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Found 1,328 results
  1. Content Article
    On 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.  
  2. News Article
    Dozens 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
  3. News Article
    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
  4. News Article
    Campaigners 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
  5. News Article
    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
  6. Content Article
    In 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.
  7. Content Article
    A common theme of recent international inquiries is that well intentioned investigations often make things worse. Harm is compounded when we fail to listen, validate and respond to the rights and needs of all the people involved. When lengthy processes do not result in meaningful action, suffering can be exacerbated and result in further damage to wellbeing, relationships, and trust. At its worst, compounded harm produces undesirable outcomes such as a community believing an essential service is unsafe, or a clinician leaving their profession. In considering how best to respond, it is important to remember that health systems are comprised of people and relationships, as well as rules and processes. Once we think about safety as a human and relational approach, rather than one that only seeks to lessen risk and enforce regulation, we can consider how to best proceed. Whether an act is intentional or not, a dignifying approach involves working together to repair the harm involved. Restorative responses are ideal for this purpose, as Jo Wailling, Co-chair of the National Collaborative for Restorative Initiatives in Health Aotearoa New Zealand, explains in this blog on the Patient Safety Commissioner website.
  8. News Article
    Ministers must begin paying compensation to the families of children disabled by the epilepsy drug sodium valproate by next year, a report will say this week. The report’s author, Dr Henrietta Hughes, England’s patient safety commissioner, says valproate is “a bigger scandal than thalidomide, in terms of the numbers of people affected”. She will back calls for financial redress for the thousands of children left physically and mentally disabled. Every month, three babies are still being born who have been exposed to the drug. Speaking before the report’s launch, Hughes, 54, a GP, said the state had failed pregnant women by not telling them about key information regarding the drug’s risks. “These families have already been betrayed, because they weren’t given the right information to be able to make decisions to keep themselves and their family safe,” she said. “There are senior politicians of every stripe who have expressed their sincere sympathy and support for patients who have been harmed. I take the view that people who seek high office need to also accept the responsibility that comes with that high office. “The time for redress is now. The government is responsible. I’ve been asked to give them options for redress and I’ve done that. They have the recommendations, they have the advice, they have everything they need. Get on with it.” Read full story (paywalled) Source: The Times, February 2024
  9. Content Article
    Join Alan Lindemann, an obstetrics-gynecology physician, who shares his insights and real-life experiences, shedding light on the issues surrounding patient care, medical decision-making, and the role of institutions and personal connections in shaping health care outcomes. Discover how the pursuit of quality care can sometimes be obstructed by self-interest and the need to protect reputations. Alan also proposes innovative ideas to enhance transparency and public involvement in health care quality assurance.
  10. News Article
    “What if I told you one of the strongest choices you could make was the choice to ask for help?” says a young, twentysomething woman in a red sweater, before recommending that viewers seek out counselling. This advert, promoted on Instagram and other social media platforms, is just one of many campaigns created by the California-based company BetterHelp, which offers to connect users with online therapists. The need for sophisticated digital alternatives to conventional face-to-face therapy has been well established in recent years. If we go by the latest data for NHS talking therapy services, 1.76 million people were referred for treatment in 2022-23, while 1.22 million actually started working with a therapist in person. While companies like BetterHelp are hoping to address some of the barriers that prevent people from seeking therapy, such as a dearth of trained practitioners in their area, or finding a therapist they can relate to, there is a concerning side to many of these platforms. Namely, what happens to the considerable amounts of deeply sensitive data they gather in the process? Moves are now under way in the UK to look at regulating these apps, and awareness of potential harm is growing. Last year, the UK’s regulator, the Medicines and Healthcare products Regulatory Agency (MHRA) and the National Institute for Health and Care Excellence (Nice), began a three-year project, funded by the charity Wellcome, to explore how best to regulate digital mental health tools in the UK, as well as working with international partners to help drive consensus in digital mental health regulations globally. Holly Coole, senior manager for digital mental health at the MHRA, explains that while data privacy is important, the main focus of the project is to achieve a consensus on the minimum standards for safety for these tools. “We are more focused on the efficacy and safety of these products because that’s our role as a regulator, to make sure that patient safety is at the forefront of any device that is classed as a medical device,” she says. Read full story Source: The Guardian, 4 February 2024
