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Showing results for tags 'Patient harmed'.
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News Article
Young people put at risk by delays for treatment
Patient Safety Learning posted a news article in News
More than 70 children and young people have been put at risk by long delays in treatment by mental health services in Kent and Medway, HSJ has learned. According to a response to a Freedom of Information request submitted by HSJ, 205 harm reviews have been carried out for patients waiting for treatment following a referral to the North East London Foundation Trust, which runs the child and adolescent mental health services in Kent and Medway. Of those, 76 patients, who had all waited longer than the 18 week target time for treatment, were found to be at risk of harm. One patient had to be seen immediately as they were judged to be at “severe” risk. Seven were found to be at “moderate” risk and 68 at “low” risk. The trust said “risk” meant a risk of harm to themselves or others. But it said none of the 76 patients had come to actual harm. Read full story (paywalled) Source: HSJ, 25 February 2020 -
Content Article
Mesh implantation: Inside Out (East)
Claire Cox posted an article in Patient stories
BBC reporter, Julie Reinger, talks to women who have had mesh implants after childbirth ahead of an independent report into the procedure. -
Content ArticleThe Association for Perioperative Practice (AfPP) is calling for action to be taken after a recent never events report suggests little progress has been made to prevent errors within the perioperative environment.
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Content ArticlePresentation from Dr Neelam Dhingra-Kumar, Coordinator, Patient Safety and Risk Management, at the World Health Organization's "A Global Consultation – A decade of Patient Safety 2020–2030".
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News Article
Scottish mesh implant women to be offered case reviews
Patient Safety Learning posted a news article in News
Women in Scotland who have experienced complications following vaginal mesh surgery are to be offered an independent review of their case notes. Mesh implants have been used to treat conditions some women suffer after childbirth, such as incontinence and prolapse. However, many women experienced painful, debilitating side effects. Some of the women who have suffered complications met First Minister Nicola Sturgeon last November. She was told a number of them had understood the mesh would be completely removed but that had not happened, leaving some of the synthetic substance still attached. After hearing about their experiences, Ms Sturgeon has now written to the women she saw, confirming that in the spring they will be given the chance to sit down with an independent clinician for a review of their case notes. That will be followed up by a report and possible referral to specialist care. The case note review will initially only be offered to those who attended the first minister's meetings however, it may be offered more widely at a later date. Read full story Source: BBC News, 23 February 2020 -
News Article
Patients at risk in ‘crumbling’ mental health wards, NHS leaders warn
Patient Safety Learning posted a news article in News
Patient safety is at risk in “crumbling” NHS mental health hospitals starved of the money needed to improve dilapidated buildings, new data has revealed. Hundreds of vulnerable mentally ill patients are still being cared for in 350 old dormitory-style wards, 20 years after the NHS was told to provide all patients with en-suite rooms. A lack of funding to refurbish hospitals has also meant too many wards still have ligature points that patients can use to try to harm themselves. NHS leaders said the lack of cash from the government meant they could not deal with warnings issued by the Care Quality Commission (CQC), the sector’s watchdog. A survey of mental health trust leaders by NHS Providers has now found bosses are worried the state of psychiatric wards is undermining their ability to keep patients safe. Read full story Source: The Independent, 20 February 2020 -
News Article
Infected Blood Enquiry: Timetable and factsheet for expert hearings
Clive Flashman posted a news article in News
This is the independent public statutory inquiry into the use of infected blood. The timetable and factsheet to provide information for those attending the hearings in London on 24-28 February have just been published. Go to this link for more information >> https://www.infectedbloodinquiry.org.uk/news -
Content ArticleThe independent inquiry into how the rogue breast surgeon Ian Paterson was able to inflict harm on patients over more than decade described the UK healthcare system as “dysfunctional at almost every level.” In this BMJ analysis, Gareth Iacobucci summarises the findings of the inquiry.
