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Found 1,334 results
  1. News Article
    Ambulance crews in the North East frequently responded to emergencies without access to life-saving drugs, a damning inspection report has found. The study of North East Ambulance Service NHS Trust (NEAS) concluded patients were potentially put at risk by the poor management of medicines. The Care Quality Commission (CQC) found a deterioration of services and rated NEAS's urgent care as "inadequate". In response, NEAS said it had faced a year of "unprecedented pressures". The damaging assessment follows the launch of a full independent NHS review into numerous "tragic failings" involving patients. Announcing the review, the then health secretary Sajid Javid said he was "deeply concerned" about claims NEAS had covered up mistakes. Whistleblowers have told Newsnight multiple deaths were not investigated properly because information was not always provided to coroners and families. Read full story Source: BBC News, 1 February 2023
  2. News Article
    A prolific surgeon accused of poor care — some with a ‘catastrophic outcome’ — and altering patient notes has been found guilty of misconduct following a tribunal hearing. Jeremy Parker, who performed hundreds of operations at Colchester Hospital and the private Oaks Hospital until his suspension in 2019, faced a misconduct hearing in December and January. The medical practitioners tribunal investigated allegations that between August 2015 and November 2018, Mr Parker failed to provide good clinical care to six patients. It was also alleged he performed surgery in breach of restrictions on his clinical practice between October 2018 and January 2019 and that his actions were dishonest. Richard Holland, opening the tribunal case for the General Medical Council, said Mr Parker’s care of six patients – referred to as patients A-F – was “deficient” in a number of ways, with that provided to patient A leading to a “catastrophic outcome” where their leg was amputated below the right knee following “catastrophic blood loss” caused by severing of an artery during surgery. Read full story (paywalled) Source: HSJ, 1 February 2022
  3. News Article
    A further 1,500 patients of convicted breast surgeon Ian Paterson are to be recalled and their treatment investigated. Spire Healthcare, which runs private hospitals, said patients were being contacted after a trawl of IT systems. Paterson was jailed for 20 years in 2017 for 17 counts of wounding people with intent. The healthcare provider said it remained committed to tracking down all "outstanding patients". The former surgeon subjected hundreds of patients to needless and damaging surgery over 14 years. A 2020 independent inquiry ruled "a culture of avoidance and denial" left him free to perform botched operations in NHS and private hospitals in Birmingham and Solihull. The inquiry recommended all 11,000 patients Paterson treated should be recalled for review. Read full story Source: BBC News, 1 February 2023
  4. News Article
    The National Crime Agency and Interpol has been drafted in by detectives investigating a junior doctor accused of multiple sexual assaults on children and adults in A&E departments. Last year, Staffordshire police began an investigation into a 35-year-old medic's work at two hospitals, the Royal Stoke University Hospital in Staffordshire and the Russells Hall Hospital in Dudley, West Midlands. Source: Sunday Times Shared by Shaun Lintern Tweet, 29 January 2023
  5. News Article
    Children came to “significant” harm due to chronically low staffing levels at scandal-hit mental health hospitals, whistleblowers have said. In a third exposé into allegations of poor care at private hospitals run by The Huntercombe Group, former employees have claimed that staffing levels were so low “every day” that patients were neglected, resulting in: Patients as young as 13 being force-fed while restrained. Left alone to self-harm instead of being supervised. Left to “wet themselves” because staff couldn’t supervise toilet visits. One staff member, Rebecca Smith, said she was left in tears after having to restrain and force-feed a patient. Following a series of investigations by The Independent and Sky News, 50 patients came forward with allegations of “systemic abuse” and poor care, spanning two decades at children’s mental health hospitals run by the organisation. The government has since launched a “rapid review” into inpatient mental health units across the country following the newspaper’s reporting. Read full story Source: The Independent, 28 January 2023
  6. News Article
