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Showing results for tags 'Patient harmed'.
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News ArticleNHS bosses have been accused of using a 2013 report to “maintain a false narrative” about maternity services in Shropshire, which meant poor practices and conditions went unchallenged for years. The Independent has obtained a 2013 report, commissioned by NHS managers in Shropshire, which concluded maternity services at the Shrewsbury and Telford Hospital Trust were “safe”, of “good quality”, and “delivered in a learning organisation”. The report, written by rheumatologist Dr Josh Dixey (now high sheriff of Shropshire), delivered a glowing assessment of the care given to women and babies and appeared to gloss over hints of deeper problems within the service. Sources within the Shropshire and Telford clinical commissioning groups (CCGs), which paid £60,000 for the report, said since it was written it had been “proven to be wrong, inaccurate and to have come to the wrong conclusions and recommendations”, but also stressed it was based on the information received from the trust at the time. A leaked report last month revealed dozens of mothers and babies had died at the Shrewsbury and Telford Hospital Trust, with incidents of poor care stretching over four decades, due to repeated failures to learn from mistakes. Read full story Source: The Independent, 4 December 2019
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News Article
Hundreds of families come forward in Shropshire maternity scandal
Patient Safety Learning posted a news article in News
More than 200 new families have contacted an inquiry into mother and baby deaths at a hospital trust in Shropshire. Investigators were already looking at more than 600 cases where newborns and mothers died or were left injured while in the care of the Shrewsbury and Telford Hospital Trust. One expert says the scandal, spanning decades, may be the tip of the iceberg. Dr Bill Kirkup says it suggests failure might be more widespread in the NHS. The surge in new cases follows the leak of an interim report last week. Read full story Source: BBC News, 27 November 2019 -
Content ArticleIn a wide-ranging Report on NHS litigation reform, the Health and Social Care Committee finds the current system for compensating injured patients in England ‘not fit for purpose’ and urges a radically different system to be adopted. Reforms would introduce an administrative scheme which would establish entitlement to compensation on the basis that correct procedures were not followed and the system failed to perform rather than clinical negligence which relies on proving individual fault. The new system would prioritise learning from mistakes and would reduce costs. Currently, litigation offers the only route by which those harmed can access compensation. MPs say in addition to being grossly expensive and adversarial, the existing system encourages individual blame instead of collective learning. This is a House of Commons Committee report, with recommendations to government. The Government has two months to respond.
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Content ArticleOperations can have cognitive side-effects, particularly in the over-65s but also in the very young. How can science minimise the danger?
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Content Article
“There’s no problem with the mesh”: A personal account of the struggle to get vaginal mesh removal surgery
Anonymous posted an article in Women's health
In this blog, a woman who has suffered from severe pain and complications for 17 years due to transvaginal mesh shares her experience. She talks about how the device has changed her life, how her symptoms have been repeatedly dismissed by surgeons, and the variation she has witnessed between different specialist mesh centres.- Posted
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Content ArticleKeren Levy was fit and healthy when she first felt pain in a molar. After numerous dentists and doctors left it untreated, there were knock-on effects throughout her body. Today she is in constant pain and look almost unrecognisable She went to the dentist a number of times but X-rays showed nothing untoward. However, Karen started to develop a horribly rotting taste and knew the tooth was necrotic. She begged her dentist to give her root canal treatment or extract it, but without a visible sign this was needed she was refused. Instead she was referred to her GP, implying her distress was bereavement due to her mother recently dying. Many months later, Keren was referred to a different dentist who gave her a 3D scan that showed the original tooth to be necrotic, as she had said five months before. Evidence of the infection was clear in the surrounding bone. Her dentist records that the delay in treating the original dental infection appears to have triggered a systemic response in my body’s autonomic or endocrine system. Having had perfect health, eventually I had to have 12 root canals; all those teeth were necrotic. Confronted by the facts, the first dentist Keren saw said that, had he been in his Athens surgery, he would have carried out a root canal on the original tooth. But here, in the UK, he had been concerned he could be held to account by General Dental Council (GDC) regulations, given the X-ray image had not been “definitive”. An editorial in the British Dental Journal (BDJ) as long ago as 2014 described a climate of “fear and distrust” that had led to defensive dentistry because of the prospect of legal action or disciplinary procedures if anything goes wrong. Karen's case is a horrific example of excessive diagnostic testing delay, instead of treatment. Months of referrals to neurologists, maxillo-facial specialists, psychologists, GPs, oral medicine departments and other dentists went against common sense and ensured responsibility could never be laid at a particular dentist’s door. Invariably, the first question was: “What did the last dentist say?”
