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Found 1,328 results
  1. News Article
    A damning report into hundreds of baby deaths has condemned the trust at the centre of the biggest maternity scandal in the history of the NHS for blaming mothers while repeatedly ignoring its own catastrophic blunders for decades. The independent inquiry into maternity practices at Shrewsbury and Telford hospital NHS trust uncovered hundreds of cases in which health officials failed to undertake serious incident investigations, while deaths were dismissed or not investigated appropriately. Instead, grieving families were denied access to reviews of their care and mothers were blamed when their babies died or suffered horrific injuries. A combination of an obsession with natural births over caesarean sections coupled with a shocking lack of staff, training and oversight of maternity wards resulted in a toxic culture in which mothers and babies died needlessly for 20 years while “repeated failures” were ignored again and again. Tragically, it meant some babies were stillborn, dying shortly after birth or being left severely brain damaged, while others suffered horrendous skull fractures or avoidable broken bones. Some babies developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries. The report, led by the maternity expert Donna Ockenden, examined cases involving 1,486 families between 2000 and 2019, and reviewed 1,592 clinical incidents. “Throughout our final report we have highlighted how failures in care were repeated from one incident to the next,” she said. “For example, ineffective monitoring of foetal growth and a culture of reluctance to perform caesarean sections resulted in many babies dying during birth or shortly after their birth. “In many cases, mother and babies were left with lifelong conditions as a result of their care and treatment. The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the trust and a culture of not listening to the families involved. “There was a tendency of the trust to blame mothers for their poor outcomes, in some cases even for their own deaths. What is astounding is that for more than two decades these issues have not been challenged internally and the trust was not held to account by external bodies. “This highlights that systemic change is needed locally, and nationally, to ensure that care provided to families is always professional and compassionate, and that teams from ward to board are aware of and accountable for the values and standards that they should be upholding. Going forward, there can be no excuses.” Read full story Source: The Guardian, 30 March 2022
  2. News Article
    When Debbie Greenaway was told by doctors that she should try to deliver her twin babies naturally, she was nervous. But the doctor was adamant, she recalls. “He said: ‘We’ve got the lowest caesarean rates in the country and we are proud of it and we plan to keep it that way'." For Greenaway, labour was seemingly endless. She was given repeated doses of syntocinon, a drug used to bring on contractions. By the second day, the midwife was worried for one of the babies, whom the couple had named John. “She was getting really concerned that they couldn’t find John’s heartbeat.” Her husband remembers “the midwife shaking her head”. “She said a number of times that we should be having a caesarean.” By the time doctors finally decided to perform an emergency C-section, it was too late. Starved of oxygen, baby John had suffered a catastrophic brain injury. When he was delivered at 3am, he had no pulse. Efforts to resuscitate him failed. Their son’s death was part of what is now recognised as the largest maternity scandal in NHS history. The five-year investigation will reveal that the experiences of 1,500 families at Shrewsbury and Telford Hospital Trust between 2000 and 2019 were examined. At least 12 mothers died while giving birth, and some families lost more than one child in separate incidents, the report is expected to show. The expert midwife Donna Ockenden and a team of more than 90 midwives and doctors will deliver a damning verdict on the Shrewsbury trust, its culture and leadership — and failure to learn from mistakes or listen to families. At its heart is how a toxic obsession with “normal birth” — fuelled by targets and pressure from the NHS to reduce caesarean rates — became so pervasive that life-or-death decisions on the maternity ward became dangerously distorted for nearly two decades. Read full story (paywalled) Source: The Times, 26 March 2022
  3. News Article
    The Care Quality Commission is to prosecute an acute trust after a patient was injured when allegedly exposed to “avoidable harm”. United Lincolnshire Hospitals Trust is due to appear tomorrow afternoon at Boston Magistrates’ Court. The alleged incident took place at Lincoln County Hospital, the CQC said. Although the CQC declined to comment further, Lincolnshire Live reported the alleged incident involved 91-year-old Iris Longmate and relates to a failure to provide safe care and treatment on or before 3 March 2019. The local publication added court papers claimed “at the same time ULHT also failed to give safe care and treatment to patients on Greetwell Ward, who were ‘being exposed to a significant risk of avoidable harm occurring’”. Proceedings are being brought under sections 22 and 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These rules require providers to take reasonable steps to minimise risks to people’s health and safety during treatment, and make it a criminal offence if a provider fails to comply and a patient suffers avoidable harm or is exposed to a risk of this happening. Read full story (paywalled) Source: HSJ, 24 March 2022
