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News Article
Number of patients hurt by rogue surgeon unknown
Patient Safety Learning posted a news article in News
Former patients of a surgeon who has been struck off say their lives have been ruined by his misconduct. The number of people harmed by Jeremy Parker is unknown but at least 123 are taking legal action. Their lawyer said the scale of harm caused by his malpractice "could be huge". A total of 53 allegations against him were found "proved" including dishonestly adding to the case notes of 14 patients, botching operations, not diagnosing infections, failing to consult colleagues and not obtaining patient consent. The General Medical Council also confirmed a patient had a leg amputated below the right knee after a procedure carried out by Mr Parker went awry. Christian Beadell from Fletchers Solicitors, which is representing former patients in a class action, said East Suffolk and North Essex NHS Trust (ESNEFT) had not answered questions over whether it had initiated a recall process to determine the number patients harmed. "It's difficult to say how many patients have been injured by him," Mr Beadell said. Read full story Source: BBC News, 8 March 2023 -
News Article
Ministers blasted by scandal inquiry chair
Patient Safety Learning posted a news article in News
The government’s response to the East Kent maternity scandal inquiry has been condemned as ‘very disappointing’ by its chair. More than four months on from the inquiry report, ministers this morning issued what they called an “initial response” to it, as a brief written statement to Parliament. It contained few specific proposals, instead saying government was kicking off a series of other reviews, and “working” with various other agencies. Inquiry chair Bill Kirkup, the well-regarded former medic and expert in care failures, told HSJ the response was poor and should have been “wider and deeper”. Dr Kirkup said the response showed government had “not grasped how fundamental” some of the issues outlined in his report were, and “what sort of initiative” was needed to address them. Read full story (paywalled) Source: HSJ, 7 March 2023 -
Content ArticleStatement from Maria Caulfield, Parliamentary Under Secretary of State (Minister for Mental Health and Women's Health Strategy) on the Government’s initial response to the report of the independent review into the maternity and neonatal services at East Kent University NHS Foundation Trust that was published on the 19 October 2022. NHS England commissioned Dr Bill Kirkup to undertake this review following concerns about the quality and outcomes of care.
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Content Article
In a series of blogs for the hub, Emma Plunkett and Nancy Redfern, part of the Joint Working Group on Fatigue, will highlight the impact staff fatigue has not only on the staff themselves but also on patient safety, and why healthcare needs a robust fatigue risk management system like other safety-critical industries. In their first blog, Emma and Nancy share how they became involved in investigating night shift fatigue after the death of a colleague driving home tired. They discuss how they set up the Joint Working Group on Fatigue and the aims of the #FightFatigue campaign. -
News Article
Infighting delays valproate compensation
Patient Safety Learning posted a news article in News
Source: The Times. 5 March Shared on Twitter @ShaunLintern -
News Article
Less than 3% of NHS England trusts hit key cancer waiting-time target
Patient Safety Learning posted a news article in News
Patients are being warned of a “shocking gap in cancer care” as new figures reveal that fewer than 3% of England’s NHS trusts met a key waiting-times target last year for cancer patients to be treated within two months of an urgent GP referral. Of 125 hospital trusts in England analysed, only three (2.4%) hit the standard of treating 85% of patients within 62 days after an urgent referral in 2022. Some trusts have not hit the standard for at least eight years. More than 66,000 patients were forced to wait more than two months for their first treatment last year after a referral, the figures reveal. One leading cancer charity said this weekend the cancer care system was not fit for purpose, with “lives left hanging in the balance”. Daisy Cooper, the Lib Dems health spokesperson, said the figures showed that even before the pandemic struck, the number of hospital trusts meeting targets was falling rapidly. “Now the situation is so bad that barely any hospitals are able to provide patients with the treatment they need on time. Ministers have consistently failed to plan ahead or provide adequate funding, while taking patients and NHS staff for granted. There is a shocking gap in cancer care from one area to another,” she said. Read full story Source: The Guardian, 5 March 2023 -
Content Article
In this opinion piece, Kath Sansom, founder of Sling the Mesh, looks at why an audit of pelvic mesh outcomes due to be published in April 2023 has again failed to capture the true extent of the harm caused by the procedure. She outlines why the approach taken by the Government and NHS Digital was flawed and why it is so important to understand both the proportion of women who have experienced harm as a result of the procedure, and the nature of their injuries and side effects.- Posted
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Content ArticleIt's now a decade since the Francis Report, which outlined the causes of serious failures in care at Mid Staffordshire NHS Foundation Trust. The report and prior media coverage exposed a wide set of issues surrounding the culture and transparency of health care, and these topics remain of major concern today. In this article for the Nuffield Trust, Shaun Lintern has interviewed Sir Robert Francis KC about the weight of those patient stories and treatment of the NHS's staff, then and now.