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Content ArticleSharon Hartles is a critical criminologist and member of the Open University’s Harm and Evidence Research Collaborative. In this article, Sharon reflects on the significant impact of the harm caused by Primodos, a widely used hormone pregnancy test prescribed to women in the UK between 1958 and 1970. Primodos is now known to cause miscarriage, stillbirth and birth defects, and this article examines the culture of denial and an absence of state and corporate pharmaceutical accountability that allowed patients to continue to be harmed over decades.
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Content ArticleThe newly released Ockenden report into maternity services at Shrewsbury and Telford NHS trust is at least the fourth similar report in recent years, with two more in progress. Many messages are not new, and these are not isolated findings. Women and families accessing care throughout the UK continue to feel ignored. Many families remain concerned that they are not receiving full and frank investigations and explanations after the death or injury of a mother or baby. Repeated headlines understandably undermine women’s confidence in services when they should be able to trust that they will receive safe, high quality care writes Marian Knight and Susanna Stanford in this BMJ Editorial.
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Content ArticleIn this article, the first in a series of two on pelvic mesh and its medicolegal challenges, Dr Ivan Ramos-Galvez, Consultant in Pain Medicine and expert witness, explores the uses of pelvic mesh and the complications that can arise. The second in the series focuses on the physical and psychological effects pelvic mesh implants can have on claimants.
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Content ArticleThis analysis by Paul Gallagher, Health Correspondent at i News discusses the prevalence of maternity scandals in the NHS, in light of the publication of the Ockenden Review into failings in maternity services at Shrewsbury and Telford NHS Trust. He highlights the importance of implementing the findings of the review, particularly focusing on the need for a comprehensive plan to tackle workforce shortages. He also highlights the continued existence in some trusts of a culture of covering up harm, evidenced by staff at Shrewsbury being pressured not to talk to investigators, right up until the report's publication.
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Content ArticleThis report presents the findings and conclusions of an independent review into clinical governance arrangements within maternity services at The North West London Hospitals NHS Trust. The independent review was set up following three maternal deaths in one year and two other serious untoward incidents (SUIs) in the Trusts's maternity unit.
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Content ArticleOut-of-hours discharge from the intensive care unit (ICU) to the ward is associated with increased in-hospital mortality and ICU readmission. This study in the journal Critical Care Medicine was part of the REcovery FoLlowing intensive CarE Treatment mixed methods study. It aimed to map the discharge process and describe the consequences of out-of-hours discharge to inform practice changes to reduce the impact of discharge at night. The study identified significant limitations in out-of-hours care provision following overnight discharge from ICU. The authors recommend changes to help make daytime discharge more likely, and new systems to ensure patient safety where night time discharge is unavoidable.
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Content ArticleThis is the transcript of a statement given in the House of Commons by the Secretary of State for Health and Social Care, Sajid Javid MP, in response to the publication of the final report of the Ockenden Review. In the statement he makes a commitment that the local trust, NHS England and the Department of Health and Social Care will accept all 84 recommendations made by the Review. This is followed by questions from MPs in the Chamber and Mr Javid's responses.
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Content ArticleNHS Resolution has published a set of three reports which explore clinical issues that contribute to compensation claims within Emergency Departments.
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Content ArticleThe Patient Safety Movement are looking for patients, family members, health workers and administrators to reach out if they have an experience related to harm or death due to a medication error in the operating room. While the specific numbers may be debated, that medication errors, while rare in the operating, could have catastrophic consequences. The Patient Safety Movement are interested in hearing your perspective concerning this issue. Please email events@patientsafetymovement.org if you have a story that you’d like to share. If you are worried about anonymity please submit your story at the link below.
