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News Article“Gut-wrenching,” says Lisa McManus. She is looking for words to describe how she and other thalidomide survivors feel ahead of a historic apology by Anthony Albanese for government failings in the tragedy. She is grateful for recognition of the medical disaster and relieved that a decade of advocacy has come to fruition. Around 80 of the 146 recognised survivors will witness the apology in Canberra on Wednesday in what McManus hopes will be “a step in the healing process”. But she is also frustrated that too many others have not lived to see the day. Thalidomide caused birth defects including “shortened or absent limbs, blindness, deafness or malformed internal organs”, according to the Department of Health. The drug was not tested on pregnant women before approval, and the birth defect crisis led to greater medical oversight worldwide, including the creation of Australia’s Therapeutic Goods Administration. Survivors and independent reports have criticised the government of the day for not acting sooner to remove thalidomide from shelves when problems became apparent. McManus leads Thalidomide Group Australia, having lobbied governments for a decade for an apology and better support. She’s “extremely grateful” for the apology, and says many survivors are anxious, excited and nervous – but that the apology itself can’t be the end. “I’m relieved it’s happening, I just can’t say ‘thank you’,” McManus says. “I’m very happy to think it’s here, but it won’t fix things, and I don’t want the government thinking they will deliver this and it’ll all be fine.” Read full story Source: The Guardian, 28 November 2023
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News Article
Police investigate 105 cases of alleged negligence in Brighton hospital
Patient Safety Learning posted a news article in News
Police are investigating 105 cases of alleged medical negligence at the Royal Sussex County Hospital in Brighton amid claims of a cover-up. Specialist officers from the National Crime Agency and Sussex police are looking into cases of harm, which include at least 40 deaths, in the general surgery and neurosurgery departments between 2015 and 2021. An email from Sussex police, released to The Times after a court application, revealed the huge investigation is looking into 84 cases connected to neurology and 21 related to gastroenterology. Most of the families are yet to be told that their case is among them. Officers were called in by the senior coroner after she heard of allegations made by two consultant surgeons at University Hospitals Sussex NHS Foundation Trust, one of the largest NHS organisations with 20,000 staff. The trust has been accused of bullying the whistleblowers and attempting to cover up the circumstances of the deaths. Mansoor Foroughi, a consultant neurosurgeon, was sacked for “acting in bad faith” in December 2021 after raising concerns about 19 deaths and 23 cases of serious patient harm. Another whistleblower, Krishna Singh, a consultant general surgeon, claimed that he lost his post as clinical director because he said the trust promoted insufficiently competent surgeons, introduced an unsafe rota and had cut costs too quickly. Read full story (paywalled) Source: The Times, 27 November 2023 -
News Article
Police to investigate former neurologist Michael Watt
Patient Safety Learning posted a news article in News
The police have begun an investigation into the clinical practices of former consultant neurologist Michael Watt. He was at the centre of Northern Ireland's largest patient recall in 2018. Over 5,000 patients were recalled amid concerns over his clinical practice. In a highly significant move, an email was sent to patients and families of deceased patients and explained that the investigation is called Operation Begrain. It will be conducted by a major investigation team led by Det Ch Insp Neil McGuinness and Det Insp Gina Quinn. Danielle O'Neill, a former patient of Dr Watt, said she and others are in "complete shock and hope that at last justice will be done". "It's been a long and difficult five years and it is not over yet," she added. Earlier this month a medical tribunal found that the former doctor's fitness to practice was "currently impaired" and that his professional performance was "unacceptable". An appeal will be made to former patients who have concerns regarding their medical treatment by Michael Watt, to come forward to the police. A short questionnaire will also be shared in order to "capture patients' concerns", that information will go straight to the investigation team and will be the first step in the police investigative process. Read full story Source: BBC News, 28 November 2023 -
News Article
NHS in crisis as almost half of maternity wards are offering substandard care
Patient Safety Learning posted a news article in News
Almost half of all English maternity units are offering substandard care, making it one of the worst performing acute medical services in the NHS, Byline Times analysis has found. The analysis, based on inspections of English hospitals by the Care Quality Commission (CQC), found that 85 of 172 inspected maternity services in England received ratings of ‘inadequate’ (18) or ‘requires improvement (67) at their latest inspection. Some 65% of maternity wards were given subpar ratings for patient ‘safety’ one of several metrics looked at by the CQC. The findings come after the health regulator began a focused inspection programme of maternity wards last year after the a government review into the Shropshire maternity scandal, which saw 300 babies left dead or brain damaged by shoddy care. In one unit at Gloucestershire Royal Hospital, there was a shortage of midwives, not all medicines practices were safe which “potentially placed women at risk of harm” and serious incidents were not being investigated. The report found a backlog of 215 patient safety incidents that had not yet been looked into, as of March this year. Maria Caulfield, Minister for Women’s Health Strategy, told Byline Times that “maternity care is of the utmost importance to this Government” and stressed they have “invested £165 million a year since 2021 to grow the maternity workforce and improve neonatal services”. “Every parent must be able to have confidence in the care they receive when giving birth, and we are working incredibly hard to improve maternity services, focusing on recruitment, training, and the retention of midwives,” she added. Read full story Source: Byline Time, 28 November 2023 -
Content ArticleRetrospective chart review is the standard for estimating prevalence of adverse events. Manual review of the electronic health record (EHR) is resource intensive. This study from Garzón González et al. describes the construction and validation of electronic trigger set, TriggerPrim, to rapidly identify charts with potential adverse events in primary care. The resulting set has five triggers: ≥3 appointments in a week at the PC center, hospital admission, hospital emergency department visit, prescription of major opioids, and chronic benzodiazepine treatment in patients 75 years or older. Use of TriggerPrim reduced time in the EHR by half.