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Content ArticleIn this article, John Tingle, Assistant Professor at the University of Birmingham Law School, discusses recent developments in patient safety in the context of possible reform of the clinical negligence system in the UK.
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News Article
The mesh in my body is a 'ticking time bomb'
Patient Safety Learning posted a news article in News
Sam Hindle has 23cm of polypropylene mesh in her body and lives in constant fear that it will become unstable and cause irreversible damage. "You are in your own Battle Royale, strapped to a time bomb, and thinking when is it going to go off," she told the BBC. Sam, 46, is one of hundreds of women in Scotland who have suffered life-changing symptoms since they had a transvaginal mesh implant. After years of campaigning by the women, the Scottish government has promised it will cover the costs of mesh removal at private clinics in the UK and US. But Sam has been waiting more than two years just for a referral to the Complex Mesh Surgical Service in Glasgow to start the process. The Scottish government announced last year that it had signed a contract to allow NHS patients to visit a US expert for mesh removal surgery The contract with Gynaecologic and Reconstructive Surgery of Missouri, where Dr Dionysios Veronikis operates, follows a similar contract agreed with Spire Healthcare in Bristol. The cost of each removal procedure is estimated to be £16,000 to £23,000. But in order to access such treatment, women have to be assessed by the national service in Glasgow. Women like Sam say there are waiting years to just get referred for assessment. With further delays for appointments and then waits for surgery. Read full story Source: BBC News, 2 March 2023 -
Content ArticleThe Harmed Patients Alliance (HPA) was founded to highlight and promote restorative approaches to healthcare harm. To support their campaign for action, HPA carried out a survey of 44 people asking how those harmed by their contact with healthcare felt about the response, and what impacts this had on them. They were also asked what could have been done differently.
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Content ArticleMidurethral tapes (MUTs) were the most common surgical treatment for stress urinary incontinence (SUI) between 2008 and 2017. Transobturator tapes were introduced as a novel way to insert MUTs. Some women have experienced life-changing complications, and opt to undergo a total excision of transobturator tape (TETOT). This study, published in Neurourology and Urodynamics, aims to report clinical outcomes of all women who underwent TETOT in a specialist mesh centre.
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News Article
CCTV to be used ‘pro-actively’ by trusts to combat abuse
Patient Safety Learning posted a news article in News
Mental health trusts are exploring wider use of CCTV to review incidents of seclusion or restraint in response to high-profile abuse scandals, HSJ has learned. All providers of mental health, learning disability and autism services were ordered to review safety and asked to feed back to NHS England’s national team. The request was made in a letter from national director Claire Murdoch sent in response to abuse allegations aired by BBC Panorama and Channel 4’s Dispatches. The review is taking place alongside NHSE’s launch of a £36m three-year quality programme. This aims to identify providers and systems needing support, commission a culture and leadership development programme for all trusts, and produce a new model for safe inpatient care. Results of trust-level reviews, seen by HSJ, show at least five providers aim to use CCTV more “pro-actively”, as a tool for boosting safety. Read full story (paywalled) Source: HSJ, 27 February 2023 -
Content ArticleThe Healthcare Safety Investigation Branch (HSIB) have published a third interim report for this investigation which focuses on staff wellbeing across the urgent and emergency care systems and the impact that this has on patient safety.