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Content Article
In this blog Patient Safety Learning sets out its initial response to the report of the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust (also known as the Ockenden Maternity Review).- Posted
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Content ArticleThe Independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust was commissioned in 2017 to assess the quality of investigations relating to newborn, infant and maternal harm at the Trust. When it commenced this review was of 23 families’ cases, but it has subsequently grown to cover cases of maternity care relating to 1,486 families, the majority of which were patients at the Trust between the years 2000 and 2019. Some families had multiple clinical incidents therefore a total of 1,592 clinical incidents involving mothers and babies have been reviewed with the earliest case from 1973 and the latest from 2020.
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Content ArticleIn this article in the journal Health Expectations, the authors explore how current investigative responses can increase the harm for all those affected by failing to acknowledge and respond to the human impacts. They argue that when investigations respond to the need for healing alongside learning, it can reduce the level of harm for everyone involved, including including patients, families, health professionals and organisations.
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Content ArticleAt the moment, we’ve got maternity scandals day in, day out, which are pure evidence of the fact that our maternity units are just not up to scratch. They’re unsafe for mothers, unsafe for babies, and that is not acceptable. Suzanne White, a former radiographer and a clinical negligence lawyer for the past 25 years, looks at the maternity safety scandals across the NHS and considers if any lessons have been learnt.
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In this blog Patient Safety Learning’s Chief Executive, Helen Hughes, discusses the connection between procurement, supply chains and patient safety, ahead of an upcoming Safety for All Campaign webinar on this topic. -
Content Article
CORESS reports
Patient Safety Learning posted an article in Surgery
CORESS is an independent charity, which aims to promote safety in surgical practice in the NHS and the private sector. CORESS receives confidential incident reports from surgeons and theatre staff. These reports are analysed by the Advisory Board, who make comments and extract lessons to be learned. Aiming to educate, and avoid blame, CORESS calls on surgeons to recognise a near miss or adverse event, react by taking action to stop it happening and then report the incident to CORESS so that the lessons can be published. Every month CORESS highlight's one of the cases reported for you to consider the issues raised and read the experts comments. -
Content ArticleMedication errors are the most common adverse event in hospitals and have significant economic and health consequences. This white paper developed by the European Collaborative Action on Medication Errors and Traceability (ECAMET) Alliance collects the results of a pan-European survey on medication errors. It includes 25 reports comprising 13 country reports in English, eight translations in other languages, a private hospitals report, specialised oncology and ICU reports and one consolidated report. It makes several recommendations to reduce medication errors in hospitals and highlights the need to: establish a culture of safety. create strategies to improve communication. raise awareness and organise regular multi-disciplinary training meetings. systematically use accreditation/certification systems. introduce technological tools.
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Content ArticleHealthcare professionals have a duty to be open and honest with patients and people in their care when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress. This is know as the professional duty of candour. This joint guidance from the General Medical Council and Nursing & Midwifery Council provides detailed guidance for healthcare professionals on: being open and honest with patients in your care, and those close to them, when things go wrong. encouraging a learning culture by reporting errors.
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Content ArticleThis US study in The Journal of Nursing Care Quality examined the relationship between nurse-reported patient safety grades and both burnout and the nursing work environment. It found that healthcare organisations may reduce negative patient safety ratings by reducing nurse burnout and improving the work environment at an organisation-wide level.
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Content ArticleSurgical fires, which in the perioperative environment is a fire that occurs on or in a patient while in the operating theatre, are recognised as an international patient safety concern. This is due to the risks of injury to both patients and healthcare professionals. Surgical fires are categorised as either airway or non-airway and occur most commonly in the head, face, neck, upper chest or during ENT surgical procedures. The Association for Perioperative Practice (AfPP) along with a coalition of patient safety focused organisations are calling for more to be done to prevent surgical fires. Lindsay Keeley, patient safety and quality lead for the AfPP, explains why such incidents must be classified as ‘Never Events’, the common causes of surgical fires and the AfPP recommendations and standards for safe use of devices.
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