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Showing results for tags 'Patient harmed'.
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News Article
Surgeon claims Bath's RUH 'covered up' patient blinding
Patient Safety Learning posted a news article in News
A surgeon sacked by a hospital after raising safety concerns has accused the trust of a cover-up after a patient was partially blinded during an operation. Juanita Graham, 41, lost the sight in her left eye during an operation at Bath's Royal United Hospital (RUH) in 2019. She is now suing the trust. Serryth Colbert said he was put down as the lead author on an investigation into the incident, but said he "did not write a word" of it. Mr Colbert has described the hospital investigation into Mrs Graham's operation as "deeply flawed". The surgeon, who specialises in the head, neck, face and jaw, has made several serious allegations about patient safety at the RUH, and believes these claims led to him being regarded as a troublemaker and dismissed in October 2023. Mrs Graham, from Trowbridge, said she was still traumatised by the operation on her eye. "I remember coming round, seeing the time and felt like a gush and I couldn't see," she said. "The next time I remember waking up again, I thought it was my partner but it was a surgeon and he was crying. I said 'what's gone wrong?'". After the operation, a Root Cause Analyses (RCA) report produced by the trust said the hospital was not to blame, although it did say the risks could have been explained more clearly to Mrs Graham. Mr Colbert, whose name was added as the lead investigator, said his only involvement in the report was when he was called on the phone by a nurse, who he said did the RCA, to explain what the operation involved. The 48-year-old surgeon said: "I have been put down here to my amazement as the lead author on this. "That is not correct. I did not write a word of this. "The conclusion is the root cause of the complication was down to a bit of paperwork which could have been performed a bit better. "The root cause was not down to paperwork. It was all covered up... that was indefensible." Read full story Source: BBC News, 29 February 2024- Posted
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- Surgeon
- Speaking up
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Content ArticleThis systematic review of qualitative evidence aimed to improve understanding of the processes and outcomes of redress and reconciliation following a life-changing event, from the perspectives of individuals experiencing the event and their families. The authors searched six bibliographic databases for primary qualitative evidence exploring the views of individuals who have experienced a life-changing event, and/or their family or carers, of redress or reconciliation processes. This was supplemented with targeted database searches, forward and backward citation chasing and searches of Google Scholar and relevant websites. The review identified three themes identified by patients and families that represent procedural elements required to support a fair and objective process: transparency, person-centred and trustworthy. A further theme identified—restorative justice—is about how a fair process feels to those who have experienced a life-changing event. It highlights the importance of an empathic relationship between the different parties involved in the process and the significance of being able to engage in meaningful action. Theses findings provide insights on how to conduct a fair review into instances of medical harm.
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- Patient harmed
- Harmed Care Pathway
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Content ArticleStrategies to reduce medication dosing errors are crucial for improving outcomes. The Medication Education for Dosing Safety (MEDS) intervention, consisting of a simplified handout, dosing syringe, dose demonstration and teach-back, was shown to be effective in the emergency department (ED), but optimal intervention strategies to move it into clinical practice remain to be described. This study aimed tov describe implementation of MEDS in routine clinical practice and associated outcomes. The study was conducted in five stages (baseline, intervention 1, washout, intervention 2, and sustainability phases). The 2 intervention phases taught clinical staff the MEDS intervention using different implementation strategies. The study found that both MEDS intervention phases were associated with decreased risk of error and that some improvement was sustained without active intervention. These findings suggest that attempts to develop simplified, brief interventions may be associated with improved medication safety for children after discharge from the ED
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- Medication
- Paediatrics
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News ArticleScrapping the new Therapeutic Products Act (TPA) will leave thousands of New Zealanders exposed to ongoing harm from dodgy medical devices, warn patient safety advocates and legal experts. The act, which was due to come into force in 2026, would have modernised the regulation of medicines and natural health products, and made medical devices, as well as cell, gene and tissue therapies, subject to a similar regulatory regime as drugs. The industry has backed the move, saying the new law was heavy-handed and would stop people getting access to the latest lifesaving technological advances. However, Auckland woman Carmel Berry — who was left in constant knife-like pain from plastic mesh implanted during surgery — said she was “living proof” of the old system’s failures. It took more than 10 years of lobbying by her and the other founders of Mesh Down Under to get authorities to take action — a decade in which hundreds of other people were injured. She is horrified that the TPA, signed into law in only July, is on the chopping block. Beginning work to repeal it was No 47 out of 49 points on the Government’s to-do list for its first 100 days. “I’m horrified. After so many years of developing and rewriting the act and getting it through ... shame on them.” Read full story Source: New Zealand Herald, 18 February 2024
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- New Zealand
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News Article
Staff assaulted patients at scandal-hit hospital
Patient Safety Learning posted a news article in News