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News Article
NHS care delays in England harmed 8,000 people and caused 112 deaths last year
Patient Safety Learning posted a news article in News
Almost 8,000 people were harmed and 112 died last year as a direct result of enduring long waits for an ambulance or surgery, prompting warnings that NHS care delays are “a disaster”. The fatalities included a man who died of a cardiac arrest after waiting 18 minutes for his 999 call to be answered by the ambulance service and was dead by the time the crew arrived. The figures are the first time NHS England has disclosed how often doctors and nurses file a patient safety report after someone suffers harm while waiting for help. They show that patient deaths arising directly from care delays have risen more than fivefold over the last three years, from 21 in 2019 to 112 last year, as the NHS has come under huge strain. The number of people who came to “severe harm” has also jumped from 96 to 152 during that period. “These data are alarming and show quite clearly the human impact the crisis in the NHS is having on individual patients,” said Rachel Power, the chief executive of the Patients Association. “We have been watching a disaster unfolding across the NHS and have repeatedly warned about the threat to patient safety because of it.” Read full story Source: The Guardian, 27 November 2023 -
News Article
Chaotic communication by NHS in England ‘causing treatment delays’
Patient Safety Learning posted a news article in News
Chaotic communication by the NHS in England is causing harmful delays to treatment and endangering patient health, according to research. Widespread communication problems that leave patients and staff scrambling to find their referrals, missing appointments, or receiving late diagnoses have been uncovered in a study by the Demos thinktank, the Patients Association, and the PMA, a professional membership body for healthcare workers. In a poll of 2,000 members of the public and NHS staff across England in October, more than half said they had experienced poor communication from the health service in the past five years, with one in 10 saying their care had been affected as a result. The research also found that over the last year, 18% had their care, or the care of an immediate family member, delayed or affected because they were referred to the wrong service, while 26% said they or a close family member had been inconvenienced because they were given the date and time of an appointment without enough notice. Miriam Levin, the director of participatory programmes at Demos, said that despite the great esteem and pride in the NHS, patients found navigating the system frustrating and stressful. “We heard countless stories of critical appointments missed, diagnoses not shared or shared too late, and referrals for treatment that went missing. This leads to real harm,” she said. Read full story Source: The Guardian, 27 November 2023 -
News Article
Bristol surgeon Tony Dixon defends not waking patient for consent
Patient Safety Learning posted a news article in News
A surgeon has said it would have been "cruel and unacceptable" to have woken up a patient to get consent for a mesh operation. Anthony Dixon is accused of failing to provide adequate clinical care to five patients at Southmead Hospital and the private Spire Hospital in Bristol. He had pioneered the use of artificial mesh to lift prolapsed bowels. Mr Dixon appeared at a Medical Practitioners Tribunal Service (MPTS) hearing in Manchester on Thursday. He faces charges of performing procedures that were not "clinically indicated", failing to carry out tests and investigations and failing to obtain consent from patients. It followed complaints many had suffered pain or trauma after having pelvic floor surgery using artificial mesh, a technique known as laparoscopic ventral mesh rectopexy (LVMR). Giving evidence, he was asked why he did not consider waking up one female patient who underwent an LVMR, to get her consent to surgery. Mr Dixon said it would have meant giving her more drugs for pain relief and could have "multiplied the risks" to her. He is also accused of failing to advise patients about the risks of procedures, failing to discuss non-surgical options and dismissing patients' concerns when they experienced pain or other symptoms following surgery. Read full story Source: BBC News, 23 November 2023 Related reading on the hub: Woman’s mesh consent form was changed after signing – how can patients be better protected? -
News Article
Eye patients pay for private treatment – or risk going blind in NHS backlog
Patient Safety Learning posted a news article in News
