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Found 1,334 results
  1. Content Article
    The USA President’s Council of Advisors on Science and Technology have released their report to the US President, Joe Biden, on patient safety. The report contains recommendations aimed at dramatically improving patient safety in Amercia.
  2. Content Article
    The horrifying case of neonatal nurse Lucy Letby, convicted of murdering seven babies and attempting to murder six others at the Countess of Chester Hospital, has raised hard questions for NHS leaders about how organisations respond to concerns about staff, but could digital systems help detect NHS staff who harm patients at an earlier point? If the pattern connecting Letby to the babies’ deaths had been detected by a digital system, would the response from the trust have been different? Would a machine have been believed?    Alison Leary, chair of healthcare and workforce modelling at London South Bank University and a leading expert on nursing and data, suggests there is potentially a much bigger role for digital in patient safety.
  3. Content Article
    This is an oral statement given to the House of Commons by the Secretary of State for Health and Social Care, Steve Barclay MP, to update on the Lucy Letby statutory inquiry.
  4. News Article
    Two hundred women in the UK who claim they were left in pain after having a permanent contraception device fitted, can now take group legal action through the courts, against its manufacturer. The Essure coil "has caused irreparable damage physically and mentally", the women's lawyers say. German maker Bayer says it will defend itself vigorously against the claims. When Essure was withdrawn from sale, in 2017, the UK medicines regulator said there was no risk to safety. Lawyers in England began legal action in 2020 and now have permission to bring a group claim on behalf of 200 women. Other women wishing to join the group action have until 2024 to do so. The Essure device is a small metal coil inserted into a woman's fallopian tubes. Scar tissue forms around the coil, creating a barrier that keeps sperm from reaching the eggs. Launched in 2002, the device was marketed as a simpler alternative to sterilisation by surgery. But some women say they suffered constant pain and complications, including heavy bleeding, with some ending up having hysterectomies or the device removed altogether. Read full story Source: BBC News, 5 September 2023
  5. Content Article
    In 2020, the Independent Medicines and Medical Devices Safety Review (IMMDS), chaired by Baroness Cumberlege, highlighted the avoidable harm caused by both pelvic and sodium valproate. It also set out the devastating impact on people’s lives when patients’ voices go unheard. The Minister for Mental Health and Women’s Health Strategy, Maria Caulfield MP, asked the Patient Safety Commissioner (PSC) to explore redress options for those who have been harmed by pelvic mesh and sodium valproate. The work will focus on what a suitable redress scheme for those affected should look like, to meet the needs of those affected. 
  6. News Article
    Tonjanic Hill was overjoyed in 2017 when she learned she was 14 weeks pregnant. Despite a history of uterine fibroids, she never lost faith that she would someday have a child. But, just five weeks after confirming her pregnancy she seemed unable to stop urinating. She didn’t realize her amniotic fluid was leaking. Then came the excruciating pain. “I ended up going to the emergency room,” said Hill, now 35. “That’s where I had the most traumatic, horrible experience ever.” An ultrasound showed she had lost 90% of her amniotic fluid. Yet, over the angry protestations of her nurse, Hill said, the attending doctor insisted Hill be discharged and see her own OB-GYN the next day. The doctor brushed off her concerns, she said. The next morning, her OB-GYN’s office rushed her back to the hospital. But she lost her baby. Black women are less likely than women from other racial groups to carry a pregnancy to term — and in Harris County, where Houston is located, when they do, their infants are about twice as likely to die before their 1st birthday as those from other racial groups. Black fetal and infant deaths are part of a continuum of systemic failures that contribute to disproportionately high Black maternal mortality rates. “This is a public health crisis as it relates to Black moms and babies that is completely preventable,” said Barbie Robinson, who took over as executive director of Harris County Public Health in March 2021. “When you look at the breakdown demographically — who’s disproportionately impacted by the lack of access — we have a situation where we can expect these horrible outcomes.” Read full story Source: KFF Health News, 24 August 2023
  7. News Article