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News Article
Surgeon suspended over treatment concerns
Patient Safety Learning posted a news article in News
A doctor who worked at the same private healthcare firm as rogue breast surgeon Ian Paterson has been suspended, it has emerged. Spire Healthcare said Mike Walsh – a specialist in trauma and orthopaedic surgery – was suspended in April 2018 over concerns about patient treatment. Almost 50 of his patients from its Leeds hospital had been recalled. The details emerged following an independent inquiry into Paterson, who is serving a 20-year jail sentence. Earlier this month, an inquiry into the breast surgeon found that a culture of "avoidance and denial" had allowed him to perform botched and unnecessary operations on hundreds of women. Spire said in a statement that it acted after concerns were raised about Mr Walsh's work at its hospital in Leeds in 2018. The company, which contacted the Royal College of Surgeons to assist with its investigation, said it had reviewed the notes of fewer than 200 patients, of which "fewer than 50" had been invited back for a follow-up appointment. "Where we have identified concerns about the care a patient received, we have invited the patient to an appointment with an independent surgeon to review their treatment," a spokesman for Spire Healthcare said. "This is a complex case and the review is ongoing." It said that Mr Walsh, who was immediately suspended after the concerns were raised, was no longer working with Spire Healthcare. The company said any patients at its Spire Leeds Hospital who had concerns about their treatment under Mr Walsh should contact the hospital. It said its findings had also been shared with the Care Quality Commission and the General Medical Council (GMC). Read full story Source: BBC News, 17 February 2020 -
News ArticleThe Equality and Human Rights Commission have launched a legal challenge against the Secretary of State for Health and Social Care over the repeated failure to move people with learning disabilities and autism into appropriate accommodation. Their concerns are about the rights of more than 2,000 people with learning disabilities and autism being detained in secure hospitals, often far away from home and for many years. These concerns increased significantly following the BBC’s exposure of the shocking violation of patients’ human rights at Whorlton Hall, where patients suffered horrific physical and psychological abuse. The Equality and Human Rights Commission have sent a pre-action letter to the Secretary of State for Health and Social Care, arguing that the Department of Health and Social Care (DHSC) has breached the European Convention of Human Rights (ECHR) for failing to meet the targets set in the Transforming Care program and Building the Right Support program. These targets included moving patients from inappropriate inpatient care to community-based settings, and reducing the reliance on inpatient care for people with learning disabilities and autism. Rebecca Hilsenrath, Chief Executive of the Equality and Human Rights Commission, said: 'We cannot afford to miss more deadlines. We cannot afford any more Winterbourne Views or Whorlton Halls. We cannot afford to risk further abuse being inflicted on even a single more person at the distressing and horrific levels we have seen. We need the DHSC to act now." "These are people who deserve our support and compassion, not abuse and brutality. Inhumane and degrading treatment in place of adequate healthcare cannot be the hallmark of our society. One scandal should have been one too many." Read full story Souce: Equality and Human Rights Commission, 12 February 2020
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Content ArticleThe Independent Inquiry into the Issues raised by Paterson, published on Tuesday 4 February 2020, was prompted by the case of Ian Paterson, a breast surgeon who was convicted of wounding with intent some of the 11,000 patients he treated and jailed for 20 years in 2017. More than 200 patients and family members gave evidence as part of the Inquiry and it is estimated that he could have harmed more than 1000 patients.[1] The Inquiry gave those involved an opportunity to be heard and to learn how this happened, in both the NHS and the independent sector. It found that this “is the story of a healthcare system which proved itself dysfunctional at almost every level when it came to keeping patients safe, and where those who were the victims of Paterson’s malpractice were let down time and time again”.[2] At Patient Safety Learning we have reflected on some of the key patient safety themes that have emerged from this Inquiry and the actions required these issues. You can read Patient Safety Learning's full response here.
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News Article
Fast response to terror attacks saves lives. UK medics should not be held back
Patient Safety Learning posted a news article in News
The Streatham terrorist attack has again highlighted one of the most difficult decisions the emergency services face – deciding when it is safe to treat wounded people. In the aftermath of the stabbings by Sudesh Amman, a passer-by who helped a man lying on the pavement bleeding claimed ambulance crews took 30 minutes to arrive. The London Ambulance Service (LAS) said the first medics arrived in four minutes, but waited at the assigned rendezvous point until the Metropolitan police confirmed it was safe to move in. Last summer, the inquest into the London Bridge attack heard it took three hours for paramedics to reach some of the wounded. Prompt treatment might have saved the life of French chef Sebastian Belanger, who received CPR from members of the public and police officers for half an hour. A LAS debriefing revealed paramedics’ frustration at not being deployed sooner. A group of UK and international experts in delivering medical care during terrorist attacks have highlighted alternative approaches in the BMJ. In Paris in 2015, the integration of doctors with specialist police teams enabled about 100 wounded people in the Bataclan concert hall to be triaged and evacuated 30 minutes before the terrorists were killed. The experts writing in the BMJ believe the UK approach would have delayed any medical care reaching these victims for three hours. These are perilously hard judgment calls. Policymakers and commanders on the scene have to balance the likelihood that long delays in intervening will lead to more victims dying from their injuries against the increased risk to the lives of medical staff who are potentially putting themselves in the line of fire by entering the so-called 'hot zone'. First responders themselves need to be at the forefront of this debate. As the people who have the experience, face the risks and want more than anyone to save as many lives as possible, their leadership and insights are vital. In the wake of the Streatham attack the government is looking at everything from sentencing policy to deradicalisation. Deciding how best to save the wounded needs equal priority in the response to terrorism. Read full story Source: The Guardian, 7 February 2020 -
News Article
Teeth-whitening: Reports of illegal procedures up 26%
Patient Safety Learning posted a news article in News
Reports of illegal teeth-whitening that could leave patients at risk of health problems including burns or lost teeth have increased, the BBC has found. General Dental Council (GDC) figures showed a 26% rise in reports last year. Teeth-whitening can only be performed legally in the UK by professionals registered with the GDC. One beauty school claimed to have provided "thousands" of candidates with illegitimate qualifications, an undercover investigation found. Failure to comply with the requirement to be registered can result in a criminal record and an unlimited fine. Untrained beauticians using teeth-whitening kits have been known to cause tooth loss, burns and blisters. Dr Ben Atkins, president of the Oral Health Foundation, said: "When things go wrong in dentistry, they can really go wrong. I've been that dentist with the full back up service when the patient's had that heart attack. It would be catastrophic for the patient and the person who's been trained and told it's legal to do it." Read full story Source: BBC News, 10 February 2020 -
Community Post*Trigger warning. This post includes personal gynaecological experiences of a traumatic nature. What is your experience of having a hysteroscopy? We would like to hear - good or bad so that we can help campaign for safer, harm free care. You can read Patient Safety Learning's blog about improving hysteroscopy safety here. You'll need to be a hub member to comment below, it's quick and easy to do. You can sign up here.
