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Found 683 results
  1. News Article
    A hospital trust has been told to "immediately improve" its maternity and surgical services. The Care Quality Commission (CQC) made unannounced inspections in September and October at four of the hospitals run by University Hospitals Sussex NHS Foundation Trust. Inspectors raised concerns about staff shortages, skills training and risk management. At the trust's four maternity services, inspectors found departments "did not have enough staff to keep women and babies safe" and staff were "not up to date" with training. Infection prevention measures in surgical services at the Royal Sussex County Hospital were "not consistently applied" and managers were not running services well, inspectors noted. The report also said morale was low and often staff "did not have time to report incidents". The trust said it has taken "urgent action" to make improvements. Read full story Source: BBC News, 10 December 2021
  2. News Article
    The mother of a man who took his own life said bereaved families would be left "in limbo" by a mental health trust's serious incident report delays. Local health officials have raised concerns over the "timeliness" of Cambridgeshire and Peterborough NHS Foundation Trust's (CPFT) reports. Maria Nowshadi, whose son James died in 2020, said they should be done quickly "so there's answers for families". Ms Nowshadi said: "These investigations should happen in a timely, quick manner so there's answers for families, but also in case there's any learning to be had... to make sure there's no further deaths that happen in the same way, because of any errors within the system." She said when the original date the report was due to be completed passed, she "reached the stage where I was looking at the mailbox every day". She said she told a patient liaison officer: "This is actually starting to affect my mental health. The chief nurse at Cambridgeshire and Peterborough's Clinical Commissioning Group (CCG), Carol Anderson, said there were "concerns... [around] serious incident processes and reporting" at CPFT. A CCG spokeswoman added they had agreed an extension with CPFT "for the completion of serious incident reports due to additional pressures due to the pandemic and staff redeployment". "Our overall concern is the timeliness of serious incident reporting, so that we can ensure that learning is put in place as soon as possible," she added. Read full story Source: BBC News, 17 November 2021
  3. News Article
    A ‘culture of distrust’ between consultants and the use of incident reporting as a tool of ‘reprisal’ impacted patient care at a trust’s cardiology department, a review has concluded. An external review undertaken for Hull University Teaching Hospitals Trust has made a series of recommendations after looking into allegations of bullying and several examples of poor care within its cardiology services. In a report published in the trust’s board papers, the Royal College of Physicians reported a “perceived tendency to downplay clinical incidents, and, to undermine those who wanted to raise patient safety issues”. It added: “We met a group of individual consultants who did not work well as a team. There is a culture of distrust, a lack of departmental cohesion and allegations of bullying in the department. All of which reinforce a clear divide between the interventional and non-interventional consultant cardiologists." “There have been a number of allegations of belittling, intimidation and undermining…The review team heard accounts of a culture where datix has been used as a tool for possible personal reprisal along with ignoring/downplaying incidents that have been raised.” The review concludes: “This behaviour is impacting on patient care and therefore, all medical staff should be reminded of good medical practice as the [General Medical Council] code of conduct of how doctors must work collaboratively with colleagues.” Read full story (paywalled) Source: HSJ, 16 November 2021
  4. News Article
    Some acute trusts have failed to report large numbers of hospital-acquired covid infections as patient safety incidents, despite NHS England describing this as ‘fundamental’. HSJ examined the numbers of “infection control” patient safety incidents reported to the national reporting and learning system in 2020-21, and compared this to separate NHS England data on covid infections most likely to have been acquired in hospital. The number of incidents reported to the NRLS in the 12-month period should in theory be higher, as it covers all types of hospital-acquired infections, while the NHSE data only covered covid infections in the last seven months of the year. This appears to hold true nationally, with almost 59,000 incidents reported to the NRLS, compared to around 36,000 likely hospital-acquired covid infections suggested by the NHSE data. But for around a third of trusts, the incident numbers reported to the NRLS were smaller, with some appearing to report very low numbers. Helen Hughes, chief executive of patient safety charity Patient Safety Learning, said: “The scale of the under-reporting set out in these findings is particularly concerning.” “As this data informs assessment of performance at both organisational and national levels, it is possible that this could create a false assurance about the extent of harm in this period,” Ms Hughes said. “Where organisations are now retrospectively completing serious incident reports, there are obvious questions as to whether key insights will have been lost as memories of incidents fade over time and their causes.” “However, they rely on the capacity and commitment of staff behind them. The pandemic has placed an enormous strain on the health service and we have heard from staff the time constraints this has put on them to report patient safety incidents,” she added. Read full story (paywalled) Source: HSJ, 15 October 2021