Patients are being forced to pay for urgent eye care or risk going blind because of long NHS waits. MPs will today hear the scale of the “emergency” with four in five high street optometrists revealing their patients have paid for private procedures in the past six months. Dame Andrea Leadsom, the former House of Commons leader, business secretary and environment secretary, is being called on to commit to improving NHS eye care in her new role as public health minister. Four in five optometrists say they have patients waiting more than a year to be referred for an NHS appointment or treatment, according to analysis by the Association of Optometrists (AOP), leaving them at risk of going blind. About 640,000 people are waiting for an NHS ophthalmology appointment, more than any other speciality – accounting for about one in 11 people on the 7.8 million waiting list. About half of these people say their sight is deteriorating while they wait to be seen. Tens of thousands have been waiting more than a year, the AOP said. In a letter to Dame Leadsom, Adam Sampson, the chief executive of the AOP, said that high street optometrists should be used more widely across the NHS for “cataract surgery, help for glaucoma and age-related macular degeneration”. Mr Sampson said: “With the expansion of primary eye care services, more patients will have a better chance of receiving improved treatment, faster and locally, which could prevent avoidable irreversible sight loss.” Read full story (paywalled) Source: The Telegraph, 23 November 2023 -
Content ArticlePresentation slides from Session 1 of the SEHTA 2023 International MedTech Expo & Conference. This session was on patient voice engagement. Presentations can be downloaded below.
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Content Article
Thirlwall Inquiry
Mark Hughes posted an article in Other reports and inquiries
The Thirlwall Inquiry has been set up to examine events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital. This website provides information about inquiry team, terms of reference and publications relating to this. -
News ArticleThe public inquiry into the Lucy Letby murders will seek changes to NHS services and culture next year despite the fact that formal hearings are likely to be delayed until the autumn. Inquiry chair Lady Justice Thirlwall will issue an update message later today. In it she will stress the inquiry will “look for necessary changes to be made to the system of neonatal care in this country in real time and at the earliest opportunity, avoiding delays in making meaningful change”. HSJ understands Lady Thirlwall will look to agree on some changes, based on the inquiry’s evidence gathering and discussions with the sector before it begins oral hearings – which are unlikely to start for at least a year due to ongoing legal action. Lady Thirlwall will say the legal constraints mean its early work will focus on the experience of families who were named in the cases already heard; and “on the effectiveness of NHS management, culture, governance structures and processes, as well as on the external scrutiny and professional regulation supposed to keep babies in hospital safe and well looked after”. She said, “I want this to be a searching and active inquiry in the sense that it will look for necessary changes to be made to the system of neonatal care in this country in real time and at the earliest opportunity, avoiding delays in making meaningful change”. Read full story (paywalled) Source: HSJ, 22 November 2023
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News ArticlePatient safety is being put at risk by the “toxic” behaviour of doctors in the NHS, the health ombudsman has said. Rob Behrens, who investigates complaints about the NHS in England, warned that the hierarchical and high-handed attitude of clinicians was undermining the quality of care in some hospitals. He called for medical training to be redesigned to encourage a more empathetic and collaborative approach from doctors. Pointing to failings in the treatment of sepsis and the problems in maternity services, Behrens said he was “shocked on a daily basis” by what he saw as ombudsman. Too often, “organisational reputation has been put above patient safety”, he told The Times Health Commission. The ombudsman warned of a “Balkanisation” of health professionals, with rivalries between doctors and nurses or midwives and obstetricians harming patient care. “For all the brilliance of clinicians quite often they’re not very good at working together,” he said. “Time and again, the handover from one clinician to another, from one shift to another, or the inability to raise the issue at a senior level has been a key factor in what has gone wrong.” Read full story (paywalled) Source: The Times, 18 November 2023
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News Article
Most NHS maternity units not safe enough, says regulator
Patient Safety Learning posted a news article in News
England's healthcare regulator has told BBC News that maternity units currently have the poorest safety ratings of any hospital service it inspects. BBC analysis of Care Quality Commission (CQC) records showed it deemed two-thirds (67%) of them not to be safe enough, up from 55% last autumn. The "deterioration" follows efforts to improve NHS maternity care, and is blamed partly on a midwife shortage. The Department for Heath and Social Care (DHSC) said £165m a year was being invested in boosting the maternity workforce, but said "we know there is more to do". The BBC's analysis also revealed the proportion of maternity units with the poorest safety ranking of "inadequate" - meaning that there is a high risk of avoidable harm to mother or baby - has more than doubled from 7% to 15% since September 2022. The CQC, which also inspects core services such as emergency care and critical care, said the situation was "unacceptable" and "disappointing". "We've seen this deterioration, and action needs to happen now, so that women can have the assurance they need that they're going to get that high-quality care in any maternity setting across England," said Kate Terroni, the CQC's deputy chief executive. The regulator has been conducting focused inspections because of concerns about maternity care. These findings are "the poorest they have been" since it started recording the data in this way in 2018, Ms Terroni said. Read full story Source: BBC News, 16 November 2023 -