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News ArticleDozens of women who thought they were having a "complete mesh removal" have discovered material has been left behind, the BBC's Victoria Derbyshire programme has been told. Some women have been left unable to walk, work or have sex after having the initial vaginal-mesh implants. Specialist surgeons say in some cases total or partial mesh removal can be beneficial. But some women said their symptoms had become worse. One was left suicidal. Vaginal-mesh implants remain available on the NHS in England but only when certain conditions are met. In Scotland, the use of mesh was halted in 2018. One paitent said her surgeon had promised her a "full mesh removal", but she has now been told more than 10cm (4in) could have been left behind. She had the mesh implanted several years ago to treat urinary incontinence and said she had woken after the surgery with "chronic pain in my legs, my groin and my hips". It is believed she suffered nerve damage. A year later – after being told by one expert a mesh removal would be unlikely to resolve her pain – she found a surgeon who told her the implant could be completely removed. She had two operations, each taking her half a year to recover from, and was told there had been a full removal. But "within a few months" the pain began to return and her health deteriorated and she found out that only 5–8cm had been removed. "My whole world turned upside down," she said, breaking into tears. She has since been told by a separate specialist her form of mesh was one of the most difficult to remove and could cause significant nerve damage if not removed properly. She said she had never been told this by her surgeon. The number of women affected is unknown but the Victoria Derbyshire programme understands there are at least dozens of such cases. The Royal College of Obstetricians and Gynaecologists said in a statement that it took "each and every complication caused by mesh very seriously". It said: "Women must be informed of all options available and the benefits and risks of each so they can make the best decision about their care." Read full story Source: BBC News, 6 February 2020
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Content ArticleThe Parliamentary Under-Secretary of State for Health and Social Care, Ms Nadine Dorries, responds to the Paterson Inquiry in the House of Commons. It is followed by questions from MPs in the chamber and Ms Dorries' responses.
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News ArticleA whistleblower raised the alarm over patient safety at West Suffolk Hospital because of concerns about the behaviour of a doctor who had been seen injecting himself with drugs, the Guardian has revealed. The incident had already prompted internal complaints from senior staff at West Suffolk hospital, but the whistleblower decided to take matters a step further when the same doctor was later involved in a potentially botched operation. The whistleblower then wrote to relatives of a dead patient and urged them to ask questions about the conduct of the doctor and his background. When they did this, the hospital launched a widely criticised “witch-hunt” in an attempt to find out the identity of the leaker. The doctor’s drug use, which the trust has never acknowledged until now, helps explain why it demanded fingerprint and handwriting samples from staff – tactics which the NHS regulator roundly condemned in a hard-hitting report last week. Read full story Source: Guardian, 5 February 2020
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Content ArticleIn April 2017, Ian Paterson, a surgeon in the West Midlands, was convicted of wounding with intent, and imprisoned. He had harmed patients in his care. The scale of his malpractice shocked the country. There was outrage too that the healthcare system had not prevented this and kept patients safe. At the time of his trial, Paterson was described as having breached his patients’ trust and abused his power. In December 2017, the Government commissioned this independent Inquiry to investigate Paterson’s malpractice and to make recommendations to improve patient safety. This report presents the Inquiry’s methodology, findings and recommendations. More importantly, it tells the story of the human cost of Paterson’s malpractice and the healthcare system’s failure to stop him, and something of the enduring impact this has had on the lives of so many people.