  5. News Article
    The chief inspector of hospitals has called for honesty about the impact of the coronavirus pandemic on patients warning poor care could become normalised. Professor Ted Baker told The Independent it was vital staff continued to report incidents and revealed the Care Quality Commission had seen a 60% rise in whistleblowing concerns during the last national lockdown in November. He said staff must report incidents and be free to speak up about any concerns as well as being transparent with families where things have gone wrong. He emphasised that where a patient was unable to get the care they clinically needed because of the demand on services, this would amount to a notifiable patient safety incident. Professor Baker’s comments follow multiple anonymous leaks from NHS staff to The Independent in recent weeks, showing how bad the situation has become in some hospitals. Many staff have only spoken out on condition of anonymity. Many hospitals have declared major incidents, cancelled operations and been forced to stretch staffing ratios to unsafe levels to cope with the increasing numbers of COVID-19 patients. Read full story Source: The Independent, 7 January 2021
  6. News Article
    A hospital for men with learning disabilities has been placed in special measures after the Care Quality Commission (CQC) identified “serious risks to patient safety”. The CQC said it had also suspended its current rating of “good” for caring for Cygnet Woodside, Bradford, West Yorkshire, following an inspection in September. The commission said it carried out the unannounced inspection following allegations of abuse by staff towards a patient, which are subject to an ongoing police investigation. The hospital said it was “disappointed” with the CQC’s assessment, stressing that the inspection was triggered by its own management notifying the commission of a concern it had identified. It said the report “does not provide an entirely accurate representation” of the hospital. Dr Kevin Cleary, the CQC deputy chief inspector of hospitals and lead for mental health, said: “Our latest inspection of Cygnet Woodside found that the hospital was not ensuring its patients’ safety.” Cleary added: “The service showed warning signs that increased the likelihood of a closed culture developing. This would have put people at serious risk of coming to harm if we didn’t take action.” He said care was compromised because there was not always the right number or skill level of staff looking after patients. Read full story Source: Guardian, 23 December 2020
  7. News Article
    Eleven patients have suffered harm after being kept waiting in ambulances outside accident and emergency departments, a review has found. South East Coast Ambulance (SECamb) Service Foundation Trust launched the review after a specific incident at Medway Foundation Trust on Monday 16 November. Although details of the incident have not been released, HSJ has been told one patient waited for nine hours before being seen in the trust’s A&E department that day. The review covered all long waits across SECAmb’s area over the last few weeks. Out of 120 cases examined, 11 patients were found to have suffered some degree of harm, SECAmb’s executive director of nursing and quality Bethan Eaton-Haskins told Kent’s health overview and scrutiny committee last week. However, the trust has not revealed which hospitals were involved. Ms Eaton-Haskins said the ambulance trust was “struggling significantly” with handovers and expecting the recent pressure experienced at Medway FT to affect the county’s other hospitals soon. However, she indicated some other trusts in Surrey and Sussex had also had long delays. Ambulance services have been concerned for some time that handover delays could pose significant problems this winter. They are thought to have contributed to the North West Ambulance Service Trust declaring a major incident earlier this month. HSJ has also been told of waits of several hours in other ambulance trusts. Read full story (paywalled) Source: HSJ, 1 December 2020
  8. News Article
    An Essex maternity department has been served with further warnings by the Care Quality Commission (CQC) and again rated “inadequate”. Serious concerns were raised about the services at Basildon University Hospital in the summer, after several babies were found to have been starved of oxygen and put at risk of permanent brain damage. Despite the CQC issuing warning notices to Mid and South Essex Foundation Trust in June 2020, a subsequent visit on 18 September found multiple problems had persisted. The CQC’s findings at Basildon included: the service was short-staffed and concerns were not escalated appropriately multidisciplinary team working was “dysfunctional”, which sometimes led to safety incidents doctors, midwives and other professionals did not support each other to provide good care. Read full story (paywalled) Source: HSJ, 19 November 2020
  9. News Article