  4. News Article
    A man who experiences regular mental health crises says an NHS scheme designed to offer support during emergency episodes has become broken. The trust running the service says a crisis team offers immediate support in an emergency, and a 24-hour helpline. But when Mark Doody, who has bipolar disorder, cried "down the phone, begging the team for help", he was told to call an ambulance, his wife said. The trust said a 999 call could sometimes be the appropriate action. Trish Doody cited a "dreadful" deterioration in mental healthcare where the couple lived in Redditch, Worcestershire. She said while her husband was able to get support if an emergency happened "between 9am and 5pm", assistance became difficult outside of those hours. Mr Doody said his condition meant he experienced a mental health crisis every three months. He has also made suicide attempts. Mental healthcare provision in the county had gone downhill over the last 20 years, Mrs Doody said, with her husband adding: "The system is just broken really." Healthwatch Worcestershire, which helps hold the NHS to account locally, said it was "exploring" whether there was a problem with the crisis helpline, and was also aware of delays for those seeking one-to-one counselling, which it said the trust was tackling. Read full story Source: BBC News, 22 March 2022
  5. News Article
    A nurse who admitted she was unfit to practise after dragging a patient with dementia to her room and forcefully attempting to administer a sedative has been suspended for a year by the nursing regulator. Carol Picton was working in the stroke unit at the Western General Hospital in Edinburgh in November 2017 when colleagues raised concerns about her treatment of a vulnerable older woman. Witnesses who gave evidence to an NMC fitness to practice (FtP) panel said they heard the patient screaming in distress after being roughly dragged by her arm back to her room by Ms Picton. The nurse then attempted to forcefully administer the anti-psychotic drug Haloperidol without checking the correct dosage, the hearing was told. She tried to give the drug orally using a 2ml injection syringe rather than an oral syringe. Ms Picton denied forceful mistreatment and panel found no evidence she had shown insight into her misconduct When the patient spat out the drug Ms Picton gave her more without knowing how much she had ingested, risking an overdose, the panel heard. Ms Picton, who was referred to the NMC by her employer following an internal investigation, was also said to have tilted the patient’s bed to prevent her getting out and leaving her room. The panel, which found five charges proven, concluded that Ms Picton’s actions were ‘deplorable’ and amounted to harassment and abuse. Read full story Source: Nursing Standard, 21 March 2022
  6. News Article
    Women and NHS staff have warned that mothers are being “forgotten” after giving birth, with a staff crisis only making matters worse. Kate, a 32-year-old from Leeds, says she has been left in “excruciating” pain for nine years after horrifying postnatal care. Other women have told The Independent stories of care ranging from “disjointed” to “disastrous”. It comes as midwives warn there are “horrendous” shortages in community services, which have prevented women from accessing adequate antenatal and postnatal care. Mary Ross-Davie, the Royal College of Midwives’ director for professional midwifery, said that with each Covid wave midwifery staffing has been hit worse than the last. To provide safe care during labour, antenatal and postnatal care, teams are sent into wards putting “huge pressure on care”. She said this could mean clinicians end up “missing things”, such as women struggling emotionally after birth. The warnings over poor antenatal and postnatal care come after experts at the University of Oxford said in November there were “stark” gaps in postnatal care, despite the highest number of deaths being recorded in the postnatal period. Dr Sunita Sharma, lead consultant for postnatal care at Chelsea and Westminster Trust, said that when NHS maternity inpatient staffing overall is in crisis “often the first place staff are moved from is the postnatal ward, which is clinically very appropriate, but it can come at a cost of putting more pressure on postnatal care for other mothers”. Dr Sharma said postnatal teams were doing their best to improve services but need national drivers and funding to sustain improvement. Read full story Source: The Independent, 16 March 2022
  7. News Article