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News Article
Paterson scandal: Is the NHS learning from mistakes?
Patient Safety Learning posted a news article in News
Shipman, Mid Staffordshire, Morecambe Bay, and now Ian Paterson, the breast surgeon that performed botched and unnecessary operations on hundreds of women. The list of NHS-related scandals has got longer. It's tempting to say the health service has not learned lessons even after a string of revelations and reviews. But is that fair? asks BBC Health Editor Hugh Pym. The inquiry, chaired by Bishop Graham James, makes clear there were failings at every level of a dysfunctional health system when it came to patient safety. The public and private health systems did not compare notes about suspicious behaviour by a consultant. Staff working with Paterson thought that his surgical methods were unusual but, perhaps cowed by being ignored after raising concerns, kept their heads down. Add to that the power and status of a surgeon in the medical world and, in the words of the report, Paterson was "hiding in plain sight". So could it happen again? James says it's clearly impossible to eliminate the activities of determined criminals in any profession. He acknowledges that some improvements have been made on policing. But he says that a decade on from the Paterson scandal, he is not convinced that medical regulators, with a combined budget of half a billion pounds a year, are doing enough collectively or collaboratively to make the system safe for patients. The review chair notes tellingly that while regulators spoke of major improvements which should identify another Paterson, some doctors and nurses had told the inquiry that it was "entirely possible that something similar could happen now". Read full story Source: BBC News, 4 February 2020 -
Content ArticleIn April 2017, Ian Paterson, a surgeon in the West Midlands, was convicted of wounding with intent, and imprisoned. He had harmed patients in his care. The scale of his malpractice shocked the country. There was outrage too that the healthcare system had not prevented this and kept patients safe. At the time of his trial, Paterson was described as having breached his patients’ trust and abused his power. In December 2017, the Government commissioned this independent Inquiry to investigate Paterson’s malpractice and to make recommendations to improve patient safety. This report presents the Inquiry’s methodology, findings and recommendations. More importantly, it tells the story of the human cost of Paterson’s malpractice and the healthcare system’s failure to stop him, and something of the enduring impact this has had on the lives of so many people.
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Community PostI’ve just been listening to the 10 o’clock news tonight and it has been covering the report into Paterson, the breast surgeon who may have needlessly operated on thousands on women. One of the recommendations is that patient safety should be a ‘top priority’ across the NHS (again!!). Another interesting recommendation is that the NHS (and private healthcare providers) need to be better at sharing information about medical staff. Currently, medical staff seem to be able to be investigated in one hospital, and then move to another without any of their history following them. Maybe we need some sort of central system, like Doctify for employers? What do you think?
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News Article
Ian Paterson: Surgeon wounded hundreds amid 'culture of denial'
Patient Safety Learning posted a news article in News
A culture of "avoidance and denial" allowed a breast surgeon to perform botched and unnecessary operations on hundreds of women, an independent inquiry has found. The independent inquiry into Ian Paterson's malpractice has recommended the recall of his 11,000 patients for their surgery to be assessed. Paterson is serving a 20-year jail term for 17 counts of wounding with intent. One of Paterson's colleagues has been referred to police and five more to health watchdogs by the inquiry. The disgraced breast surgeon worked with cancer patients at NHS and private hospitals in the West Midlands over 14 years. His unregulated "cleavage-sparing" mastectomies, in which breast tissue was left behind, meant the disease returned in many of his patients. Others had surgery they did not need - some even finding out years later they did not have cancer. Patients were let down by the healthcare system "at every level" said the inquiry chair, Bishop of Norwich the Rt Revd Graham James, who identified "multiple individual and organisational failures". One of the key recommendations from the report is that the Government should make patient safety a the top priority, given the ineffectiveness of the system identified in this Inquiry. Read full story Source: BBC News, 4 February 2020 -
News ArticleA Surrey hospital trust has become the first in the country to appoint a nurse dedicated to preventing patient falls and medication mix-ups. The consultant nurse has been appointed by Ashford and St Peter's (ASP) Hospital NHS Foundation Trust to reduce the number of patients who are injured while being treated at its sites. This includes looking at ways to reduce the amount of people who fall over, suffer with venous thromboembolism or experience tissue damage while in hospitals in north west Surrey. The trust says the harms prevention nurse will be the first in the country hired for such a role and will also work with the team who look at incidents of medication mix-ups and mistakes. Read full story Source: Surrey Live, 4 February 2020
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Content ArticleThis document records the findings of an online survey sent to 7,106 members of the RCN’s Emergency Care Association network exploring their experiences of corridor care.
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Content ArticleThere are few validated tools to identify treatment‐related adverse events across cancer care settings. This study seeks to develop oncology‐specific 'triggers' to flag potential adverse events among cancer patients using claims data.