  11. News Article
    Concerns have been raised that patients may not be receiving “vital” safety information after HSJ discovered a high-risk medication was frequently not being dispensed as originally packaged. In 2018, the Medicines and Healthcare Products Regulatory Agency asked pharmacies to dispense valproate-containing medications in their original pack where possible, to ensure packages include safety warnings. It also asked manufacturers to produce smaller pack sizes and add pictorial warnings, while pharmacists were additionally asked to add stickered warnings to the outer box of any valproate-containing medication not dispensed in its original packaging. Yet, data obtained via freedom of information requests to the NHS Business Services Authority revealed that while the proportion and number of valproate-containing items dispensed as split packs – as opposed to whole packs – had decreased over the last five years, split packs still accounted for more than half of items dispensed in 2022-23. Emma Murphy, of campaign group In-Fact, said the figures on split pack dispensing were “quite horrifying” and showed “the system is not working”. She added: “Attitudes have got to change – prescribers, GPs etc need to be proactive and warn women of the risks because this isn’t just a side effect, this is harming real babies. As a mum of five affected children, the consequences of valproate in pregnancy on that baby is devastating.” Alison Fuller, of Epilepsy Action, said the high proportion of split packs being dispensed made it “clear why the change in guidance introduced in October 2023 was necessary”, adding: “The manufacturer’s original full pack always contains all the relevant information, which is why it’s the best option for patient awareness.” Read full story (paywalled) Source: HSJ,
  12. Content Article
    Sentinel Event Alert newsletters identify specific types of sentinel and adverse events and high risk conditions, describes their common underlying causes, and recommends steps to reduce risk and prevent future occurrences. Accredited organisations should consider information in a Sentinel Event Alert when designing or redesigning processes and consider implementing relevant suggestions contained in the alert or reasonable alternatives.
  13. Content Article
    An otherwise healthy patient is taken to the operating room for the removal of a neck mole under monitored sedation. After the patient is given two litres of oxygen through nasal cannula and administered intravenous sedation, an alcohol-based skin preparation is applied to the surgical field. As the surgeon uses electrocautery to coagulate bleeding, a flash occurs, and the surgical drapes ignite. After extinguishing the fire by pouring water on the surgical field, assessment of the patient reveals second-degree burns on the patient’s face. Oxygen from the nasal canula had accelerated the fire and caused the nasal cannula to melt and adhere to the patient’s face. The patient was transferred to the burn unit for care, and ultimately required reconstructive plastic surgery. This case illustrates one type of injury that can be sustained during a surgical fire.  The Joint Commission issues this alert to help healthcare organizations recommit to surgical fire prevention.
  14. News Article
    A major review into a mental health unit abuse scandal has found a catalogue of failings, including repeated missed opportunities to act on concerns, and a board “disconnected” from the realities faced by patients and staff. The independent review into failings at Greater Manchester Mental Health Foundation Trust was published today, commissioned after BBC Panorama revealed a “toxic culture of humiliation, verbal abuse and bullying” at Edenfield Centre in Prestwich in September 2022. The trust’s then chair, Rupert Nichols, resigned in November 2022, and CEO Neil Thwaite stepped down in spring last year. Review chair Professor Oliver Shanley, a former mental health trust CEO and chief nurse, describes in his report how the trust’s culture and leaders’ “insufficient curiosity” contributed to the “invisibility” of the deterioration in care quality. He says its board was focused on “expansion, reputation and meeting operational targets”. Read full story (paywalled) Read the report of the Independent Review into Greater Manchester Mental Health NHS Foundation Trust Source: HSJ, 31 January 2024
  15. News Article
    Unregulated healthcare workers are a risk to the most vulnerable patients, a former victim’s commissioner has warned after The Independent and Sky News uncovered a “horrifying” sexual abuse scandal within NHS mental health services. Dame Vera Baird called for a formal framework for healthcare assistants and support workers, who do not have a mandatory professional register like doctors and nurses and can “come in and go out from one hospital to another” without the same thorough checks. Dame Vera told The Independent that the setup did not lead to a “very safe way of working” because healthcare assistants are “in an environment where they are responsible for vulnerable people”. “If there has been abuse from mental health care assistants who are also agency staff who are coming in and going out from one hospital to another, that needs to be looked at,” she said. “This is not a very safe way of working. Some kind of framework around agency staff seems to be very important [to have].” She warned that sexual predators may go into mental health services and work in units where patients can be “highly sexualised”, prompting a “dreadful combination”. Read full story Source: The Independent, 30 January 2024