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News Article
‘Institutionalised’ staff ‘perpetuating long hospital stays’
Patient Safety Learning posted a news article in News
Nearly half of NHS patients with a learning disability or autism are still being kept inappropriately in hospitals, several years into a key programme to reduce inpatient care, a national review reveals. The newly published review by NHS England suggests 41% of inpatients, assessed over an eight-month period to May 2022, should be receiving care in the community. Reasons given for continued hospital care in the NHSE review included lack of suitable accommodation, with 19% having needs which could be delivered by community services; delays in moving individuals into the community with appropriate aftercare; legal barriers, with one region citing “ongoing concerns for public safety” as a barrier for discharge; and no clear care plans. In some cases, individuals were placed in psychiatric intensive care units on a long-term basis, because “there was nowhere else to go”, while another instance cited a 20-year stay in hospital. Other key themes included concerns about staff culture, particularly “institutionalisation” and suggestions that discharge delays were not being sufficiently addressed. The report adds: “While the process around discharge can be time consuming, staff may perpetuate this by accepting such delays as necessary or inevitable.” Read full story (paywalled) Source: HSJ, 22 February 2023 -
Content ArticleThis report details the findings of a thematic review of Safe and wellbeing reviews (SWRs) between October 2021 and May 2022. SWRs are undertaken for children, young people and adults that are autistic and/or have a learning disability who are being cared for in a mental health inpatient setting. SWRs are part of the NHS response to the safeguarding adults review concerning the tragic deaths of Joanna, Jon, and Ben at Cawston Park Hospital, who were each detained for a long period of time and did not receive appropriate care.
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News Article
Prostate cancer screening breakthrough as harms linked to testing reduced
Patient Safety Learning posted a news article in News
Prostate cancer screening may be a step closer after a study suggested that harms linked to testing have reduced thanks to advances in medical technology. Screening for prostate cancer has been heavily debated in medical circles due to potential harms including side effects from biopsies and unnecessary testing for those with no clinically significant cancer. A new study set out to examine whether the “seesaw has been tipped” in favour of screening. Researchers from Prostate Cancer UK combined the results of the latest clinical trials and real-world data on the “prostate cancer screening pathway” to examine the risk-to-harm benefit. Prostate Cancer UK said that on average 67%t fewer men experienced harm during the diagnostic process with the newer techniques compared with older methods. Prostate Cancer UK said the UK National Screening Committee, which makes recommendations to the Government, is to re-examine prostate cancer screening. Dr Matthew Hobbs, lead researcher on the analysis and director of research at Prostate Cancer UK, said: “We’ve known for some time now that testing more men reduces prostate cancer deaths, but there have always been concerns about how many men would be harmed to achieve this. “However, our evidence shows that screening may now be a lot safer than previously thought. That’s why we are so pleased that the committee is going to review the evidence once more. Read full story Source: The Independent, 23 February 2023 -
Content ArticleElectronic prescribing (ePrescribing) systems allow healthcare professionals to enter prescriptions and manage medicines using a computer. Sheikh and colleagues set out to find out how these ePrescribing systems are chosen, set up and used in English hospitals. Given that these systems are designed to improve medication safety, we looked at whether or not these systems affected the number of prescribing errors made (mistakes such as ordering the wrong dose of medication). They also tried to see whether or not the systems were good value for money (or more cost-effective). Finally, they made recommendations to help hospitals choose, set up and use ePrescribing systems.