    A mental health trust has been told to make ‘urgent improvements’ by regulators after a fourth inpatient death occurred with similar themes to three other patients dying within 12 months. The warning, issued by the Care Quality Commission (CQC) to Devon Partnership Trust, was made after an unannounced inspection at the trust’s Langdon Hospital – following the death of a patient who died by suspected suicide in July. Last week HSJ revealed how the death was the fourth inpatient death within the last 12 months at the trust, with each incident having recurring themes. The latest death happened at Langdon Hospital in Dawlish, on one of the trust’s medium secure wards (Ashcombe), with the patient using a ligature point. It was a similar incident to another serious incident in May on a different ward (Holcombe) at the hospital, and it prompted the inspection from the CQC in mid-August. While the death remains under investigation by the trust, early details shared with the CQC reveal that the incident happened in an area of the ward which had been changed to an “isolation area” under the trust’s COVID-19 infection prevention strategy. However, this meant there were not “good lines of sight” for staff monitoring patients – according to the CQC’s inspection report. There were also “low staffing levels on the wards”, according to staff which spoke to the CQC. The staff also told inspectors they were “stressed, exhausted and burnt out following the demands of the pandemic”. According to the CQC, some staff had concerns about areas on the ward where patients had “unrestricted access to items including sports equipment that could be used as weapons for self-harm”. Although the ward’s ligature assessment claimed those areas were always supervised by staff, this was disputed by the staff themselves, the report said. Read full story Source: HSJ, 3 November 2020
  10. News Article
    The National Pharmacy Association (NPA) has asked community pharmacies to report all patient safety incidents despite growing work pressure due to a persisting virus pandemic. Since March, there has been a significant decrease in the number of patient safety incidents being reported, the NPA said in its medication safety update for the second quarter of 2020. Overall, there was a 44.5% decrease in the number of incidents reported during the second quarter of the year, compared to the first quarter of 2020. There was a 40.6% decrease in the number of patient safety incidents when compared to the same quarter in 2019. “This is a significant reduction in number of incidents being reported. This may be due to the increased workload and pressure on pharmacy teams due to COVID-19 pandemic, whereby pharmacy teams may not be prioritising reporting of patient safety incidents, or due to other, as yet unknown, reasons,” NPA said in its update. NPA advises community pharmacists to ensure that they report the actual degree of harm caused to the patient and not the potential harm that could have happened. The pharmacy body also suggested pharmacists should make sure that they complete a detailed outcome if an incident did lead to moderate or severe harm to the patient. This allows a thorough analysis to be undertaken by the NPA. Community pharmacists are also advised to ensure the incident form is fully completed, is accurate and includes sufficient details to allow meaningful analysis of the incident. Read full story Source: Pharmacy Business, 27 October 2020
  11. News Article
    More than 200 people who went through hotel quarantine in Victoria, Australia, must be screened for HIV amid fears of cross-contamination from incorrect usage of blood glucose test devices. Several such devices were used on multiple people in quarantine between 29 March and 20 August, necessitating screenings for blood-borne diseases such as hepatitis B and C and HIV. These monitors, which take a small sample of blood from a fingertip, are intended for repeated use by only one person. While the needle is changed between usages, microscopic traces of blood can remain within the body of the machine, creating a low clinical risk of cross-contamination and infection. Safer Care Victoria, the state’s healthcare quality and safety agency, has assured the public there is no risk of COVID-19 spread as the disease is not transmitted by blood. These devices have since been taken out of circulation. In a statement, a spokesman for the agency said they have identified 243 people who had been tested by one of the shared machines during the timeframe in question, and will be contacted for screening. Everyone “who had conditions or episodes that may have required the test will also be contacted as a precaution”. The Victorian premier, Daniel Andrews, labelled the incident a “clinical error that was made some time ago”. “Safer Care Victoria have made some announcements in relation to a clinical error that was made some time ago, very low risk, but you can’t take any risks with these things. You have to follow them up properly and that’s exactly what has happened,” he said at a press conference on Tuesday. Read full story Source: The Guardian, 20 October 2020
  12. News Article
