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News ArticleExhausted after three sleepless days in labour, Jane O’Hara, then 34, screamed and burst into tears when the midwives and doctors at Harrogate District Hospital told her the natural birth she wanted was not going to happen. She ended up needing life-saving surgery and 11 pints of blood after a severe haemorrhage. Mercifully, Ivy was fine and is now a healthy 12-year-old. In recent weeks, the NHS has been rocked by the conclusions of an inquiry into the worst maternity disaster in its history: 201 babies and nine mothers died and another 94 babies suffered brain damage as a result of avoidable poor care at Shrewsbury and Telford Hospital NHS Trust. This has been linked to a culture of promoting natural — that is, vaginal — birth and avoiding caesarean sections. Blame thus far has been aimed largely at the NHS — but parents have started speaking out online about what they believe has been the role of the National Childbirth Trust (NCT), a leading provider of antenatal classes in Britain, in promoting vaginal births. “I can absolutely point to key decisions that I made that were influenced by the NCT’s mantra. I was led into a position where I believed I had more control over my birth than I actually did,” says O’Hara, who is now a professor of healthcare quality and safety at the University of Leeds. She believes she was a victim of a “normal birth” ideology that was heavily promoted at the NCT classes she attended. Read full story (paywalled) Source: The Times, 10 April 2022
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News ArticleA scandal-hit children’s mental health hospital will close months after an investigation by The Independent uncovered claims of poor care and systemic abuse. Taplow Manor hospital, in Maidenhead, was threatened with closure by the NHS safety watchdog, the Care Quality Commission, only last week if it failed to make improvements following a damning report. Active Care Group, which runs the hospital, confirmed it would close by the end of May, saying a decision by the NHS to stop admitting patients had rendered its “service untenable”. The move comes after an investigation by The Independent and Sky News heard from more than 50 patients who alleged “systemic abuse” by the provider, while Taplow Manor is facing two police probes – one into a patient death and a second into the alleged rape of a child involving staff. Read full story Source: The Independent, 29 March 2023
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News ArticleMothers and babies are being put at risk because maternity services are still providing unsafe care, despite a series of scandals that have cost lives, the NHS ombudsman has warned. More tragedies will occur unless the health service takes decisive action to put an end to repeated and deeply ingrained problems which lead to “the same mistakes over and over again”, he said. Rob Behrens, the NHS ombudsman for England, voiced his concerns when he launched a report on Tuesday which details the failings several women experienced while giving birth. It also sets out the lessons the NHS needs to learn, but Behrens claimed that too many trusts were not doing so. Behrens voiced alarm that, although efforts have been made to improve the care mothers and their children receive, progress is too slow – and that means patients remain in danger. His report says that: “We recognise that people working in maternity services want to provide high-quality care. Culture, systems and processes can get in the way of achieving that goal. “But improvements are not happening quickly enough, and we have not seen sustainable change. We must do more to make services safer for everyone.” Read full story Source: The Guardian, 28 March 2023 Further reading on the hub: Patient Safety Learning - Mind the implementation gap: The persistence of avoidable harm in the NHS
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News Article
Birmingham hospital apologises after delays leave baby disabled
Patient Safety Learning posted a news article in News
Dilshad Sultana was 36 weeks pregnant with her second child in 2019 when she experienced stomach pain and noticed her baby was moving less. Mrs Sultana, from Sutton Coldfield, said she had been due to have a Caesarean section on 8 July but on 20 June she started to feel pain in her abdomen and lower back. She said she was confused but that it did not feel like a contraction and called hospital staff at about 17:00 to say it felt like her baby was moving less. After following advice to rest and take pain relief, she attended hospital at about 22:30 and staff started monitoring Shanto's heart rate. It was not until almost three hours later that Shanto was delivered by emergency C-Section. Shanto suffered severe brain damage and would spent the next 22 days in intensive care, suffering seizures and multiple brain haemorrhages. Shanto now requires around-the-clock care and Mrs Sultana enlisted lawyers to pursue a care of medical negligence against the trust. Birmingham Women's and Children's NHS Foundation Trust has admitted liability and made a voluntary interim payment allowing the family to move to a new home specifically adapted to meet Shanto's extensive care, therapy and equipment needs. Fiona Reynolds, the chief medical officer, said: "We'd like to offer our heartfelt apologies again to the family. "It's clear the standard of care we offered to them fell below those required and expected. For this, we are truly sorry." Now, Mrs Sultana is campaigning for change - she wants to see mothers listened to in maternity care and more attention paid to monitoring babies' heart rates. Read full story Source: BBC News, 27 March 2023 -