    NHS Tayside has been criticised over its handling of disgraced brain surgeon Sam Eljamel in a new report. The internal due diligence review criticised health board management for putting the doctor under indirect supervision in June 2013 rather than suspending him. The surgeon harmed dozens of patients but was allowed to continue operating until he was suspended in late 2013. Some of his patients were left with life-changing injuries. He was employed as a surgeon by NHS Tayside for 18 years and later became the head of the neurosurgery department in Ninewells Hospital in Dundee. NHS Tayside has apologised to former patients of Prof Eljamel and committed to assisting in the Scottish government's independent commission for patient concerns. The health board claimed it became aware of concerns around the surgeon in June 2013, but an NHS whistleblower told the BBC the health board knew as early as 2009 that there were serious concerns. He is now working as a surgeon in Libya. Read full story Source: BBC News, 1 September 2023
  8. News Article
    The inquiry into how nurse Lucy Letby was able to murder seven babies will now have greater powers to compel witnesses to give evidence. In a significant move, ministers upgraded the independent inquiry after criticism from families of the victims that it did not go far enough. The inquiry, ordered after Letby was found guilty this month, was not initially given full statutory powers. Health Secretary Steve Barclay said he had listened to the families. He said he had decided a statutory inquiry led by a judge was the best way forward and "respects the wishes" of the families. Mr Barclay said the key advantage was the power of compulsion. "My priority is to ensure the families get the answers they deserve and people are held to account where they need to be," he added. He said an announcement about who would chair the inquiry would be made in the coming days - ministers have already said it will be a judge. Richard Scorer, a lawyer who is representing two of the families, welcomed the government's announcement. "It is essential that the chair has the powers to compel witnesses to give evidence under oath, and to force disclosure of documents. Without these powers, the inquiry would have been ineffectual and our clients would have been deprived of the answers they need and deserve," he said. Read full story Source: BBC News, 30 August 2023
  9. Content Article
    In this blog, Sling the Mesh founder Kath Sansom highlights the variation in medical treatment depending on where you live in the world. Describing patient safety advocacy as "like a giant game of chess—but a hideous version where innocent people get hurt," she describes recent developments in the use of pelvic mesh globally. New Zealand recently suspended the use of a particular type of pelvic mesh at the same time as a Canadian study recommended its use for stress urinary incontinence (SUI). Kath gives a brief history of mesh sling suspension and argues that patient safety needs joined up thinking to protect women around the world.
  10. News Article
    More than half of NHS staff believe bosses would ignore whistleblowers amid fresh concerns hospitals could be covering up potential scandals following the Lucy Letby case. New national figures seen by the The Independent reveal that in the majority of hospitals, most doctors and nurses do not believe their concerns would be acted upon if they were raised with senior managers. It comes after The Independent revealed that NHS bosses accused of ignoring complaints about Letby were the very same people later appointed to act on whistleblower concerns at the hospital where she murdered seven babies and tried to kill six more. Several doctors who worked alongside her during the killing spree say they attempted to raise the alarm with hospital managers – only to have their pleas ignored. They believe the lack of action by bosses resulted in more babies being killed, stating managers who failed to act were “grossly negligent” and “facilitated a mass murderer”. In nearly three-quarters of general hospitals – such as the Countess of Chester where Letby worked – fewer than half of staff believed their trust would act on a concern, according to results from the latest NHS staff survey. Read full story Source: The Independent, 27 August 2023
  11. Content Article
    In this anonymous blog, a patient shares their experience of orthodontic treatment which they undertook to reduce overcrowding of their teeth. However, instead of solving the problem, the treatment caused multiple, complex dental issues that have resulted in severe pain and a high financial cost. The patient talks about how their orthodontist has been unwilling to take any responsibility for the issues caused, threatening legal action if the patient pursues any claims against them. They also discuss the reluctance of other orthodontists to get involved in trying to treat the issues they now face, and call for regulators and governments to look into the issue of negligent orthodontic treatment.
  12. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them.  Kath talks to us about why she set up Sling the Mesh and the significant impact that campaigning has on her life. She also highlights the need to establish systems that will identify and prevent avoidable harm, including long term tracking to investigate trends of harm, reporting of industry payments to clinicians and making logging side effects mandatory for healthcare professionals.