  16. News Article
    Physician associates have attempted to illegally prescribe drugs at dozens of NHS trusts and missed life-threatening diagnoses, a dossier claims. Doctors working across the country claim patients’ lives have been put at risk by physician associates (PAs) who they say have failed to respond appropriately to medical emergencies – alleging more than 70 instances of patient harm and “near misses”. The Telegraph has seen responses from more than 600 doctors to a survey on PAs run by Doctors’ Association UK (DAUK), a campaign group. The data suggest that at over half of England’s hospital trusts, doctors are being replaced by PAs on the rota, despite associates only completing a two-year postgraduate course and having no legal right to prescribe. A spokesperson from the Department of Health said their role “is to support doctors, not replace them”. The Telegraph has interviewed more than a dozen surveyed doctors, as well as other clinicians worried about patient safety. At Dudley Group NHS Trust, one junior doctor said a PA had missed an “obvious heart attack” on an ECG, having “just signed it as if it was normal”. A clinician in primary care alleged PAs repeatedly misdiagnosed a patient’s metastatic cancer as muscle ache – despite blood results that were “tantamount” to a cancer diagnosis. They said: “The patient could have been saved eight months of pain; their life could have been prolonged.” Read full story (paywalled) Source: The Telegraph, 27 January 2024
  17. Content Article
    Young mother and former GB youth swimmer, Alexis, agrees to enter NHS England psychiatric care following a family tragedy. She could never imagine that her three-day admission will turn into a three-year ordeal. Then undiagnosed with autism, and often the subject of 24-hour surveillance as well as long periods in solitary confinement, Alexis descends to the darkest reaches of locked-in, psychiatric care. There, she encounters the kind of threat she never could have imagined in a secure mental health hospital. In a bid to break free, Alexis plots a daring escape. This series discusses rape and sexual assault.
  18. News Article
    Tens of thousands of sexual assaults and incidents have been reported in NHS-run mental health hospitals as a “national scandal” of sexual abuse of patients on psychiatric wards can be revealed. Almost 20,000 reports of sexual incidents in the last five years have been made in more than half of NHS mental health trusts, according to exclusive data uncovered in a joint investigation and podcast by The Independent and Sky News. The shocking findings, triggered by one woman’s dramatic story of escape following a sexual assault in hospital revealed in a podcast, Patient 11, show NHS trusts are failing to report the majority of incidents to the police and are not meeting vital standards designed to protect the UK’s most vulnerable patients from sexual harm. Throughout the 18-month investigation, multiple patients and their families spoke to The Independent about their stories of sexual assault and abuse while locked in mental health units. Dr Lade Smith, president of the Royal College of Psychiatrists, called the findings “horrendous”, while shadow health secretary Wes Streeting said it was a “wake-up call” for the government. Dr Smith told The Independent: “There is no place for sexual violence in society, which has a profound and long-lasting negative impact on people’s lives. Today’s horrendous findings show that there is still much to do to make sure that patients and staff in mental health trusts are protected from sexual harms at all times. “It is deeply troubling to see that so many incidents in mental health settings go unreported.” Read full story Source: The Independent, 29 January 2024
  19. News Article
    More than 30 members of staff at a major NHS mental health hospital have been suspended over claims of serious misconduct including falsifying medical records and mistreating patients, The Independent has learned. The suspensions come after an internal investigation into serious conduct allegations at Highbury Hospital in Nottinghamshire, which employs hundreds of staff members. The suspended employees include registered professionals – such as doctors, nurses and nursing associates – and non-registered professionals, which would cover healthcare assistants and non-clinical staff. It comes just a week after the same trust – Nottinghamshire Healthcare Foundation Trust – was issued with a warning by the safety watchdog over concerns about the safety of patients at Rampton Hospital, a high secure hospital which has housed patients such as Charles Bronson and Ian Huntley. In an email leaked to The Independent, the trust told staff: “We are saddened to report that over recent weeks it has been necessary to suspend over 30 colleagues due to very serious conduct allegations. “These allegations have included falsifying mental health observations, as well as maltreatment of patients in our care. “We hope we have your understanding in taking action when the conduct of colleagues falls so far outside of what patients deserve.” Read full story Source: The Independent, 23 January 2024
  20. Content Article
    Sharing his own personal experiences of harm, Richard highlights four routes where patients and families can report patient safety incidents to ensure patients' voices can be heard and, most importantly, acted upon.