    The NHS 111 service has permanently stopped nurses and other healthcare professionals in a clinical division handling calls with people suspected of having COVID-19 after an audit of recorded calls found more than 60% were not safe. The audit was triggered in July after many of the medical professionals recruited to work in that clinical division of the 111 service sounded the alarm, saying they did not feel “properly skilled and competent” to fulfil such a critical role. An investigation was launched into several individual cases after the initial review found that assurances could not be given “in regard to the safety of these calls”, according to an email, seen by the Guardian, from the clinical assurance director of the National Covid-19 Pandemic Response Service. In a further email on 14 August, she told staff that after listening to a “significant number” of calls “so far over 60% … have not passed the criteria demonstrating a safe call”. A number of “clinical incidents” were being investigated, she said, because some calls “may have resulted in harm”. One case had been “escalated as a serious untoward incident with potential harm to the patient”. NHS England declined to answer questions about any aspect of these apparent safety failings, saying it was the responsibility of the South Central ambulance service (SCAS), which set up a section of NHS 111 called the Covid-19 Clinical Assessment Service (CCAS). Read full story Source: The Guardian, 1 October 2020
  13. News Article
    Ten workers at a mental health unit have been suspended amid claims patients were "dragged, slapped and kicked". Inspectors said CCTV footage recorded at the Yew Trees hospital in Kirby-le-Soken, Essex, appeared to show episodes of "physical and emotional abuse". The details emerged in a Care Quality Commission (CQC) report after the unit was inspected in July and August. A spokeswoman for the care provider said footage had been passed to police. The unannounced inspections were prompted by managers at Cygnet Health Care, who monitored CCTV footage of an incident on 18 July. At the time, the 10-bed hospital held eight adult female patients with autism or learning difficulties. The CQC reviewed 21 separate pieces of footage, concluding that 40% "included examples of inappropriate staff behaviour". "People who lived there were subjected not only to poor care, but to abuse," a CQC spokesman said. Workers were captured "physically and emotionally abusing a patient", and failing to use "appropriate restraint techniques", the report said. It identified "negative interactions where staff visibly became angry with patients" and two cases where staff "dragged patients across the floor". "We witnessed abusive, disrespectful, intimidating, aggressive and inappropriate behaviour," the inspectors said. Read full story Source: BBC News, 23 September 2020
  14. News Article
    Some hospitals are using an out of date triaging tool for emergency patients suffering from sepsis that could leave them at risk of harm. A warning has been issued to NHS trusts to make sure their triage tools are up to date with the latest advice after several reported incidents in accident and emergency departments. The Royal College of Emergency Medicine flagged the risk to NHS England in a letter seen by The Independent warning patients could come to harm if action wasn’t taken. NHS England and NHS Digital has issued an alert to hospital chief executives warning of a potential safety risk. It told members: “The latest version of the system has updated treatment priorities especially in relation to the treatment of adult and paediatric sepsis. It is therefore crucial that if your organisation uses the Manchester Triage System clinical risk management triage tool, please ensure that the most recent version is being used and where this is not the case, specific local mitigation for the risks is in place.” It added that hospitals should ensure the latest versions of any clinical systems were being used to safeguard patient care. Read full story Source: The Independent, 8 April 2021
  15. News Article
    Wards at a trust facing an inquiry over the deaths of vulnerable patients have been downgraded to ‘inadequate’ over fresh patient safety concerns. The Care Quality Commission said five adult and intensive wards across three hospitals run by Tees, Esk and Wear Valleys (TEWV) Foundation Trust “did not manage patient safety incidents well”. It also criticised the trust’s leaders for failing to make sure staff knew how to assess patient risk. The watchdog rated the trust’s acute wards for adults of working age and psychiatric intensive care units as “inadequate” overall as well as for safety and leadership. The trust was also served a warning notice threatening more enforcement action if the patient safety issues are not urgently addressed. At the previous inspection in March 2020, the service was rated “good”. TEWV said it has taken “immediate action” to address the issues, including a rapid improvement event for staff and daily safety briefings, and will also spend £3.6m to recruit 80 more staff. The trust’s overall rating of “requires improvement” remains unchanged after this inspection. Brian Cranna, CQC’s head of hospital inspection for the North (mental health and community health services), said: “We found these five wards were providing a service where risks were not assessed effectively or managed well enough to keep people safe from harm." “Staff did not fully understand the complex risk assessment process and what was expected of them. The lack of robust documentation put people at direct risk of harm, as staff did not have access to the information they needed to provide safe care." Read full story (paywall) Source: HSJ, 26 March 2021
  16. News Article