  13. News Article
    Details of allegations against a surgeon who left dozens of patients in agony after undergoing mesh operations have been published. A tribunal will look at whether Tony Dixon failed to provide adequate clinical care to six patients at Southmead Hospital and the private Spire Hospital in Bristol. He had pioneered the use of artificial mesh to lift prolapsed bowels. The surgeon, who was dismissed in 2019, has always maintained the operations were done in good faith, and that any surgery could have complications. The Medical Practitioners Tribunal, which starts in Manchester on 11 September and is due to end on 23 November, will look into allegations that between 2010 and 2016 Mr Dixon failed to provide adequate clinical care in a number of areas, including: ensuring procedures for some of the patients were clinically indicated adequately advising some of the patients regarding options for treatment obtaining informed consent before performing clinical procedures adequately performing a procedure for one patient providing adequate post-operative care for some communicating appropriately with some of the patients and their family members. Read full story Source: BBC News, 24 August 2023
  14. News Article
    The NHS could face a record compensation bill of more than £60m from civil claims lodged by the families of Lucy Letby’s victims, experts have said. Parents whose babies have disabilities caused by Letby’s attacks at the Countess of Chester hospital could each expect to receive a payout of more than £10m to fund their future care. Compensation paid by the NHS to parents whose babies died or were left with disabilities as a result of care at Shrewsbury hospital in Britain’s largest maternity scandal reportedly amounted to almost £50m. In a separate case, the health service had to pay £37m to a boy who was left brain damaged at birth. Stephen Jones, the head of Leigh Day’s medical negligence team in Manchester, said the trust could argue that by committing the offences, Letby breached the employer-employee relationship to an extent such that it was not responsible for her. But he added: “I think there would be outrage that the trust wouldn’t accept responsibility for babies in their care.” He said compensation could run into eight figures for a family whose baby was severely injured and had a long life expectancy. Emma Wray, a partner in Hodge Jones & Allen’s medical negligence department, suggested the NHS could set up a scheme for victims, as it has done with other scandals, to make claiming compensation easier. Read full story Source: The Guardian, 23 August 2023
  15. Content Article
    In this letter, Rob Behrens, the Parliamentary and Health Service Ombudsman, calls on the Secretary of State for Health and Social Care, Steve Barclay MP, to prioritise improving patient safety in the wake of the Lucy Letby trial.
  16. Content Article
    On 18 August 2023, Lucy Letby was found guilty of murdering seven babies and convicted of trying to kill six other infants at the Countess of Chester Hospital. Looking ahead to the forthcoming independent inquiry into this case, Patient Safety Learning, reflecting on the inquiries of the past, sets out some key patient safety themes and issues that should be considered as part of this.
  17. News Article
    At least 20 patients have suffered harm due to their follow-up appointments not being booked at a hospital department where people ‘continue to come to harm’, according to an internal review. Torbay and South Devon Foundation Trust is reviewing its ophthalmology service after 22 people were harmed following “system failures” with their follow-up appointments. The trust’s initial investigation, obtained by HSJ with the Freedom of Information Act, warned there were “potentially” other patients affected by the failures who had not yet been identified. In response, the trust said its ophthalmology department had already “undertaken a significant amount of work to address a large proportion of the actions arising from the review”, including building another operating theatre and recruiting more staff. Read full story (paywalled) Source: HSJ, 21 August 2023
  18. Content Article
    Babies would have survived if hospital executives had acted earlier on concerns about the nurse Lucy Letby, a senior doctor who raised the alarm has said. In an exclusive Guardian interview, Dr Stephen Brearey accused the Countess of Chester hospital trust of being “negligent” and failing to properly address concerns he and other doctors raised about Letby as she carried out her killings. Brearey was the first to alert a hospital executive to the fact that Letby was present at unusual deaths and collapses of babies in June 2015. The paediatrician and his consultant colleagues raised concerns multiple times over months before Letby, then 26, was finally removed from the neonatal unit in July 2016. The police were contacted almost a year later, in May 2017. Speaking publicly for the first time, Brearey told the Guardian that executives should have contacted the police in February 2016 when he escalated concerns about Letby and asked for an urgent meeting.