Staff have assaulted patients and falsified medical records following deaths, according to a shocking new report into a scandal-hit mental health hospital where Nottingham killer Valdo Calocane was a patient. Multiple incidents of staff physically assaulting patients and workers feeling too scared to report problems at Highbury Hospital have been uncovered by the Care Quality Commission (CQC). The watchdog revealed police have investigating the deaths of at least two patients in which staff involved were later found by the hospital to have falsified their medical records in a new report, published on Friday. The news comes after The Independent revealed Nottinghamshire Healthcare Foundation Trust, which runs Highbury Hospital, had suspended more than 30 staff members following allegations of mistreating patients and falsifying records of medical observations. The trust also faces a further CQC review, commissioned by health secretary Victoria Atkins, following the conviction of killer Valdo Calocane who was a patient of Highbury Hospital’s community service teams. This review is due to be published later this year. Read full story Source: The Independent, 1 March 2023- Posted
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- Patient harmed
- Criminal behaviour
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News ArticleIt is still unclear how unauthorised metal parts came to be implanted in a number of the 19 children with spina bifida who suffered significant complications after spinal surgery. But it has emerged that one child died and 18 others suffered a range of complications after surgery at Temple Street Children’s Hospital – with several needing further surgery, including the removal of metal parts which were not authorised for use. Parents of the children undergoing complex surgery were left distraught by the disclosures that emerged yesterday, after campaigning for years while the young patients in need of operations deteriorated on waiting lists. Gerry Maguire, of Spina Bifida Hydrocephalus Ireland, said “absolute horror is being visited on parents and their advocates”. He condemned as disturbing the information which is “being drip-fed to his group and “more alarmingly the families concerned”. One mother expressed concern about further delays in surgery and said children are too complex to be taken for care abroad. Read full story Source: Irish Independent, 19 September 2023
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- Surgery - Trauma and orthopaedic
- Patient harmed
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EventAt this webinar, WHO will launch two WHO publications on Medication Safety, “Global burden of preventable medication-related harm” and “Policy brief on Medication Without Harm”, to create awareness and to support implementation of the WHO Global Patient Safety Challenge: Medication Without Harm. Register
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- Medication
- Global health
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Content ArticleWellcome Collection long read on two women who battled through decades of medical paternalism: Marie Lyon, who took Primodos, and Dr Isabel Gal, the scientist who first raised the alarm.
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- Patient / family involvement
- Medication
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News Article
Health secretary urges patients to report ‘horrific’ sexual abuse allegations
Patient Safety Learning posted a news article in News
Health secretary Victoria Atkins has said mental health patients and staff must report the “horrific” sexual abuse allegations uncovered by The Independent to the police. Ms Atkins said victims would have her full support if they reported their claims to the police. Her intervention comes following a joint investigation by The Independent and Sky News, which revealed almost 20,000 reports of sexual harassment and abuse on NHS mental health wards in England. The allegations uncovered include patients claiming to have been raped by staff and other patients while being treated on mental health wards. In response to the initial investigation, Ms Atkins said a review launched last year into mental health services would now also look into sexual assault within the sector. Speaking on Sky News, she said: “These are horrific allegations that should not and must not happen in our care. Very, very vulnerable people have to stay in mental health inpatient facilities, and they do so because they need care, support, and treatment. “Some of the behaviours that have come to light are criminal offences, and so I would encourage anyone who feels able to – and I appreciate it is a difficult step – to go to the police and please report them, because they are crimes and we must drive them out.” Read full story Source: The Independent, 21 February 2024- Posted
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- Criminal behaviour
- Mental health
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News ArticleIn 2009, Emma Murphy took a phone call from her sister that changed her life. “At first, I couldn’t make out what she was saying; she was crying so much,” Murphy says. “All I could hear was ‘Epilim’.” This was a brand name for sodium valproate, the medication Murphy had been taking since she was 12 to manage her epilepsy. Her sister explained that a woman, Janet Williams, on the local news had claimed that taking the drug during her pregnancies had harmed her children. She was appealing for other women who might have experienced this to come forward. Murphy found the news segment that evening and watched it. “I was just stunned,” she says. “Watching that, I knew. I knew there and then that my children had been affected.” At that point, Murphy was a mother to five children, all under six, and married to Joe, a taxi driver in Manchester. “My kids are fabulous, all of them, but I’d known for years that something was wrong,” she says. “They weren’t meeting milestones. There was delayed speech, slowness to crawl, not walking. There was a lot of drooling – that was really apparent. They were poorly, with constant infections. I was always at the doctors with one of them." A call between Murphy and Janet Williams was the start of an incredible partnership. It led to the report published this month by England’s patient safety commissioner, Dr Henrietta Hughes, which recommended a compensation scheme for families of children harmed by valproate taken in pregnancy. Hughes has suggested initial payments of £100,000 and described the damage caused by the drug as “a bigger scandal than thalidomide”. It is estimated that 20,000 British children have been exposed to the drug while in the womb. Williams and Murphy have campaigned relentlessly to reach this point. It is by no means the endpoint – even now, an estimated three babies are born each month having been exposed to the drug. Together, the women formed In-Fact (the Independent Fetal Anti Convulsant Trust) to find and support families like theirs. They were instrumental in the creation of an all-party parliamentary group to raise awareness in government. Read full story Source: The Guardian, 22 February 2024
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- Medication
- Epilepsy
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Content ArticleNorth Central London Integrated Care System has piloted new guidelines and a local dashboard to ensure there is a safety net in place for females taking sodium valproate.This is a paywalled article published by the Pharmaceutical Journal.