News ArticleThe UK is supposed to have one of the best systems in the world for preventing vulnerable people being exploited for their organs. How then did one of its biggest hospitals become embroiled in the macabre trade of kidney harvesting? The UK’s first trial organ trafficking trial has exposed alarming vulnerabilities to a illegal trade that makes up 10% of transplants worldwide. The case has highlighted how poverty can tempt some people to sell their body parts to those willing to exploit an acute global shortage of organs for donation. The case heard that doctors at a private renal unit at London’s Royal Free hospital and the regulators, the Human Tissue Authority (HTA), were fooled by Dr Obinna Obeta, into approving his kidney transplant in July 2021. As the prosecutor, Hugh Davies, said: “If there’s a lesson to be learned here – those clinicians need to set the index of suspicion for safeguarding somewhat lower.” Dominique Martin, a professor of health ethics at Australia’s Deakin University who studies organ trafficking, said the case highlighted the need for robust vetting by hospitals and regulators. She said: “There is a level of complacency, including in the UK, the US and Australia regarding the risks of organ trafficking happening within our borders. Screening programmes may not be as strong as we assume or as consistently implemented as we might expect.” Read full story Source: The Guardian, 23 March 2023
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News ArticlePolice are investigating fresh allegations of sexual assault against a child patient by a care worker at a scandal-hit private mental health hospital group. It is the second time reports have been made about a former Huntercombe Group hospital after two care workers were quizzed over the alleged rape of a child at its Taplow Manor Hospital in Maidenhead last year. The latest allegations are from a patient at the group’s Ivetsy Bank Hospital, in Staffordshire, which was rated as inadequate last week. In a statement, Staffordshire Police confirmed it had received a report of sexual assault and said inquiries were ongoing. The news comes as the NHS’s safety watchdog has threatened to close Taplow Manor after hospital leaders failed to make improvements in care. The action comes after joint investigations by The Independent and Sky News found the private hospital had put the safety of young mental health patients at risk, with more than 50 patients and staff members alleging “systemic abuse” and poor care. Read full story Source: The Independent, 24 March 2023
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News Article
Unregulated ‘eating disorder coaches’ putting people at risk, say experts
Patient Safety Learning posted a news article in News
Vulnerable mental health patients are being put at risk by unregulated “eating disorder coaches” who do not have the necessary qualifications, experts have said. As demand for eating disorder support soars – hospital admissions for eating disorders increased by 84% in the last five years – more people are filling gaps in NHS care. So-called eating disorder coaches, who tend to be personal trainers or dietitians recovering from the illness themselves, are charging as much as £1,000 a month for sessions to offer support to others despite having little or no training and expertise. The Guardian has found that many coaches cite short courses, which are intended as professional development for psychologists, as a qualification to practise. The National Centre for Eating Disorders (NCED) offers a number of professional training courses, accredited by the British Psychological Society (BPS). The Guardian found a number of coaches were using these courses to claim they were qualified to offer professional services to people with eating disorders. Agnes Ayton, chair of the Royal College of Psychiatrists’ eating disorders faculty, said she was “amazed” to see people “advertising themselves as experts after going on one course”. “Eating disorders sit between physical and mental health so the risks associated with eating disorders can be physically debilitating and potentially fatal,” Ayton said. “I don’t know why there is not better regulation on that because there is lots of regulation for a medical professional – but therapy is the first line of treatment for eating disorders, and if it is not delivered properly, it can be harmful or misleading.” Read full story Source: The Guardian, 21 March 2023 -
News Article
Warnings against 'reckless' weight loss surgery abroad
Patient Safety Learning posted a news article in News