Content ArticleA BMJ investigation has raised concerns that the Vaccine Adverse Event Reporting System (VAERS) isn’t operating as intended and that signals are being missed. VAERS is supposed to be user friendly, responsive, and transparent. However, investigations by The BMJ have uncovered that it’s not meeting its own standards. Not only have staffing levels failed to keep pace with the unprecedented number of reports since the rollout of covid vaccines but there are signs that the system is overwhelmed, reports aren’t being followed up, and signals are being missed. The BMJ has spoken to more than a dozen people, including physicians and a state medical examiner, who have filed VAERS reports of a serious nature on behalf of themselves or patients and were never contacted by clinical reviewers or were contacted months later.
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Content ArticlePotentially serious complications occurred in 1 in 18 procedures under the care of an anaesthetist in UK hospitals, according to a national audit by the Royal College of Anaesthetists (RCA). Risks were found to be highest in babies, males, patients with frailty, people with comorbidities, and patients with obesity. Risks were also associated with the urgency and extent of surgery and procedures taking place at night and/or at weekends. The survey, published in Anaesthesia, was the RCA's seventh national audit project (NAP7) and included more than 20,000 procedures at over 350 hospital sites. NAPs study rare but potentially serious complications related to anaesthesia, and are intended to drive improvements in practice. Each focuses on a different topic and NAP7 examined perioperative cardiac arrest. Dr Andrew Kane, consultant in anaesthesia at James Cook University Hospital in Middlesbrough and a fellow at the RCA's Health Services Research Centre in London, said the new data presented "the first estimates for the rates of potentially serious complications and critical incidents observed during modern anaesthetic practice". The data confirmed that individual complications are uncommon during elective practice, but highlight the relatively higher rate of complications in emergency settings.
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News ArticleNHS staff are carrying out the equivalent of one 'never-event' every day, figures show. This is despite the Government ordering a crackdown on the mistakes, which cost hospitals an estimated £800million in compensation each year. Experts today demanded further action on 'unacceptable' levels of never-events, blaming inadequate staffing levels and a lack of investment in the NHS. A MailOnline audit of a decade's worth of NHS data found a colossal 4,328 never-events have occurred in England since 2013. This equates to roughly eight a week. Shocking incidents uncovered include women getting parts of their reproductive anatomy cut out instead of an appendix, men getting unwanted circumcisions and laser procedures to the wrong eye. The Royal College of Surgeons said the level of never-events was 'unacceptable' and blamed NHS staffing levels for increasing the risk to patients. "Surgeons will be working hard to do their best for patients, but they do so in difficult circumstances," a spokesperson said. "The NHS is overstretched, with staff shortages, a workforce suffering from burn-out and pressure to get record waiting times down. "This increases the risk of mistakes happening." Read full story Source: MailOnline, 10 October 2023
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News Article
Woman who suffered complications from vaginal mesh implant awarded at least £1m
Patient Safety Learning posted a news article in News
A woman who suffered traumatic complications from a vaginal mesh implant has been awarded a record settlement of at least £1m from the NHS. Yvette Greenway-Mansfield, 59, was given a mesh implant at Coventry’s University Hospital in 2009 and went on to suffer serious complications. Her medical negligence claim against the hospital trust found that the surgery was carried out prematurely and unnecessarily and that her consent form had been doctored to include additional risks after Greenway-Mansfield had signed it. Greenway-Mansfield said that being awarded the compensation was a “huge relief”, but added that many other women who have suffered similar damage had received little or no compensation, and criticised the government’s failure to establish a financial redress agency for victims. “I’m not the only one. There are thousands of mes,” she said. “There should be a pot of money to provide damages for these women and a care plan in place as an automatic response to mesh-damaged people. It comes down to a perception of women and women’s health problems. We’ve all had enough of it.” Read full story Source: The Guardian, 13 November 2023 -
Content Article