    A major London trust has been criticised for ‘underplaying’ the problems caused by a ‘catastrophic’ IT outage, a new report has revealed. The Guy’s and St Thomas’ Foundation Trust report also noted one patient suffered “moderate harm” and several others “low” level harm after last July’s incident, which was caused by a combination of a heatwave and ageing infrastructure. However, the trust said there was no evidence the “underplaying” of issues was deliberate. The report identified one incident of “moderate” patient harm, in which a patient was unable to receive a pancreas transplant due to staff being unable to safely monitor critical observations. The patient has since had a successful operation, the trust’s report stated. Another 20 “low” harm incidents were reported, which included delays in patients receiving their test results and/or medicines, while the report added the trust could not rule out that “further harm events may be identified” amidst an ongoing harm review. Read full story (paywalled) Source: HSJ, 27 January 2023
  7. News Article
    An NHS surgeon has admitted to botching patients’ surgeries which left them with life-changing injuries, a tribunal has heard. Dr Camillo Valero, who works at Norfolk and Norwich NHS trust and is facing allegations over his conduct towards three patients, has been admitted to severing a patient’s gallbladder during an operation. Dr Valero is facing a medical practitioner’s tribunal where he already admitted to failures during two patients’ procedures. Allegations against him include a failure to obtain a “critical view of safety” for his patients during surgeries. He is also accused of shouting at patients during an altercation in an allegedly “aggressive” manner. According to a tribunal document he was accused of asking the patient “are you a doctor?” when discussing his medication. During surgery, Dr Valero is alleged to have misinterpreted the patient’s anatomy or sought assistance from an experienced surgeon following mistakes. In the case of the third patient, allegations which have not been admitted or proven, Dr Valero is reported to have inappropriately discharged a patient with learning disabilities and did not adequately assess their mental capacity. Read full story Source: The Independent, 25 January 2023
  8. Content Article
    This investigation by the Healthcare Safety Investigation Branch (HSIB) explored the detection and diagnosis of jaundice in newborn babies, in particular babies born prematurely (before 37 weeks of pregnancy). Specifically, it explored delayed diagnosis due to there being no obvious visual signs of jaundice apparent to clinical staff. Jaundice is a condition caused by too much bilirubin in a person’s blood. Bilirubin is a yellow substance produced when red blood cells are broken down. If left undiagnosed and untreated, high bilirubin levels in newborn babies can lead to significant harm. Newborn babies have a higher number of red blood cells in their blood which increases their risk of jaundice. Jaundice can cause yellowing of the skin and whites of the eyes; however, sometimes the visual signs of jaundice are not obvious, particularly for premature or newborn babies with brown or black skin. The reference event for this investigation was the case of baby Elliana, who was born at 32 weeks and 1 day via a forceps delivery and then transferred to the Trust’s special care baby unit (SCBU). Elliana was assessed on admission to the SCBU by staff as a clinically stable premature baby and a routine blood sample was taken from around two hours after her birth to establish a baseline. Analysis of the blood sample indicated bilirubin was present and so the level was measured. This result was uploaded onto the Trust’s computer system alongside the results of the blood tests that had been requested by the clinical team. The bilirubin result was seen by a SCBU member of staff who recognised that the level was high, indicating the possible need for treatment. However, this member of staff was then required to attend an emergency and the bilirubin result was not acted upon. Another blood sample was taken when Elliana was two days old and was uploaded to the Trust’s computer system. It is unclear if this bilirubin result was seen by staff; it was not documented in clinical records and was not acted upon. Over the next two days, Elliana continued to show no visible signs of jaundice that were detected by staff and she was documented to be developing well. When Elliana was five days old, a change in her skin colour was observed and visible signs of jaundice were detected. A further blood sample was taken which showed she had a high level of bilirubin in her blood and treatment was started accordingly. Elliana’s bilirubin levels returned to within acceptable levels over the next three days and she was subsequently discharged home.