    Pregnant women should be asked how much alcohol they are drinking and the answer recorded in their medical notes, new "priority advice" for the NHS says. The advice, from the National Institute for Health and Care Excellence (NICE), is designed to help spot problem drinking that can harm babies. Infants with foetal alcohol spectrum disorder (FASD) can be left with lifelong problems. The safest approach during pregnancy is to abstain from alcohol completely. The more someone drinks while pregnant, the higher the chance of FASD - and there is no proven "safe" level of alcohol. But the risk of harming the baby is "likely to be low if you have drunk only small amounts of alcohol before you knew you were pregnant or during pregnancy", the Department of Health says. An earlier draft of the recommendations for NHS staff in England and Wales suggested transferring data on a woman's alcohol intake to her child's medical notes - but this has now been dropped, following concern women who needed help might hide their drinking. The Royal College of Midwives spokeswoman Lia Brigante said: "As there is no known safe level of alcohol consumption during pregnancy, the RCM believes it is appropriate and important to advise women that the safest approach is to avoid drinking alcohol during pregnancy and advocates for this. "We are pleased to see that the recommendation to record alcohol consumption and to then transfer this to a child's record has been reconsidered. "This had the potential to disrupt or prevent the development of a trusting relationship between a woman and her midwife." Read full story Source: BBC News, 16 March 2022
  8. News Article
    A privately run mental health hospital put in special measures last year has been rated “inadequate” again following a fresh Care Quality Commission inspection. Inspectors raised serious concerns about unsafe ward environments and staff not managing patient risks at the Priory Hospital Arnold, which has beds commissioned by Nottinghamshire Healthcare Foundation Trust. Inspectors said that while the leadership team was experienced, the registered manager had been in post since April last year and the improvements they had made “had not been fully embedded”. The registered manager had changed after the service was placed in special measures. Ligature risks were found in patients’ bathrooms despite the provider making “some progress” and undertaking “substantial work” to remove them, the CQC said. And in one instance, a patient had tried to harm themselves with a plastic bag which was a restricted item on the ward. CQC head of hospital inspection for mental health and community services Craig Howarth said staff “had not followed the patient’s risk assessment” and had not searched the patient on their return from a visit off the ward. He added: “It was also concerning that despite rotas showing enough staff were available across the hospital, staff gave examples of when a lack of staffing had impacted on patient care and safety. “Despite the measures in place, the risks to patients were not reduced and there was evidence of incidents of harm to patients.” Read full story (paywalled) Source: HSJ, 15 March 2022
  9. News Article
    Serious safety concerns have been raised about a children’s mental health hospital where staff lacked respect for patients, as the provider faces a police investigation into another one of its units. The Huntercombe Hospital in Stafford has been rated as “inadequate” by watchdog the Care Quality Commission (CQC) after inspectors found the safety of children within the hospital was at risk. The concerns about this hospital come as The Independent revealed police have launched an investigation into another mental health unit run by the provider in Maidenhead. Following an inspection in October inspectors sent an urgent warning notice to the provider, after it found there were not enough staff to keep patients safe. The hospital was described as relaying on agency workers who did not have knowledge of the patients. The CQC inspectors found children’s wards were dirty with poor hygiene measures in the hospital and patients at risk of infection. According to the report staff were found “sitting with their eyes closed for prolonged periods of time”, and that staff observations of at risk patients were “undermined by a blind spot where people could self-harm unseen.” Craig Howarth, CQC head of inspection for mental health and community health services, said: “Further to these issues, we saw that staff sometimes showed a lack of respect to patients and one ward was poorly furnished and maintained and there wasn’t always enough emphasis on some people’s individual requirements.” Read full story Source: The Independent, 11 March 2022
  10. News Article
