjoyed in 2017 when she learned she was 14 weeks pregnant. Despite a history of uterine fibroids, she never lost faith that she would someday have a child. But, just five weeks after confirming her pregnancy she seemed unable to stop urinating. She didn’t realize her amniotic fluid was leaking. Then came the excruciating pain. “I ended up going to the emergency room,” said Hill, now 35. “That’s where I had the most traumatic, horrible experience ever.” An ultrasound showed she had lost 90% of her amniotic fluid. Yet, over the angry protestations of her nurse, Hill said, the attending doctor insisted Hill be discharged and see her own OB-GYN the next day. The doctor brushed off her concerns, she said. The next morning, her OB-GYN’s office rushed her back to the hospital. But she lost her baby. Black women are less likely than women from other racial groups to carry a pregnancy to term — and in Harris County, where Houston is located, when they do, their infants are about twice as likely to die before their 1st birthday as those from other racial groups. Black fetal and infant deaths are part of a continuum of systemic failures that contribute to disproportionately high Black maternal mortality rates. “This is a public health crisis as it relates to Black moms and babies that is completely preventable,” said Barbie Robinson, who took over as executive director of Harris County Public Health in March 2021. “When you look at the breakdown demographically — who’s disproportionately impacted by the lack of access — we have a situation where we can expect these horrible outcomes.” Read full story Source: KFF Health News, 24 August 2023
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News Article
NHS failed to act on brain surgeon who harmed patients
Patient Safety Learning posted a news article in News
NHS Tayside has been criticised over its handling of disgraced brain surgeon Sam Eljamel in a new report. The internal due diligence review criticised health board management for putting the doctor under indirect supervision in June 2013 rather than suspending him. The surgeon harmed dozens of patients but was allowed to continue operating until he was suspended in late 2013. Some of his patients were left with life-changing injuries. He was employed as a surgeon by NHS Tayside for 18 years and later became the head of the neurosurgery department in Ninewells Hospital in Dundee. NHS Tayside has apologised to former patients of Prof Eljamel and committed to assisting in the Scottish government's independent commission for patient concerns. The health board claimed it became aware of concerns around the surgeon in June 2013, but an NHS whistleblower told the BBC the health board knew as early as 2009 that there were serious concerns. He is now working as a surgeon in Libya. Read full story Source: BBC News, 1 September 2023 -
News ArticleThe inquiry into how nurse Lucy Letby was able to murder seven babies will now have greater powers to compel witnesses to give evidence. In a significant move, ministers upgraded the independent inquiry after criticism from families of the victims that it did not go far enough. The inquiry, ordered after Letby was found guilty this month, was not initially given full statutory powers. Health Secretary Steve Barclay said he had listened to the families. He said he had decided a statutory inquiry led by a judge was the best way forward and "respects the wishes" of the families. Mr Barclay said the key advantage was the power of compulsion. "My priority is to ensure the families get the answers they deserve and people are held to account where they need to be," he added. He said an announcement about who would chair the inquiry would be made in the coming days - ministers have already said it will be a judge. Richard Scorer, a lawyer who is representing two of the families, welcomed the government's announcement. "It is essential that the chair has the powers to compel witnesses to give evidence under oath, and to force disclosure of documents. Without these powers, the inquiry would have been ineffectual and our clients would have been deprived of the answers they need and deserve," he said. Read full story Source: BBC News, 30 August 2023
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News ArticleMore than half of NHS staff believe bosses would ignore whistleblowers amid fresh concerns hospitals could be covering up potential scandals following the Lucy Letby case. New national figures seen by the The Independent reveal that in the majority of hospitals, most doctors and nurses do not believe their concerns would be acted upon if they were raised with senior managers. It comes after The Independent revealed that NHS bosses accused of ignoring complaints about Letby were the very same people later appointed to act on whistleblower concerns at the hospital where she murdered seven babies and tried to kill six more. Several doctors who worked alongside her during the killing spree say they attempted to raise the alarm with hospital managers – only to have their pleas ignored. They believe the lack of action by bosses resulted in more babies being killed, stating managers who failed to act were “grossly negligent” and “facilitated a mass murderer”. In nearly three-quarters of general hospitals – such as the Countess of Chester where Letby worked – fewer than half of staff believed their trust would act on a concern, according to results from the latest NHS staff survey. Read full story Source: The Independent, 27 August 2023