  19. News Article
    Patients whose lives were damaged by surgery for bowel problems are calling for a long-awaited report to be published. More than 200 patients underwent mesh bowel operations in Bristol that they might not have needed. The surgery was carried out by Tony Dixon at Southmead Hospital and the private Spire Hospital, in Redland. A review by North Bristol NHS Trust was published in May 2022, but patients are still waiting to hear from Spire. Jill Smith, 69, from Westbury-on-Trym, paid privately to go to Spire. She said she is still in severe pain following her surgery. "Emotionally it has affected me big time. It is just horrible," she said. "The stress and panic I get going anywhere, is, 'will I have an accident or something?'." Read full story Source: BBC News, 18 August 2023
  20. News Article
    A teaching trust has had its maternity services downgraded to ‘inadequate’ after inspectors found stillbirths and massive haemorrhages were not being treated as ‘serious incidents’. Maternity services at St George’s University Hospitals Foundation Trust in south London were previously inspected in 2016, when they were assessed as “good”. The Care Quality Commission (CQC) said serious incident declaration meetings at St George’s were regularly classing serious incidents as “adverse incidents”, meaning executives were not informed and there were missed opportunities for learning and development. Inspectors also found incidents such as severe perineal tears, emergency hysterectomy, and birth injuries were rated as causing low or no harm when a higher level would have been appropriate, or and sometimes downgraded from a higher rating. Carolyn Jenkinson, CQC’s deputy director of secondary and specialist healthcare, said: “We saw areas where significant and urgent improvements are needed to ensure safe care is provided to women, people using this service, and their babies. “Both staff and people using the service were being let down by leaders who failed to respond quickly, resulting in care that was unsafe, and in the delivery suite, also chaotic.” Read full story (paywalled) Source: HSJ, 17 August 2023
  21. Content Article
    The Maternity Survey 2022, run by Ipsos on behalf of the Care Quality Commission, looked at the experiences of women and other pregnant people who had a live birth in early 2022. In this article Anita Jefferson from Ipsos looks at the results of this and considers what they tell us about experiences of maternity services.
  22. News Article
    An 11-year-old boy suffered permanent brain damage after birth because of negligence by hospital midwives who then fabricated notes, a high court judge has ruled. Jayden Astley’s challenges in life include deafness, motor impairments, cognitive difficulties and behavioural difficulties, his lawyers said. After a five-day trial at the high court in Liverpool, Mr Justice Spencer ruled that staff at the Royal Preston hospital in Lancashire were negligent in their treatment of Jayden in 2012. The brain injury was caused by prolonged umbilical cord compression that resulted in acute profound hypoxia – lack of oxygen – sustained during the management of the birth, the court found. Midwives failed to accurately monitor Jayden’s heart rate when he was born and failed to identify his bradycardic, or slow, heart rate during delivery. The judge also found that some entries in notes were fabricated. In his judgment Spencer said it was agreed that all permanent damage to Jayden’s brain would have been avoided if he had been delivered three minutes earlier. Read full story Source: The Guardian, 2 August 2023
  23. News Article
    Every day Sharon Smith has to take a strong morphine tablet to dull the excruciating pain she has lived with for more than a decade. “I am in chronic pain every day. It’s affected our whole family and I’ve lost all my independence,” said Smith, from Leigh, Greater Manchester. Over four years from 2009, she endured three operations on her spine at Salford Royal Hospital, which as an NHS trust was once fêted as England’s safest. But the hospital had a dark secret: an incompetent leading surgeon who, an independent review would later find, had already “contributed” to the death of a girl in 2007. Now a wider investigation has confirmed that dozens of other patients who went under John Bradley Williamson’s knife were harmed or received poor care. Read full story (paywalled) Source: The Times, 30 July 2023
  24. Content Article
    In 2021, a multi-professional staff support group was established under the Northern Care Alliance NHS Foundation Trust’s Freedom to Speak Up process which raised new questions and concerns around the probity and clinical standards of a Consultant Spinal Surgeon (“Consultant Spinal Surgeon A”) whilst they were employed at Salford Royal NHS Foundation Trust (now part of the Northern Care Alliance NHS Foundation Trust) (“the Trust”). As a result, the Trust commissioned the Spinal Patient Safety Look Back Review (“SPSLBR”) and Investigation Group to evaluate these concerns, including obtaining independent expert advice.In January 2022, the Trust commenced the SPSLBR to investigate and manage patient safety concerns raised in respect of Consultant Spinal Surgeon A who was employed at Salford Royal NHS Foundation Trust (now part of the Northern Care Alliance NHS Foundation Trust) between 1991 and January 2015. This report outlines the investigation carried out by the SPSLBR Investigation Group on behalf of the Trust to investigate and manage potential Serious Incidents (“SI”) caused by the errors and omissions attributable to clinics, surgery and/or consultations undertaken by Consultant Spinal Surgeon A within the scope identified in the Terms of Reference. 
  25. Content Article
    The Duty of Candour for Wales statutory guidance.
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