    It has been nine years living “like a prisoner” in “excruciating” pain and Kate is still facing a wait for surgery to tackle the horrifying mistakes in her postnatal care. Despite a difficult birth at Leeds General Hospital, Kate described the atmosphere at the trust’s labour ward as “lovely”. However, her experience quickly deteriorated into “hell” after she was told she had third-degree tears and was admitted to a postnatal ward, describing the care she received as “awful”. A few days following her discharge, which occurred before she’d had a bowel movement, Kate said she was left “screaming in pain” at home, “bleeding a lot from the back passage” and “incontinent”. Despite reporting these symptoms to the maternity department, Kate was told it was a “normal” experience. “I felt like nobody was listening to me,” Kate said. After six months, living in “intense pain”, with “flooding diarrhoea” and not able to leave the house, she was told by the NHS her symptoms were down to postnatal depression. She was referred to a colorectal surgeon, who found her anal sphincter was “fully open almost as if it wasn’t ever stitched”. Following an operation in 2015 to fix the issue, Kate developed sepsis, nearly losing her life and meaning it took 18 weeks for her wound to heal. However, her ordeal did not stop there. She had developed nerve damage, chronic pelvic pain, incontinence, coxalgia and a prolapse as a result of her problems being neglected for so long. By 2022, nine years later, she is now waiting for a colostomy bag operation – the only option to address her pain. Kate told The Independent: “Everywhere I go I have to plan the full day. I need to know where the toilets are. I don’t go out of the house. I’ve felt like a prisoner in my own home for nine years. “It makes me so emotional thinking about everything they have put me through. It hasn’t just affected my life, it’s also affected my partner and family. I have lost so much time that I’ll never get back. I couldn’t enjoy life and do the things that all mothers do with their babies. “There was no care, no sympathy, nothing. Nobody cared for me apart from my surgeon at Sheffield. I’ve forgotten what it feels like to feel normal. I can’t remember life without pain." Read full story Source: The Independent, 13 March 2022
  11. News Article
    A patient who spent months in hospital because of a medical error received anonymous letters alleging safety concerns at the unit that treated her. Marilyn Smith was diagnosed with tetanus after she was discharged following treatment for a leg injury at Hinchingbrooke Hospital in Huntingdon, Cambridgeshire. She said she was not asked about her tetanus immunisation status and was discharged from Hinchingbrooke without a booster shot. A few days later she woke up with trismus, commonly known as lockjaw, and was unable to open her mouth - a symptom of tetanus, which only a handful of people contract in the UK each year. She subsequently spent more than 120 days in hospital in Hinchingbrooke, and then Peterborough, when her condition worsened and she was moved to critical care, placed in an induced coma and needed intubation. She said she now struggled to walk. She received the first anonymous letter, claiming to be from "a group of current and previous A&E staff at Hinchingbrooke", in the post in January after she had been home from hospital for two weeks. "I wasn't a letter to me, but a letter about me," Ms Smith said. It described alleged shortcomings in her care. Two subsequent letters made similar claims and on the same day the third arrived at her house, on 24 February, the BBC also received one giving Ms Smith's name and address and describing the alleged failures in her initial care. This letter stated "the trust has been ignoring concerns about patient safety" and contained further allegations that related to an individual. She has since instructed a lawyer to look at her case because, she said, she did not want anybody else to suffer like she had. Read full story Source: BBC News, 8 March 2022
  12. News Article
    Vulnerable people released from immigration detention in the UK are too often left without crucial continuity of care, leading to quickly deteriorating health, concludes a report. The report comes from Medical Justice, a charity that sends independent volunteer clinicians into immigration removal centres across the UK to offer medical advice and assessments to immigration detainees. The charity said that between 1 October 2020 and 30 September 2021 a total of 21 362 people were detained in UK immigration centres and 17 283 were released into the community, having been granted bail or leave to enter the UK or remain. Of these, 2239 were considered to be “adults at risk.” One woman whose delay in treatment “could potentially have life or limb threatening consequences”, struggled to re-arrange an orthopaedic oncology appointment that she missed because she had been detained. One released Medical Justice client described how he ended up a number of times in Accident & Emergency, having been unable to secure a recommended cardiology appointment. The report found that release from detention is often unplanned, chaotic and medically unsafe. Medical Justice sees repeated cases of vulnerable people released into the community without adequate care plans, with little or no information and support about entitlement and how to access a GP, and rarely with referrals to community support services such as local mental health teams. This has included people who had very recently attempted suicide in detention. Read full story Source: BMJ, 4 March 2022
  13. News Article