  9. News Article
    Record numbers of patients suffered severe harm last month because they spent so long in the back of ambulances waiting to get into A&E, new NHS figures reveal. An estimated 57,000 people in England “experienced potential harm”, of whom 6,000 were exposed to “severe harm”, in December – both the largest numbers on record – because they had to wait at least an hour to be handed over to hospital staff, according to NHS ambulance service bosses. The health union Unison, which represents many ambulance staff, said the data showed that the ambulance service “is barely coping” with the huge number of calls it is receiving. A senior ambulance service official said the high volume of patients being put at risk because they had to wait outside A&E so long before receiving medical attention, and paramedics being prevented from answering other 999 calls, was “horrific” and “astronomical”. He added: “These figures also show that whatever NHS England say they are doing to try to resolve this huge problem, it clearly isn’t working.” Martin Flaherty, Association of Ambulance Chief Executives (AACE) managing director, said: “Our December 2022 data for handover delays at hospital emergency departments shows some of the worst figures we have recorded to date and clearly underlines that not enough is being done to reduce and eradicate these dangerous, unsafe and harmful occurrences.” Read full story Source: The Guardian, 25 January 2023
  10. News Article
    A trust that sacked a whistleblower who had warned them about potential patient harm from a new procedure has been told to pay her more than £200,000. Jasna Macanovic won her case against Portsmouth Hospitals University Trust last year after the employment tribunal found board members had broken employment rules, including by telling her she would get a good reference if she agreed to quietly resign. Earlier this month, an employment tribunal judgment to establish the compensation she was owed said the trust had subjected Dr Macanovic to “a campaign of harassment” and rejected Portsmouth’s claim she had contributed to her own dismissal. The consultant nephrologist, who had been at the trust for 17 years, raised concerns about a technique called “buttonholing” – carried out to make kidney dialysis more convenient and less painful – that she claimed had caused harm to patients. After the procedures continued, the dispute escalated, culminating with Dr Macanovic being dismissed in March 2018. The employment tribunal panel said Dr Macanovic had raised her concerns about buttonholing properly, adding: “She was not alone in her concerns. The consultant body were fairly evenly divided. “She, however, went further than others, and where she believed that risks were being downplayed she did not hesitate to describe this as a cover-up or an act of dishonesty. Most people would not use that language, and it did cause very serious offence, but it had a specific meaning. It was not a general slur.” Read full story (paywalled) Source: HSJ, 23 January 2023
  11. News Article
    Ministers have ordered an inquiry into the quality of care in mental health inpatient units in England after a series of scandals in which vulnerable patients were abused or neglected. Maria Caulfield, the mental health minister, announced the establishment of a “rapid review” in a written ministerial statement in the House of Commons on Monday. The inquiry “is an essential first step in improving safety in mental health inpatient settings”, she said. In recent years, coroners and the Care Quality Commission, the NHS care watchdog, have repeatedly raised concerns about dangerously inadequate care that inpatients have received. It will examine the evidence of “patient safety risks and failures in care” in units that hold and treat patients who have serious conditions including psychosis and personality disorder. It will look in particular at evidence of failings brought forward by patients and their families and how better use of data can help show that care has fallen below acceptable levels. The inquiry will be headed by Dr Geraldine Strathdee, a psychiatrist who used to be NHS England’s national clinical director for mental health. She is likely to look at problems including patients being subjected to controversial restraint techniques, left at risk of being able to take their own lives and segregated from fellow inpatients, and the impact of their experiences on their recovery. Read full story Source: The Guardian, 23 January 2023
  12. News Article
    A record number of patients suffered “severe harm” as a result of ambulance delays in December, soaring by nearly 50 per cent in just one month as the NHS crisis deepened. Almost 6,000 suffered permanent or long-term harm due to long waits to hand over patients outside A&Es – up from just over 4,000 in November. A further 14,000 patients were likely to have suffered “moderate harm”, an analysis by The Independent of NHS ambulance data and estimates of harm by the Association of Ambulance Chief Executives (AACE) found. This includes incidents that resulted in patients needing further treatment or procedures, the cancelling of treatment, or being transferred to another area. Miriam Deakin, director of policy and strategy at NHS Providers, said the figures are a “worrying reminder of the huge pressure the NHS is under”. She said: “Trust leaders are doing everything they can to provide patients with safe, high-quality care but they know patients face lengthy handover delays far too often, contributing to avoidable harm.” Read full story Source: The Independent, 20 January 2023