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News ArticleDetails of allegations against a surgeon who left dozens of patients in agony after undergoing mesh operations have been published. A tribunal will look at whether Tony Dixon failed to provide adequate clinical care to six patients at Southmead Hospital and the private Spire Hospital in Bristol. He had pioneered the use of artificial mesh to lift prolapsed bowels. The surgeon, who was dismissed in 2019, has always maintained the operations were done in good faith, and that any surgery could have complications. The Medical Practitioners Tribunal, which starts in Manchester on 11 September and is due to end on 23 November, will look into allegations that between 2010 and 2016 Mr Dixon failed to provide adequate clinical care in a number of areas, including: ensuring procedures for some of the patients were clinically indicated adequately advising some of the patients regarding options for treatment obtaining informed consent before performing clinical procedures adequately performing a procedure for one patient providing adequate post-operative care for some communicating appropriately with some of the patients and their family members. Read full story Source: BBC News, 24 August 2023
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News Article
Lucy Letby: NHS could face record compensation bill of more than £60m
Patient Safety Learning posted a news article in News
The NHS could face a record compensation bill of more than £60m from civil claims lodged by the families of Lucy Letby’s victims, experts have said. Parents whose babies have disabilities caused by Letby’s attacks at the Countess of Chester hospital could each expect to receive a payout of more than £10m to fund their future care. Compensation paid by the NHS to parents whose babies died or were left with disabilities as a result of care at Shrewsbury hospital in Britain’s largest maternity scandal reportedly amounted to almost £50m. In a separate case, the health service had to pay £37m to a boy who was left brain damaged at birth. Stephen Jones, the head of Leigh Day’s medical negligence team in Manchester, said the trust could argue that by committing the offences, Letby breached the employer-employee relationship to an extent such that it was not responsible for her. But he added: “I think there would be outrage that the trust wouldn’t accept responsibility for babies in their care.” He said compensation could run into eight figures for a family whose baby was severely injured and had a long life expectancy. Emma Wray, a partner in Hodge Jones & Allen’s medical negligence department, suggested the NHS could set up a scheme for victims, as it has done with other scandals, to make claiming compensation easier. Read full story Source: The Guardian, 23 August 2023 -
News ArticleAt least 20 patients have suffered harm due to their follow-up appointments not being booked at a hospital department where people ‘continue to come to harm’, according to an internal review. Torbay and South Devon Foundation Trust is reviewing its ophthalmology service after 22 people were harmed following “system failures” with their follow-up appointments. The trust’s initial investigation, obtained by HSJ with the Freedom of Information Act, warned there were “potentially” other patients affected by the failures who had not yet been identified. In response, the trust said its ophthalmology department had already “undertaken a significant amount of work to address a large proportion of the actions arising from the review”, including building another operating theatre and recruiting more staff. Read full story (paywalled) Source: HSJ, 21 August 2023
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News Article
Mesh bowel patients call for publication of Bristol Spire Hospital report
Patient Safety Learning posted a news article in News
Patients whose lives were damaged by surgery for bowel problems are calling for a long-awaited report to be published. More than 200 patients underwent mesh bowel operations in Bristol that they might not have needed. The surgery was carried out by Tony Dixon at Southmead Hospital and the private Spire Hospital, in Redland. A review by North Bristol NHS Trust was published in May 2022, but patients are still waiting to hear from Spire. Jill Smith, 69, from Westbury-on-Trym, paid privately to go to Spire. She said she is still in severe pain following her surgery. "Emotionally it has affected me big time. It is just horrible," she said. "The stress and panic I get going anywhere, is, 'will I have an accident or something?'." Read full story Source: BBC News, 18 August 2023 -
News Article
Staff ‘let down by leaders’ as ‘chaotic’ service gets double downgrade
Patient Safety Learning posted a news article in News
A teaching trust has had its maternity services downgraded to ‘inadequate’ after inspectors found stillbirths and massive haemorrhages were not being treated as ‘serious incidents’. Maternity services at St George’s University Hospitals Foundation Trust in south London were previously inspected in 2016, when they were assessed as “good”. The Care Quality Commission (CQC) said serious incident declaration meetings at St George’s were regularly classing serious incidents as “adverse incidents”, meaning executives were not informed and there were missed opportunities for learning and development. Inspectors also found incidents such as severe perineal tears, emergency hysterectomy, and birth injuries were rated as causing low or no harm when a higher level would have been appropriate, or and sometimes downgraded from a higher rating. Carolyn Jenkinson, CQC’s deputy director of secondary and specialist healthcare, said: “We saw areas where significant and urgent improvements are needed to ensure safe care is provided to women, people using this service, and their babies. “Both staff and people using the service were being let down by leaders who failed to respond quickly, resulting in care that was unsafe, and in the delivery suite, also chaotic.” Read full story (paywalled) Source: HSJ, 17 August 2023