    Hospitals across Ukraine are “desperate” for medical supplies, doctors have warned, as oxygen stores are hit and other vital health supplies run low amid bombardment from Russian forces. UK-based Ukrainian doctors have issued an urgent appeal for donations of supplies as they travel to eastern Europe in response to reports of shortages of medical equipment and medicines. The World Health Organisation warned on Sunday evening that oxygen supplies in Ukraine were “dangerously low” as trucks were unable to transport oxygen supplies from plants to hospitals across the country. Dr Volodymyr Suskyi, an intensive care doctor at Feofaniya Clinical Hospital in Kyiv, told The Independent he had been forced to use an emergency back-up system to supply oxygen to a patient on life support after the area near plant which supplies his hospital was bombed. Dr Dennis Olugun, a UK-based doctor who is leading the group of medics from the Ukrainian Medical Association of the United Kingdom (UMAUK) to deliver medical supplies, said the situation was “desperate” in some areas. He said some hospitals did not have basic necessities such as rubber gloves. He told The Independent: “What they need in the hospitals is portable ultrasound machines, portable x-ray machines because they have so many patients they much rather walk around the wards and do whatever diagnostic work rather than transporting patients." The Association of the British Pharmaceutical Industry and European Federation of Pharmaceutical Industries and Associations have called for medicines, pharmaceutical ingredients and raw materials to be excluded from the scope of sanctions being levied against Russian trade. Read full story Source: The Independent, 1 March 2022
  14. News Article
    Patient safety will be harmed and victims of medical negligence denied justice because of flaws in the government’s health and care bill, the NHS ombudsman has told the Guardian. Rob Behrens, the parliamentary and health service ombudsman, fears he and his staff will not be able to get to the bottom of clinical blunders because under the bill he will be denied potentially vital information collected by the NHS’s Healthcare Safety Investigation Branch (HSIB). The ombudsman said the legislation would allow the HSIB to “operate behind a curtain of secrecy” and undermine his own investigations into lapses in patient safety and could deny grieving families the full truth about why a loved one died. Behrens has spoken out because he is concerned about government plans for NHS staff involved in an incident to give evidence about mistakes privately in a “safe space” to the HSIB, which cannot be shared with anyone else except coroners. His exclusion from seeing material gathered in that way could force him to take the agency to the high court to access it, he said. “If the ‘safe space’ provisions become law as drafted there is a real risk to patient safety and to justice for those who deserve it. This is a crisis of accountability and scrutiny,” he said. Julia Neuberger, a crossbench peer who chairs University College hospitals NHS trust, has tabled an amendment to the bill in the House of Lords seeking to give the ombudsman access to information obtained via “safe space” processes. Unless ministers rethink the plan “there could be serious consequences for members of the public who use the ombudsman service”, she recently told a Lords debate. “If the ombudsman is unable to investigate robustly all aspects of complaints about the NHS, except with the permission of the high court, patients may find it harder to get access to justice. The NHS may well become less accountable for its system failings,” she said. Peter Walsh, chief executive of patient safety charity Action Against Medical Accidents, backed Behrens. “The so-called safe space is a red herring with serious unintended consequences. There is no evidence staff do not take part in investigations for fear of information being known. It is bullying employers and over-zealous regulators that staff fear. Denying people their right to have the ombudsman investigate properly does nothing to address that.” Read full story Source: The Guardian, 28 February 2022
  15. News Article
    A London mum says she has been left in "agony" and only able to walk 10 minutes at a time after a transvaginal mesh implant perforated her organs. Anna Collyer, 53, had a transvaginal mesh fitted in 2015 at St. Helier hospital in Sutton. The mesh is a net-like implant and aims to give permanent support to the weakened organs and to repair damaged tissue. The mesh implants are designed to be permanent, but last April, Anna started to experience severe pain when the mesh cut into her organs leaving her "unable to live any sort of life anymore," she said. Even when doctors partially removed the mesh last June - her symptoms persisted. Anna, who lives in Morden, told MyLondon: "I could feel something sharp inside me. The pain relief tablets were not touching it. I was in agony. "It's got to the stage now where 10 minutes is all I can walk, because the pain is excruciating. I have pain in pelvis, groin, hips, back and shooting pains in legs. The level is horrendous. I have to lie down all the time. The vaginal mesh procedure was once common place in the UK, with more than 92,000 women receiving one between April 2007 and March 2015 in England alone. But the treatment was “paused” and The Independent Medicines and Medical Devices Safety Review was ordered by the then health secretary, Jeremy Hunt, in 2018 amid mounting safety concerns. Women told the review team of “excruciating chronic pain feeling like razors inside their body" and felt dismissed when reporting complications including “unacceptable labelling of so many symptoms as ‘normal’ and attributable to ‘women’s problems’”, the report says. The new review accuses medial professionals of displaying “an institutional and professional resistance” to changing practice. The report concluded that “those harmed are due not only an apology, but better care and support through specialist centres”. Read full story Source: MyLondon. 22 February 2022