    NHS hospitals have been forced to pay millions of pounds to regulators after wrongly claiming their maternity units were among the safest in the country. Seven NHS trusts, including some now at the centre of major care scandals, will have to pay back a total of £8.5m after self-assessments of their maternity services were found to be false. Families whose babies died as a result of avoidable errors at some of the hospitals told The Independent it was further evidence of poor governance and management failings. NHS Resolution, which acts as the health service’s insurer for clinical negligence, launched the maternity incentive scheme in 2018 in an effort to focus action on 10 key safety areas in maternity, including ensuring they have systems in place to review deaths, monitor women and plan staffing levels as well as reporting incidents to the Healthcare Safety Investigation Branch which investigates maternity incidents in the NHS. Among the trusts forced to give money back over the first two years of the scheme include Shrewsbury and Telford Hospital Trust, which paid back £953,000. An inquiry into its maternity service found a dozen women and more than 40 babies died as a result of poor care in one of the largest maternity scandals in NHS history. East Kent Hospitals University Trust, which is facing an inquiry into baby deaths and a criminal prosecution by the Care Quality Commission over the death of baby Harry Richford in 2017, face paying back £2.1m over two years. Derek Richford, who helped expose failings at East Kent after the death of his grandson, told The Independent it was “abhorrent” that the trust claimed “vital NHS funds by falsely claiming that they had achieved 10/10 for maternity safety when the truth was in fact 6/10. East Kent Trust did this two years running and even when asked to check their submission, reconfirmed the erroneous data to NHS Resolution.” An evaluation of the scheme by NHS Resolution said it was “recognised that recent examples of poor governance from trusts in relation to the certification of submissions require further action”. Read full story Source: The Independent, 7 March 2021
  17. News Article
    A man who was treated with imported blood products in the 1980s became the first haemophiliac in the UK to test HIV positive and die of Aids, an inquiry has heard. Kevin Slater, from Cwmbran, was 20 when he developed Aids in 1983 the Infected Blood Inquiry has been told. He was not informed that he had been diagnosed with the condition for at least 18 months and died in 1985. Records show it was recommended that the diagnosis be kept from him. The UK-wide inquiry is looking into what has been described as the worst treatment disaster in the history of the NHS. Haemophilia is a blood condition which affects the clotting of blood in those affected. In the 1980s some of the blood products used to treat the condition were infected with HIV. The inquiry heard there were about 100 haemophiliac patients in Wales at the time. Mr Slater's sister-in-law Lynda Maule said she does not believe he was ever told he had Aids. "He was treated disgustingly," she told the inquiry. "There was no care, nothing. Read full story Source: BBC News, 2 February 2021
  18. News Article
    The Healthcare Safety Investigation Branch (HSIB) has launched an investigation into the risks involved in prescribing, dispensing and administering medicines to children. The investigation was triggered after HSIB was notified of an incident including a child aged four years, who, after being diagnosed with a blood clot in her leg following a surgical procedure, received ten times the intended dose of anticoagulant on five separate occasions, over three days. This, HSIB said, was owing to errors that occurred during the prescription, dispensing and administration processes. The errors resulted in the child being admitted to the paediatric intensive care unit, with evidence of a bleed in her brain, where she stayed for three months until she was discharged with an ongoing care plan. HSIB said that studies showed that prescribing errors were the most frequent type of medication error in children’s inpatient settings. The investigation will look at this and other incidents to examine the role of multidisciplinary teamworking and checking in medication errors, as well as considering the risks associated with the implementation of electronic prescribing and medication administration (ePMA) systems in clinical areas using weight-based paediatric prescribing. “‘Wrong dose’ errors are a particular risk in children’s wards,” said Alice Oborne, consultant pharmacist in safe medication practice and medicines safety officer at Guy’s and St Thomas’ NHS Foundation Trust. Read full story Source: The Pharmaceutical Journal, 26 January 2021
  19. News Article
    Two-thirds of women at the heart of a review into maternity services at a Welsh health board could have had very different outcomes if they had received better care, a report has found. The Independent Maternity Services Oversight Panel (Imsop) focused on the experiences of pregnant women at Cwm Taf Morgannwg health board. Its maternity services have been in special measures since "serious failings" were found two years ago. Concerns emerged in late 2018 that women and babies may have come to harm because of staff shortages and failures to report serious incidents. This sparked a major independent review, which gave a damning verdict on maternity services in Cwm Taf Morgannwg health board. Published on Monday, the Imsop report focuses on the care of mothers between January 2016 and September 2018. It found that 19 reviews of maternal care (68%) revealed at least one factor where "different management would reasonably have been expected to alter the outcome". The panel's chairman, Mick Giannasi, said: "These findings will be concerning and potentially distressing for the women and families involved, and it will be difficult for staff." "Of the 28 episodes of care, we concluded that in 27 of them, our independent teams who reviewed the care would have done something differently. Put simply, what went wrong, might not have gone wrong if things had been done differently." Read full story Source: BBC News, 25 January 2021