  13. News Article
    During the pandemic, nearly half a million people in the UK missed out on starting medication to help prevent heart attacks and strokes, a new study suggests. The British Heart Foundation (BHF) team looked at prescribing data for the first 18 months after Covid hit. Some 491,000 people (27,000 a month) appear to have missed out on blood pressure pills, and 316,000 did not get treatment to lower their cholesterol. The team says more needs to be done to make sure that anyone who needs treatment gets it. During the pandemic, normal NHS services were severely disrupted. For example, there was a reduction in diagnosis, monitoring and treatment of high blood pressure, and other heart and circulation disease risk factors. Although the NHS took action, including providing more than 220,000 blood pressure monitors for people to use at home, data shows two million fewer people in England were recorded as having controlled hypertension in 2021 compared to the previous year. Lead investigator Prof Reecha Sofat, who is based at the University of Liverpool, said the findings, published in the journal Nature Medicine, highlight the impact Covid has had on other important health conditions: "Despite the incredible work done by NHS staff, our data show that we're still not identifying people with cardiovascular risk factors at the same rate as we were before the pandemic. " Read full story Source: BBC News, 20 January 2023
  14. Content Article
    The Health and Social Care Select Committee have published a new report reviewing the progress that the UK Government has made in implementing the recommendations of the Independent Medicines and Medical Devices Safety Review, sometimes referred to as the Cumberlege Review. This blog sets out Patient Safety Learning’s reflections on this report.
  15. Content Article
    Emergency access to healthcare is in crisis. Unmet need in primary and community care and low capacity in hospitals and social care has left the emergency health services gridlocked and overwhelmed, unable to provide safe care. This Cross party House of Lords Public Services Committee report recommends that a COBR Committee be assigned the responsibility to address the crisis in emergency healthcare. In the long-term, it recommends a a substantial overhaul is needed, one which sets out a bold new operating model for the system as a whole, and which is backed by equally bold leadership.
  16. Content Article
    In this blog Patient Safety Learning considers the impact on patient safety of the shortage of hospital beds facing the NHS this winter. It focuses on two specific issues stemming from this, the increasing numbers of patients being cared for in corridors and other non-clinical areas, and current proposals to reduce the number of patients waiting to be discharged.
  17. News Article
    A series of concerns about serious incidents at a mental health trust are being investigated by the Care Quality Commission, with a referral also made to the police, HSJ has learned. HSJ understands that various incidents at Black Country Healthcare Foundation Trust have been raised with the Care Quality Commission by whistleblowers. According to a well-placed source, one of the alleged incidents involved alleged inappropriate sexual behaviour, and this has been referred to West Midlands police. Other complaints are understood to include staff using mental health inpatients’ rooms to sleep in, and an information governance breach in which patient information was shared with members of staff who did not need to receive them. It is understood this was in an email raising patient safety concerns. Read full story (paywalled) Source: HSJ, 17 January 2023
  18. News Article
    Complications after a procedure to treat IBS left Jennifer Hill in pain – and fighting for compensation. Earlier this year, an NHS inquiry found surgeon Anthony Dixon had caused women to “suffer harm” as a result of the mesh operations he carried out between 2007 and 2017. Dixon, who is now banned from practising in the UK, carried out hundreds of laparoscopic ventral mesh rectopexy (LVMR) operations for both the North Bristol NHS Trust and privately at Bristol’s Spire Hospital. Mesh is used to repair the pelvic floor, but the inquiry concluded that women should have been offered alternative treatments first. Jennifer Hill, from Herefordshire, is one of those women. She wishes she could go back in time and not have her mesh operation, which took place in May 2012. “I was totally unaware of the controversy surrounding mesh,” she says. “I still kick myself that I didn’t get a second opinion or ask more questions.” Read full story (paywalled) Source: The Telegraph, 11 January 2023
  19. Content Article
    With the NHS under relentless pressure this winter and as records keep getting broken for all the wrong reasons, Helen Buckingham takes a closer look at why hospitals are so full, and emphasises the importance of supporting and helping the health service’s staff.