Seven British patients who travelled to Turkey for weight loss surgery died after operations there, a BBC investigation into the trend has found. Others have returned home with serious health issues after having had gastric sleeve operations, during which more than 70% of the stomach is removed. The operations, used to treat morbid obesity, are carried out in the UK, but, because it can take years to get one through the NHS, some people are looking abroad for treatment. British doctors say that they're treating an increasing number of patients who have travelled to Turkey and returned with serious complications. Dr Ahmed Ahmed, a leading surgeon and member of council at the British Obesity and Metabolic Surgery Society, says he's treated patients returning from Turkey who have had an entirely different operation to the one they understood they had paid for. The BBC has also been told that some people are being accepted for surgery who do not have a medical need for it. The BBC contacted 27 Turkish clinics to see if they would accept someone for treatment who was considered to have a normal BMI. Six of the clinics we approached were happy to accept someone with a BMI of 24.5 for extreme weight loss surgery. Separately, the BBC also found that some clinics who refused the treatment actually then encouraged patients to put on weight, to enable them to be accepted for surgery. One said: "You need to gain 6.7kg to have sleeve surgery. I think you can easily eat some food and then lose weight easily." Another asked: "How soon can you gain weight?" Dr Ahmed says the practices are "reckless" and "unethical". Read full story Source: BBC News, 21 March 2023 -
News Article
Hundreds left with lost or damaged eyesight after NHS delays
Patient Safety Learning posted a news article in News
Hundreds of patients have lost their eyesight or had it irreparably damaged because of NHS backlogs, new research suggests. NHS England clinicians have filed 551 reports of patients who lost their sight as a result of delayed appointments since 2019, with 219 resulting in “moderate or severe harm”, according to an FoI request by the Association of Optometrists, which believes that hundreds more cases are unreported. Its chief executive, Adam Sampson, said sight loss was a “health emergency”, and urged ministers to introduce a national eye health strategy to enable high street and community optometrists to ease some of the burden on hospitals. He said: “There are good treatments available for common age-related eye conditions like macular degeneration but many hospital trusts simply do not have the capacity to deliver services. “Optometry is ideally placed to take away some of that burden – optometrists are already qualified to provide many of the extended services needed and are available on every high street, so patients can be treated closer to home. It’s incomprehensible and absolutely tragic that patients are waiting, losing their vision, in many parts of the country because of the way eye healthcare is commissioned.” Read full story Source: The Guardian, 21 March 2023 -
News Article
‘Insufficiently curious’ leaders ‘tolerated’ safety failures
Patient Safety Learning posted a news article in News
Leaders at a mental health trust tolerated high levels of safety incidents and accepted verbal assurance with ‘insufficient professional curiosity’, a critical report has found. An NHS England-commissioned review into governance at Tees, Esk and Wear Valleys Foundation Trust has been published, reviewing the organisation’s response to serious safety concerns flagged at the former West Lane Hospital in Middlesbrough. It follows separate reports identifying “systemic failures” over the deaths of inpatients Christie Harnett, Nadia Sharif and Emily Moore. The new report, conducted by Niche Consulting, criticises board and service leaders’ handling of concerns about the regular occurrence of restraint and self-harm. More than a dozen incidents of inappropriate restraint, some seeing patients dragged along the floor, were identified in November 2018, resulting in multiple staff suspensions and some dismissals. Niche found there was a “lack of accountable leadership at all levels” and lack of evidence for decisions in response to the November 2018 incidents. Read full story (paywalled) Source: HSJ, 21 March 2023 -
News ArticleA scandal-hit hospital group has been sanctioned by inspectors after The Independent revealed “systemic abuse” at a string of children’s mental health units. England’s safety watchdog issued an official warning to Ivetsey Bank Hospital in Staffordshire, run by The Huntercombe Group, after an extensive investigation by this newspaper found the private hospital had put the safety of young mental health patients at risk. The Care Quality Commission also downgraded the hospital’s rating to “inadequate”. If improvements are not made in line with the warning notice, the hospital could be forced to close. An inspection was carried out two weeks after The Independent revealed widespread allegations of abuse and excessive restraint across The Huntercombe Group’s hospitals. The investigation revealed the provider, which also runs Taplow Manor children’s hospital in Maidenhead, was facing allegations from more than 50 former patients as well as claims of poor care from staff whistleblowers and dozens of negligence claims. Read full Source: The Independent, 15 March 2023
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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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Content ArticleA BBC Newsnight investigation hears devastating evidence and testimony of ambulance failings in the north east of England. What does it take to run a safe service that patients can trust?