  16. News Article
    Next month, a report will be published into one of the biggest scandals in the history of the NHS, the failures of maternity care at the Shrewsbury and Telford Hospital NHS Trust. The BBC's Michael Buchanan who helped uncover the problems examines why so many failures were allowed to happen for so long. Kayleigh Griffiths' baby, Pippa, died at 31 hours old. The cause of death, the couple were later told, was an infection - Group B Strep. The Shrewsbury and Telford Hospital NHS Trust told the family they would carry out an investigation. But after several weeks of silence, Kayleigh contacted the trust to be told it was an internal investigation and the couple's input wouldn't be required. Kayleigh, an NHS auditor at a different trust, feared the truth was being hidden from her. That's when she decided to send the email to Rhiannon Davies, whose baby, Kate, also died at the Shrewsbury and Telford Hospital NHS Trust As the bond between the mothers deepened, their conversations morphed into something else. Armed with little more than a gnawing suspicion, they started to scour the internet, coroner's records and death notices to see if any other families had received poor maternity care at the Shropshire trust. They collated 23 cases dating back to 2000 - including stillbirths, neonatal deaths, maternal deaths and babies born with brain injuries. Appalled by what they had found, they wrote to the then health secretary Jeremy Hunt in December 2016, asking him to order an investigation. He agreed and in May 2017, senior midwife Donna Ockenden was appointed to lead the review. One of the themes the inquiry has already noted, in an interim report published in December 2020, is that in many cases the trust failed to investigate after something went wrong, or simply carried out its own inquiry. Panorama has discovered the trust even developed its own investigation system, what they called a High Risk Case Review. It was outside any national framework that has been used to help learn lessons from incidents and doesn't appear to be a system that's used in any other NHS organisation. Another consequence of the unorthodox system was that fewer incidents were reported to NHS regulators, limiting the opportunity to learn lessons. One of the earliest cases on the original list of 23 compiled by the two couples was the death of Kathryn Leigh in 2000. Panorama has investigated the case and discovered that a theme identified almost two decades ago was to come up repeatedly in subsequent incidents. The publication of the final report by Donna Ockenden next month will be a watershed moment in the history of the NHS - the revelation of multiple instances of maternity failures in a rural corner of England. Pippa Griffiths and Kate Stanton-Davies lived fewer than 40 hours between them, but their legacy, in terms of improved maternity care, could last decades. Read full story Source: BBC News, 23 February 2022 Source:
  17. News Article
    The government of Mexico City handed out nearly 200 000 “ivermectin based kits” last year to people who had tested positive for Covid-19, without telling them they were subjects in an experiment on the drug’s effectiveness. The results of that experiment were then written up by public officials in an article placed on popular US preprint server SocArXiv. It became one of site’s most viewed articles, claiming that ivermectin had reduced hospital admissions by 52-76%. But those officials have been under fire at home since SocArXiv withdrew the paper earlier this month, calling it “either very poor quality or else deliberately false and misleading.” Opposition deputies in Mexico City’s Congress demanded hearings and said they would bring legal action against the paper’s lead author, José Merino, head of the city’s Digital Agency for Public Innovation. Explaining the decision to withdraw the article—the first to be taken down by SocArXiv—the site’s steering committee wrote that it had responded “to a community groundswell beseeching us to act” in order “to prevent the paper from causing additional harm.” The committee wrote, “The paper is spreading misinformation, promoting an unproved medical treatment in the midst of a global pandemic. The paper is part of, and justification for, a government programme that unethically dispenses (or did dispense) unproven medication apparently without proper consent or appropriate ethical protections.” Read full story Source: BMJ, 22 February 2022
  18. News Article