  20. Content Article
    This survey from the Care Quality Commission (CQC) looked at the experiences of women and other pregnant people who had a live birth in early 2022.
  21. Content Article
    In this article, HSJ's Annabelle Collins reflects on the increasing number of NHS staff quitting their jobs and the risk to patient safety of 'corridor care'.
  22. Content Article
    This study, published in the International Urogynecology Journal, involved 18 interviews with women who had experienced vaginal mesh complications. Four themes were identified:perceived impact of mesh complicationsattitudes of medical professionalssocial support and positive growth. The impact of vaginal mesh complications were wide-reaching and varied, affecting many aspects of the participants lives including mental health, relationships and sexual intimacy. Authors conclude that a greater awareness would lead to better support for women experiencing mesh complications.
  23. News Article
    Patient safety is at risk “every single day”, with patients in desperate need of intensive care waiting hours in Accident and Emergency departments across Scotland, the deputy chair of British Medical Association Scotland has said. The harrowing description of the scenes in hospitals came as health secretary Humza Yousaf admitted patients were receiving care he would not want to receive himself as the NHS continues to battle intense winter pressures. Dr Lailah Peel, deputy chair of the Scottish arm of the British Medical Association (BMA), told the BBC’s Sunday Show the crisis was “years in the making”. She blamed a creaking social care system and increased delayed discharges. The comments come after details of a January 2021 briefing from the Royal College of Emergency Medicine (RCEM) and the College of Paramedics to the health secretary warned of an unacceptable situation in Scotland’s hospitals. Reported in the Sunday Times, the briefing also specified the actions needed to avoid a similar situation during the current winter crisis, warning an increase of at least 1,000 new beds was needed as well as more doctors and nurses. Dr Peel said it was the case patients were “absolutely” dying in hospitals in Scotland due to the ongoing crisis in the health service. "There’s no shadow of a doubt that that is happening,” she told the BBC. Read full story Source: The Scotsman, 8 January 2023
  24. Content Article
    In December 2022, the All Party Parliamentary (APPG) for Whistleblowing heard evidence on the state of the NHS following the recent report on the avoidable deaths and life changing injuries caused to mothers and babies at the East Kent Trust. The culture at this hospital was described as one where “everyone knew the problems” and where whistleblowers were “thrown to the lions”. A culture attributed to 45 of the 65 baby deaths reviewed.  This blog first appeared on the Whistleblowers UK website in December 2022.
  25. News Article
    With NHS staff being forced to witness our patients dying in corridors, in cupboards, on floors and in stranded ambulances, we can only thank our lucky stars that the country’s second most powerful politician is the man who last year published Zero: Eliminating Unnecessary Deaths in a Post-Pandemic NHS. Because the chancellor, Jeremy Hunt, cannot possibly stand back and permit these crisis conditions to continue, can he? He knows better than anyone – having written 320 pages on precisely this fact – that avoidable deaths are the very worst kinds of death, the ones that sicken families and clinicians to their core. Let’s remind ourselves of how strongly Hunt feels about this subject. The blurb of his book, published only last May, rings out with moral righteousness. “How many avoidable deaths are there in the NHS every week?” he asks. “150. What figure should we aim for? Zero. Mistakes happen. But nobody deserves to become a statistic in an NHS hospital. That’s why we need to aim for zero.” He even offers a road map towards achieving that end that, unusually for a politician, centres on radical candour. Don’t lie. Don’t deflect. Don’t spin. Don’t cover up. Be honest and open about mistakes and failures because this is the first, essential step to fixing them. To the collective despair of frontline staff, the government’s actual, as opposed to rhetorical, response to the humanitarian crisis gripping the NHS is a perverse inversion of everything the chancellor purports to hold dear. Read full story Source: The Guardian, 6 January 2023
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