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Content Article
A bitter pill: Primodos (Sky News, 3 January 2023)
Patient-Safety-Learning posted an article in Medication
This Sky News investigation looks at one of the pharmaceutical industry's biggest scandals—the hormone pregnancy test Primodos which was prescribed to pregnant mothers in the UK between 1958 and 1978. Primodos was found to lead to birth defects, miscarriages and stillbirth, and regulatory failings led to avoidable harm to thousands of babies. -
Content ArticleThere is little longitudinal information about the type and frequency of harm resulting from medication errors among outpatient children with cancer. This study aimed to characterise rates and types of medication errors and harm to outpatient children with leukaemia and lymphoma over 7 months of treatment.
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Content ArticleThe MHRA is aware of cases of increased intraocular pressure in patients recently implanted with EyeCee One preloaded and EyeCee One Crystal preloaded intraocular lenses (IOLs), which are manufactured by NIDEK and distributed by Bausch + Lomb. The root cause has not been identified and further investigations are ongoing with the manufacturer. Due to the potential risks for patient safety, you should stop using these IOLs and quarantine remaining stock immediately pending the results of further investigations. Additional communications will be issued shortly advising clinicians and affected patients on the next steps.
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Content ArticleThis blog by Carl Heneghan, Professor of Evidence-based Medicine at the University of Oxford and Clinical Epidemiologist Tom Jefferson, looks at safety and regulatory issues associated with Essure, a permanent contraceptive implant. Essure anchors inside the fallopian tubes and reacts with the tissues, causing them to become inflamed and scarred. The resulting scar tissue then blocks the tubes off, intending to prevent fertilisation. The devices are about 4cm long and contain a stainless steel, nickel and titanium inner coil and an expanding outer coil containing iron, chromium and tin. Essure has been shown to cause allergic reactions, lifelong inflammatory reactions and internal injuries. The authors examine how Essure came to be approved for use in the USA, the UK and the rest of Europe, highlighting regulatory failings and conflicts of interest with the medical tech industry. They also highlight how pressure from women harmed by Essure resulted in its use being banned in several countries. The blog then describes ongoing efforts to access UK data on reports of adverse events due to Essure that are held by the Medicines and Healthcare Regulations Agency (MHRA). Freedom of Information requests for this data have been denied.
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Content ArticleSimple, and relatively inexpensive, steps to implement care bundles can have a dramatic impact on rates of surgical site infection. The Burden of Infection Symposium provided an insight into the latest evidence and guidance around best practice, as well as offering expert advice on ‘overcoming the challenges of change’. Read a summary of the symposium published in the Clinical Services Journal.
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Content ArticleTen years ago today, a public inquiry concluded that patients were subject to shocking levels of neglect at Stafford Hospital - putting it among the worst care scandals in NHS history. A young local reporter, Shaun Lintern – now The Sunday Times' health editor – helped expose the scandal. With the NHS again under huge pressure, can we be sure the same failings won't happen again? In this podcast, part of the Stories of our Times podcast series, Shaun speaks to the barrister who chaired the inquiry.
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Content Article
Patient Safety Commissioner: 100 Days Report (2 February 2023)
Patient Safety Learning posted an article in England
In this report, Dr Henrietta Hughes, Patient Safety Commissioner for England, reflects on her first 100 days in this new role. She sets out what she has heard, what she has done and her priorities for the year ahead. -
Content ArticleThis 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.
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Content ArticleThe 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.
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Content ArticleEmergency 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.
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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.- Posted
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Content ArticleWith 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.