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- Patient harmed
- Medication
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Content ArticleOn the 7 February 2024, the Patient Safety Commissioner for England published a report considering options for redress for those who have been harmed by two of the interventions covered by the Independent Medicines and Medical Devices Safety Review: sodium valproate and pelvic mesh. In this blog, Patient Safety Learning sets out the background to this report, outlines responses from patient groups and campaigners, and reflects on how this work will be taken forward.
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- Redress
- Patient harmed
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Content ArticleIntravenous therapy is an essential aspect of modern healthcare. While the benefits of using intravenous therapy usually outweigh the risks, occasionally the administration of IV therapies can go wrong. Infiltration and extravasation is a complication whereby the drug or IV therapy leaks into the tissues surrounding the vascular access device. This toolkit, developed by the National Infusion and Vascular Access Society (NIVAS), is intended to enable local services and healthcare organisations to implement polices, protocols and guidelines that will increase awareness about non-chemotherapy extravasations.
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- Blood / blood products
- Safety process
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News Article
Maternity unit rated ‘inadequate’ after delayed Caesarean warning
Patient Safety Learning posted a news article in News
A trust’s main maternity unit has been rated “inadequate” and given a warning notice amid concerns delayed Caesarean sections are causing harm to babies. The Care Quality Commission (CQC) told Maidstone and Tunbridge Wells Trust to make significant improvements in how quickly it carries out emergency C-sections, the regulator said in a report today. The trust was also told to improve risk management, governance and oversight of services at its Tunbridge Wells Hospital. Inspectors found between April and July last year, 42% of “category 1” emergency Caesareans – defined as those posing an immediate threat to the life of the woman or foetus — at the Tunbridge Wells Hospital were delayed. The National Institute for Health and Care Excellence says these should be carried out “as soon as possible and in most situations within 30 minutes of making the decision”. The report identified “ongoing recurrent delays” to emergency Caesareans overnight, as the trusts did not have a second theatre available. This “meant an increased risk of harm, including cases reported by the service such as babies with ‘acute foetal hypoxia’ had emerged due to delayed births”, the inspection report said. It also criticised the trust for not responding to a high level of post-partum haemorrhages, some of which had caused “moderate” harm. Read full story (paywalled) Source: HSJ, 16 February 2024- Posted
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- Maternity
- Patient harmed
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Content ArticleA forthcoming three-part ITV drama Breathtaking, set in a fictionalised London hospital, tells the devastating impact of the Covid-19 pandemic through the eyes of Acute Medical Consultant Dr Abbey Henderson. The series is based on Dr Rachel Clarke’s book of the same name. She worked on Covid wards and is also one of the writers on the series. Rachel joins Women's Health host Emma Barnett to discuss it. Listen from 1:40
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- Pandemic
- PPE (personal Protective Equipment)
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Content ArticleHow does it feel to confront a pandemic from the inside, one patient at a time? To bridge the gulf between a perilously unwell patient in quarantine and their distraught family outside? To be uncertain whether the protective equipment you wear fits the science or the size of the government stockpile? To strive your utmost to maintain your humanity even while barricaded behind visors and masks? Rachel is a palliative care doctor who looked after some of the most gravely unwell patients on the Covid-19 wards of her hospital. Amid the tensions, fatigue and rising death toll, she witnessed the courage of patients and NHS staff alike in conditions of unprecedented adversity. For all the bleakness and fear, she found that moments that could stop you in your tracks abounded. People who rose to their best, upon facing the worst, as a microbe laid waste to the population.