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News ArticleChildren's services could be forced to close at a hospital that is accused of leaving young patients traumatised and sick through poor care. The care regulator said it had taken action to "ensure people are safe" on Skylark ward at Kettering General Hospital (KGH) in Northamptonshire. Thirteen parents with serious concerns after their children died or became seriously ill have spoken to the BBC. A BBC Look East investigation has heard allegations spanning more than 20 years about the treatment of patients on Skylark ward, a 26-bed children's unit. The BBC discovered: An independent report found staff left a 12-year-old boy - who died at KGH in December 2019 - for four hours suffering seizures, and suggests little effort was made to obtain critical care support. In April 2019, nurses allegedly dragged a "traumatised" four-year-old girl down a corridor in agony, insisting that she could walk. Medics are accused of refusing to carry out an MRI scan, which would have detected a dangerous cyst on her spine. Mothers claim to have been threatened with safeguarding referrals, with one stating a referral was made against her after she complained her son was struggling to breathe, while another likened it to blackmail. Read full story Source: BBC News, 20 February 2023
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Content Article
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Patient Safety Learning recently interviewed Keith Conradi, former HSIB chief executive, on why healthcare needs to operate as a safety management system. In this interview, we speak to Jono Broad, part of the South West Integrated Personalised Care team at NHS England, to hear his response to this, how patients, families and relatives can get involved, and why we need to really embed patient safety in a management culture and a healthcare management system.- Posted
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Content ArticleThe Patient Safety Authority has developed a series of decision trees to determine whether a patient safety event is a serious event or incident in a range of different situations.
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Content ArticleThis policy provides a national framework for health and disability providers in New Zealand to continually improve the quality and safety of services for consumers, whānau and healthcare workers. It provides a consistent way to understand and improve through reporting, reviewing and learning from all types of harm. The policy will guide the process for reporting to the Health Quality & Safety Commission in New Zealand and for using the information gathered from learning reviews, along with quality improvement approaches, to strengthen system safety.
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News Article
Urgent action ordered at maternity scandal trust
Patient Safety Learning posted a news article in News
The trust at the centre of a maternity scandal has been ordered to report on urgent improvements in services for women and babies, amid ‘significant concerns’ about the risk of harm. The Care Quality Commission (CQC) used its enforcement powers to issue the conditions on East Kent Hospitals University Foundation Trust, after it carried out an unannounced inspection last month. However, the “section 31” warning letter has just been made public, and the first deadline for the trust to report back to the CQC is Monday (20 February). The CQC said some of the problems it found were due to the labour ward environment – but others involved monitoring of women and babies whose conditions deteriorate and the risk of cross-infection due to poor cleanliness standards. “We have significant concerns about the ongoing wider risk of harm to patients and a need for greater recognition by the trust of the steps that can be taken in the interim to ensure safety and an improved quality of care,” Carolyn Jenkinson, CQC’s deputy director of secondary and specialist healthcare, said in a statement today. Read full story (paywalled) Source: HSJ, 17 February 2023 -
Content Article
Dr Freya Smith, a Specialty Trainee in General Practice, reflects on the sinister and toxic side of medicine, using the recent Paterson and vaginal mesh scandals to demonstrate how patients have been let down by the system. In an honest and personal account, she shares with us the horror and sadness she felt at learning of these scandals and how she aspires to keep her future patients safe. -
News ArticleA high court judge has expressed her “deep frustration” at NHS delays and bureaucracy that mean a suicidal 12-year-old girl has been held on her own, in a locked, windowless room with no access to the outdoors for three weeks. In a hearing on Thursday, Mrs Justice Lieven told North Staffordshire combined healthcare NHS trust “you are testing my patience”, after she heard that a proposal to move Becky (not her real name), could not progress until a planning meeting that would not be held until next week, and that a move was not anticipated until 2 March. Three sets of doctors at the hospital trust have disagreed as to Becky’s diagnosis; at her most recent assessment doctors said she was not eligible to be sectioned, which would trigger the protections provided by the Mental Health Act, because her mental disorder was not of the “nature and degree” as to warrant her detention. In a robust exchange, the judge demanded: “Where’s the urgency in this … I cannot believe that the life and health of a 12-year-old girl is hanging on an issue of NHS procurement, when you cannot tell me what it is you’re trying to procure. “If the delay is procurement, I’m not having it,” Lieven continued. “I will use the inherent jurisdiction to make an order. We have a 12-year-old child in a completely inappropriate NHS unit for about three weeks, and it’s suddenly dawned on your client that ‘actually we’ll put her in a Tier 4 unit and we might have to do some [building] work.’” Sometimes, the judge said, “public bodies have to move faster”. Read full story Source: The Guardian, 17 February 2023
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