This blog calls for action on the careful review of established pain medication when a patient is admitted to hospital. Richard describes the experience of two elderly patients who suffered pain due to their long term medication being stopped when they were admitted to hospital. Pain control needs must not be ignored or undermined, there needs to be carer and patient involvement and their consent, and alternative pain control must be considered.- Posted
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Content ArticleIn the windowless room where he spends 24 hours a day, lying in the bed he cannot leave, Nicholas Thornton reaches for his laptop and begins to type. It is the only way he can communicate. For more than 10 years, this 28-year-old has been trapped in dementia care units and A&E wards, abused by nurses and held in padded rooms. In all this time, he’s never had the care he needs. The 28-year-old is bedbound, unable to move and unable to speak, the effects of more than 10 years trapped in hospitals and units that cannot care for his needs. Nicholas, who is autistic and has a learning disability, has been moved again and again since he was first sectioned aged 16, ferried between units hundreds of miles from his family’s home in Essex. His story comes as a four-year-long independent inquiry, led by House of Lords peer Sheila Hollins, condemns the government for failing to address the “systemic” failures that have led to people with learning disabilities being locked away in hospitals in solitary confinement for up to 20 years.
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News Article
AstraZeneca faces legal challenge over Covid vaccine
Patient Safety Learning posted a news article in News
AstraZeneca is facing legal action over its Covid vaccine, by a man who suffered severe brain injury after having the jab in April 2021. Father-of-two Jamie Scott suffered a blood clot that left him with brain damage and unable to keep working. The action, taken under the Consumer Protection Act, alleges the vaccine was "defective" as it was less safe than individuals were entitled to expect. Studies suggest Covid vaccines have saved millions of lives. In June 2022, the World Health Organization said the AstraZeneca vaccine was "safe and effective for individuals aged 18 and above". A further claim from about 80 people who say they were injured by the AstraZeneca vaccine is also due to be launched later this year but Mr Scott's case is expected to be heard first. AstraZeneca said: "Patient safety is our highest priority and regulatory authorities have clear and stringent standards to ensure the safe use of all medicines, including vaccines. "Our sympathy goes out to anyone who has lost loved ones or reported health problems. "From the body of evidence in clinical trials and real-world data, Vaxzevria [the vaccine against Covid] has continuously been shown to have an acceptable safety profile and regulators around the world consistently state that the benefits of vaccination outweigh the risks of extremely rare potential side effects." Read full story Source: BBC News, 9 November 2023 Related reading on the hub: Interview with Charlet Crichton, founder of UKCVFamily -
Content ArticleWould you know what to do if something went wrong with your medical treatment in private/independent healthcare? This guide from PHIN tells what you should understand before choosing where to have your treatment and what to do if everything doesn’t go to plan.
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Content Article
How to complain to the NHS
Patient Safety Learning posted an article in Complaints
You have the right to make a complaint about any aspect of NHS care, treatment or service The information on this NHS page will guide you through the NHS complaints process, as well as the core requirements for NHS complaints handling. -
News Article
Consultant carried out 'unnecessary' surgery for financial gain, tribunal hears
Patient Safety Learning posted a news article in News
A doctor who worked for the same private healthcare company as rogue surgeon Ian Paterson performed unnecessary shoulder operations for financial gain, a medical tribunal has heard. Orthopaedic consultant Michael Walsh worked at a Spire Healthcare hospital in Leeds from 1993 until 2018, when he was suspended after concerns were raised about his work. Spire, which runs 38 hospitals around the UK, reported him to the General Medical Council (GMC) after an investigation found he carried out operations unnecessarily or badly, with many patients left suffering pain or trauma. Mr Walsh, who also worked at another private hospital in Leeds run by Nuffield Health but is now retired, is facing dozens of medical negligence claims from patients, with some already having received payouts. Read full story Source: Medscape, 8 November 2023 -
Content ArticleThis blog by the British Society for Rheumatology (BSR) shares highlights of the evidence given to a House of Lord's inquiry into homecare medicines services' governance and accountability. The witness sessions heard evidence on levers for accountability, performance and safety, e-prescribing and workforce. The blog looks at challenges faced by providers, the need for improved regulation and accountability and lack of data and KPIs. It also describes a desktop investigation being undertaken by NHS England to understand the range of arrangements that are in place and how homecare medicines services are held to account.