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- Pandemic
- PPE (personal Protective Equipment)
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Content ArticleThe recent Hughes Report outlined the options for redress for those harmed by valproate and pelvic mesh In this blog, AvMa's Chief Executive, Paul Whiteing, discusses the trade-off of redress schemes.
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- Legal issue
- Regulatory issue
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Content ArticleThe press has all been full of headlines about staffing levels in the NHS, but this is probably a problem across healthcare around the country. What this does is provide the perfect patient safety quandary, how do we keep all the areas safe. This often results in the redeployment of nursing staff to different areas, but does this provide the required levels of safety. It appears that having several areas in an “amber” staffing level is preferable than one red area. It is simple logic, but does this create an unrealistic expectation on staff that means the safety is better but only at a barely satisfactory level? Do we think that any of these decisions influences the efficiency of a ward? Is the ward safe and effective? In this blog, Chris Elston explores these issues and uses a Safety Engineering Initiative for Patient Safety (SEIPS) to show some of the lesser appreciated risks to redeploying staff and consider some ways to reduce the risks.
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- Redeployment
- Staff factors
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Content ArticleStudies from medical and surgical intensive care units (ICU) suggest that long-term outcomes are poor for patients who have spent significant time in an ICU. This study in the American Journal of Surgery aimed to identify determinants of post-intensive care physical and mental health outcomes 6–12 months after injury. The authors found that: Delirium during an intensive care unit (ICU) stay is linked with long-term physical impairment in injury survivors who spent three or more days in the ICU. The use of ventilators in the ICU is another factor associated with long-term physical impairment and mental health symptoms in these patients. Delirium and ventilator use are potentially modifiable, suggesting opportunities for improving patient outcomes. They suggest that that this knowledge can inform the development of interventions that specifically target delirium and ventilator use to mitigate long-term impairments.
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- HDU / ICU
- Emergency medicine
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Content ArticleOn 9 January 2024, the All-Party Parliamentary Group (APPG) on birth trauma in the UK Parliament will set up an inquiry to investigate the reasons for traumatic birth and to develop policy recommendations to reduce the rate of birth trauma. Research shows that about 4–5% of women develop post-traumatic stress disorder (PTSD) after giving birth – equivalent to approximately 25,000-30,000 women every year in the UK. Studies have also found that a much larger number of women – as many as one in three – find some aspects of their birth experience traumatic. Birth trauma affects 30,000 women across the country every year. 53% of women who experienced birth trauma are less likely to have children in the future and 84% of women who experienced tears during birth, did not receive enough information about birth injuries ahead of time.
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- Obstetrics and gynaecology/ Maternity
- Pregnancy
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News ArticleDozens of new allegations of sexual assault and abuse, including claims of rape and of patients being made pregnant, have emerged following an investigation into Britain’s mental health wards. One patient with a mental health disorder became pregnant by a member of staff. Allegations of rape, and of children being groomed by healthcare assistants, were among the 40 horrifying new reports of abuse made against rogue NHS Trusts. The investigation, conducted by The Independent, alongside Sky News, revealed more than 20,000 allegations of sexual assault and harassment across more than 30 NHS England mental health trusts since 2019. Several patients, who have come forward with their own harrowing stories, had allegedly been harmed by healthcare assistants, who currently are not regulated. Natalie, whose name has been changed, was one of several patients groomed and asked to share sexually explicit photos by a healthcare assistant working at a children’s mental health ward in 2020. Natalie, who was 16 at the time, told The Independent: “The first few conversations [after I was discharged] were very innocent. However after weeks and months, he started speaking in a sexual nature, asking me to send explicit photos of myself, posting explicit photos of himself and asking to meet up for sexual advances, I didn’t realise it at the time, but he was grooming me; this was all over Snapchat. “I feel and still feel very small, and that I wasn’t looked at as a person [by the hospital], and they only saw me as a patient with no feelings that mattered. It felt like another incident at ... that just got swept under the rug.” Read full story Source: The Independent, 10 February 2024
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- Mental health
- Criminal behaviour
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News Article
Cancer waiting times in 2023 worst on record in England
Patient Safety Learning posted a news article in News