    The NHS has abandoned targets that encouraged hospitals to pursue “normal births”, over fears for the safety of mothers and babies. Maternity units were told in a letter to stop using caesarean section rates to assess their performance. It comes after repeated scandals in maternity units, blamed in part on a focus on pursuing natural births at the expense of safety. The letter from Jacqueline Dunkley-Bent, NHS England’s chief midwife, and Dr Matthew Jolly, the national clinical director for maternity, instructed “all maternity services to stop using total caesarean section rates as a means of performance management”. It added: “We are concerned by the potential for services to pursue targets that may be clinically inappropriate and unsafe in individual cases." A final report into the deaths of dozens of babies at the Shrewsbury and Telford Hospital NHS Trust will be published next month. It is expected to be highly critical. The midwife leading the inquiry, Donna Ockenden, has said women “felt pressured to have a normal birth” at the trust, adding: “There was a multi-professional, not midwife-led, focus on normal birth pretty much at any cost.” Hayley Coates, 29, lost her son Kaylan after staff at Nottingham University Hospitals NHS Trust ignored her pleas for a caesarean section in March 2018. A coroner ruled that neglect contributed to Kaylan’s death. He suffered a fractured skull when he was delivered with forceps and was starved of oxygen. Coates, a mother of three, said she welcomed the NHS England letter, adding: “I was just ignored when I asked multiple times for a caesarean section. I was told repeatedly: ‘You will have this baby naturally, you don’t want to go to theatre.’ If I had gone to theatre many hours before, my baby wouldn’t have died. They have a duty of care, and the mother’s wishes are supposed to be priority.” Read full story (paywalled) Source: The Times, 20 February 2022
  19. News Article
    Campaigners found to have been harmed by medical products have written to the health secretary warning that government inaction is "causing pain and destroying lives" by ignoring review recommendations. Some 18 months ago, an independent review recommended financial help for people damaged by some products and drugs that had been prescribed by UK doctors. The government - which set up the Independent Medicines and Medical Devices Safety Review in the first place - has chosen to ignore several of its recommendations. Alleged victims of vaginal mesh, and the drugs valproate and Primodos, have written to Health Secretary Sajid Javid and Maria Caulfield to say they feel ignored. The letter states: "Our members gave evidence to the two-year-long review, sometimes travelling long distances, often with disabilities." "Families shared intimate details of their medical problems, their daily struggles, their difficulties parenting, sometimes even their sex lives. The panel, led by Baroness Cumberlege, was set up by the government to listen, assess and direct policy towards the best course of action. "What was the point of this exercise and the hard work of the panel, if their key recommendations are then ignored by the government?" In the letter, campaigners say: "The decision not to offer an agency for redress (Cumberlege recommendation 3) means that the review has lost its teeth." "Still, no one is facing consequences of medical failures other than the patients. At a time when the public is being asked to put its faith in vaccines, this is a bad look for the government." Kath Sansom, of the campaign group Sling the Mesh, said: "Women must dutifully accept their health has been irreversibly shattered by a medical product they were told was safe, some now needing a disabled blue badge, and they must put up and shut up." Read full story Source: Sky News, 17 February 2022 MeshPrimodosSodiumValproate_LettertoMariaCaulfield_170222.pdf
  20. 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
  21. 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
  22. 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
  23. 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
  24. 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
  25. News Article
    Rishi Sunak says the government will wait for the Infected Blood Inquiry's final report before responding to questions around victim compensation. Bereaved families heckled the prime minister when he told the inquiry the government would act as "quickly as possible". Mr Sunak told the inquiry people infected and affected by the scandal had "suffered for decades" and he wanted a resolution to "this appalling tragedy". But although policy work was progressing and the government in a position to move quickly, the work had "not been concluded". He indicated there was a range of complicated issues to work through. "If it was a simple matter, no-one would have called for an inquiry," Mr Sunak said. Campaign group Factor 8 said Mr Sunak had offered "neither new information not commitments" to the victims and bereaved families, which felt "like a betrayal". Haemophilia Society chief executive Kate Burt said: "This final delay is demeaning, insulting and immensely damaging. "We urge the prime minister to find the will to do the right thing and finally deliver compensation which recognises the suffering that has been caused." Read full story Source: BBC News, 26 July 2023
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