  21. News Article
    Four carers who were convicted of abusing patients at a secure hospital have been given suspended sentences. An undercover BBC Panorama investigation showed patients being mocked by staff at Whorlton Hall in County Durham between 2018 and 2019. The four former staff, who are all men, were sentenced on Friday after being convicted by a jury last year. Judge Chris Smith said Whorlton Hall was an "unpredictable and inherently frightening place to live". The specialist hospital for people with complex needs was privately run by Cygnet, but funded by the NHS. It has since closed. Judge Smith said Whorlton Hall had a "malign culture" and was an "unpredictable and inherently frightening place to live." He added: "Each of you failed those patients and their families. It was a fundamental breach of trust." Read full story Source: BBC New, 20 January 2024
  22. Content Article
    This constructive commentary reflects on two recent related publications, the Healthcare Safety Investigation Branch (HSIB) report, Variations in the delivery of palliative care services to adults, and an article from Sarcoma UK, Family insights from Dermot’s experience of sarcoma care. Drawing from these publications, Richard, brother-in-law of Dermot, gives a family perspective, calling for a more open discussion around how we can improve palliative care and sarcoma services, and why we must listen and act upon family and patient experience and insight.
  23. News Article
    One of Britain’s three high-security hospitals – where notorious people including Ian Huntley and Charles Bronson have been detained – is so understaffed that neither workers nor patients are safe, a damning new report has found. Rampton Hospital in Nottingham faces severe staff shortages, leading workers to restrain patients and lock them away in their rooms and putting patients at risk of self harm, according to the Care Quality Commission. In a report looking into the hospital, inspectors – who rated the hospital as inadequate – said there were around half the staff needed on one ward. In one example of those at the hospital being at risk, a patient self-harmed with glass from their watch, while another was able to harm themselves with a CD while they were confined to their room. One deaf patient was secluded several times on another ward for “being loud”, according to the CQC. “We spoke with people in the learning disabilities services who told us they sometimes get locked in their room from dinner time until the next morning,” the report said. “They told us that they don’t like being locked in their rooms.” Read full story Source: The Independent, 17 January 2024
  24. News Article
    An unprecedented medicines shortage in the NHS is endangering lives, pharmacists have said, as unpublished figures reveal that the number of products in short supply has doubled in two years. A treatment for controlling epileptic seizures was the latest to be added on Wednesday to a UK drugs shortage list that includes treatments for conditions ranging from cancer to schizophrenia and type 2 diabetes. Causes of the crisis are thought to include the plummeting purchasing value of the pound since the Brexit referendum, which reduces the NHS’s ability to source medicines abroad, and a government policy of taxing manufacturers. According to Department of Health and Social Care (DHSC) figures provided to the British Generic Manufacturers Association, there were 111 drugs on a shortages list on 30 October last year and 96 on 18 December, with supply notifications issued for a further 10 treatments to NHS providers in the UK since then. It amounts to a 100% increase in shortages compared with January 2022, with pharmacists and health charities claiming the conditions of some patients were deteriorating as a result. Delyth Morgan, the chief executive of Breast Cancer Now, said her organisation had been contacted over the past 12 months by several patients unable to source the medicines they needed to control the spread of their disease. She said: “Last year many people shared with us, via Breast Cancer Now’s helpline, that they’d been facing difficulties accessing their hormone treatment including letrozole, anastrozole and tamoxifen, causing them huge worry and anxiety. Trying to track down a treatment by travelling to a number of different pharmacies is an added burden for patients at an already difficult time. “It may also sometimes be that certain brands of drugs are out of stock and people may have to switch to another brand or different drug. In the worst case someone may have a period of time without the medication, a drug which could help reduce the risk of their breast cancer coming back or spreading.” Read full story Source: The Guardian, 14 January 2024
  25. News Article
    People who go abroad for weight-loss surgery, and then need urgent medical care back in the UK, cost the NHS more than it costs to carry out the operation itself, according to new research. A study featuring five London hospitals recorded the details of 35 people who had suffered complications after travelling abroad for gastric surgery during 2022. The data, shared with the BBC's Disclosure programme, shows the patients suffered from a range of symptoms including severe malnutrition, vomiting, sepsis, hernias and haemorrhaging. Five of them needed feeding tubes inserted, while the average stay in hospital was 22 days. The interventions at the five hospitals for the 35 patients cost the NHS a total of £560,234, or £16,006 per patient, in 2022. The equivalent amount would have covered the cost of about 110 bariatric surgeries in UK hospitals. Consultant bariatric surgeon Omar Khan, one of the lead authors of the study, said the paper was intended "to try and quantify" the effect on the NHS of increasing numbers of people going abroad for weight-loss surgery - sometimes known as bariatric tourism. "We know that the waiting lists in the NHS are unfortunately long. We also know that there are new units, particularly in Turkey, which have been set up to cater for an international market," he explained. "We focused on patients with major complications, patients who were severely ill. They had leaks from the stomach, they had bleeding, they had infections. A significant portion required further surgery and some required revisional surgery." Read full story Source: BBC News, 15 January 2024
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