Cancer waiting times for 2023 in England were the worst on record, a BBC News analysis has revealed. Only 64.1% of patients started treatment within 62 days of cancer being suspected, meaning nearly 100,000 waited longer than they should for life-saving care. The waits have worsened every year for the past 11. Macmillan Cancer Support chief executive Gemma Peters called the figures "shocking". "This marks a new low and highlights the desperate situation for people living with cancer," she said. "Behind the figures are real lives being turned upside down, with thousands of people waiting far too long to find out if they have cancer and to begin their treatment, causing additional anxiety at what is already a very difficult time. "With over three million people in the UK living with cancer and an ageing population, this is only set to rise." The records go back to 2010, shortly after the cancer target was introduced. However, improvements have been made over the course of 2023 in how quickly patients are diagnosed with 72% told whether they have cancer or not within 28 days of an urgent referral. Read full story Source: BBC News, 8 February 2024- Posted
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- Cancer
- Long waiting list
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News ArticleCampaigners have accused the UK government of betraying them after a review of redress for victims of health scandals excluded families who may have been affected by the hormone pregnancy test Primodos. A report published on Wednesday by the patient safety commissioner, Dr Henrietta Hughes, found a “clear case for redress” for thousands of women and children who suffered “avoidable harm” from the epilepsy treatment sodium valproate and from vaginal mesh implants. But despite the commissioner wanting to include families affected by hormone pregnancy tests in her review, the Department of Health and Social Care (DHSC) told her they would not be included. Primodos was an oral hormonal drug used between the 1950s and 70s for regulating menstrual cycles, and as a pregnancy test. Hormone pregnancy tests stopped being sold in the late 1970s and manufacturers have faced claims that such tests led to birth defects and miscarriages. Last year, the high court dismissed a case brought by more than 100 families to seek legal compensation owing to insufficient new evidence. The Hughes report states: “Our terms of reference did not include the issue of hormone pregnancy tests. This was a decision taken by DHSC and should not be interpreted as representing the views of the commissioner on the avoidable harm suffered in relation to hormone pregnancy tests or the action required to address this. “The patient safety commissioner wanted them included in the scope but, nevertheless, agreed to take on the work as defined by DHSC ministers.” Marie Lyon, the chair of the Association for Children Damaged by Hormone Pregnancy Tests, said the families of those who took the tests felt “left out in the cold” and betrayed that they were not included in the commissioner’s review. “I feel betrayed by the patient safety commissioner, by the IMMDS [Independent Medicines and Medical Devices Safety] review and by the secretary of state for health – all three have betrayed our families because, basically, they have just forgotten us. It’s a case of ‘it’s too difficult so we will just focus on valproate and mesh’,” Lyon said. Prof Carl Heneghan, a professor of evidence-based medicine at the University of Oxford, who led a systematic review of Primodos in 2018, said: “It’s unclear to me how the commissioner can keep patients safe if they are blocked and don’t have the power to go to areas where patient safety matters.” Read full story Source: The Guardian, 7 February 2024
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- Medication
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News Article
Mesh and sodium valproate scandal victims need payouts soon, report says
Patient Safety Learning posted a news article in News
Families of children left disabled by an epilepsy drug and women injured by pelvic mesh implants should be given urgent financial help, England's patient safety commissioner has said. Dr Henrietta Hughes has called on the government to act quickly to help victims of the two health scandals. It follows a review which found lives had been ruined because concerns about some treatments were not listened to. It is estimated that, since the early 1970s, about 20,000 babies have been born with disabilities after foetal exposure to sodium valproate, which can harm unborn babies if taken in pregnancy. Scientific papers from as early as the 1980s suggested valproate medicines were dangerous to developing babies, yet warnings about the potential effects were not added to some packaging until 2016. Some families affected have been campaigning for decades to raise awareness of the potential effects of the drug, with some calling for compensation and a public inquiry. Dr Hughes was asked by the government to look into a potential compensation scheme for those affected by that scandal, as well as the one involving some 10,000 women who were injured by their pelvic mesh implants - a treatment for pelvic organ prolapse (POP) and incontinence. Read full story Source: BBC News, 7 February 2024- Posted
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- Medication
- Medical device
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Content ArticleIn late 2023, the Minister for Mental Health and Women’s Health Strategy, Maria Caulfield MP, asked the Patient Safety Commissioner for England to explore redress options for those who have been harmed by pelvic mesh and sodium valproate. This report sets out the outcome of this project and is designed to help the government understand the options available for providing redress to those patients harmed by pelvic mesh and valproate.
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- Redress
- Patient harmed
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