  20. News Article
    At least seven so-called NHS “never events” should be reclassified because the health service has failed to put in place effective measures to stop them from repeatedly happening, safety experts have said. The independent Healthcare Safety Investigation Branch (HSIB) said NHS England should remove the never event incidents from the list of 15 it requires hospitals to report, because they are not “wholly preventable” and the NHS has not adequately recognised the systemic risks that mean they keep happening. The errors include examples such as a 62-year-old man having the wrong hip replaced during surgery and a nine-year-old girl who was given a drug by injection that should have been given by mouth. Other incidents included a woman who had a vaginal swab left inside her following the birth of her first child and a 26-year-old man who had a feeding tube accidentally inserted into his lung rather than his stomach. In a new report, investigators from HSIB carried out a detailed analysis of seven incidents it has investigated which account for the majority of never events recorded by NHS hospitals in 2018-19. NHS England claims there are steps hospitals can take that mean the errors should never happen but HSIB says many of the steps are administrative, such as a checklist, and do not fully take into account the environment staff work in, the nature of the errors or how they happen. Read full story Source: The Independent, 21 January 2021
  21. News Article
    In July last year, the Independent Medicines and Medical Devices Safety Review – chaired by Baroness Cumberlege— published its landmark report, First Do No Harm. It followed a two-year review of harrowing patient testimony and a large volume of other evidence concerning three medical interventions: Primodos, sodium valproate and pelvic mesh. Yesterday, in a written statement to Parliament, the Minister for Patient Safety, Suicide Prevention and Mental Health, Nadine Dorries, gave an update on the government’s response to the recommendations of the Cumberlege Review. In an article in The Times today, Baroness Cumberlege welcomes that the government has now accepted the need for a patient safety commissioner for England and the amendment to the Medicines and Medical Devices Bill, which is being considered in the House of Lords today, which she hopes "will swiftly become law". However, she also states that "... a full response to the review's is still outstanding 6 months after publication. Action is urgently needed to ensure we help those who have already suffered and reduce the risk of harm to patients in future". Read full story (paywalled) Source: The Times, 12 January 2021
  22. News Article
    A care home in Birmingham has been heavily criticised by the care watchdog after it found physical and verbal abuse of residents with learning disabilities and autism had become “normal”. The Care Quality Commission (CQC) said it had put urgent restrictions on Summerfield House, in Birmingham, to stop any more people being admitted there. The home was looking after four residents with disabilities in August when CQC inspectors found a string of concerns. Records revealed episodes of physical, verbal and emotional abuse of the residents with staff making threats to cancel activities or threatening to call the police. The CQC found staff were not able to recognise abuse, citing an example where inspectors saw a person being hit on the head by another person with no action being taken. The watchdog’s report said abuse was happening between residents and staff. Debbie Ivanova, CQC deputy chief inspector for people with a learning disability and autistic people, said: “Our latest inspection of Summerfield House found a truly unacceptable service with a poor culture where abuse and people being placed at harm had become normal, with no action taken to prevent incidents from happening or reoccurring." Read full story Source: The Independent, 28 September 2021
  23. News Article
    The backlog of serious clinical incidents that need investigating is building up throughout the NHS, due to the impact of coronavirus and emergency service pressures. Concerns have been raised by commissioners in some areas over the delays. Meanwhile, patients and families who have been harmed are waiting longer to see their cases resolved and the organisations involved are not learning the lessons taught by care failures as quickly as they should. Staff redeployment or absences due to COVID-19 are among the reasons why many investigations are being delayed. As result, trusts are attempting to recruit additional investigators to manage their backlogs. Tina Ivanov, the trust’s director of quality governance, said: “Learning from serious incidents when they occur is an important part of our improvement culture. “We are increasing the number of trained investigators at the trust and have brought in additional resource to help complete the outstanding investigations. The reasons for the increase in outstanding serious incidents include staff absences and clinical pressures.” Read full story (paywalled) Source: HSJ, 27 September 2021
  24. News Article
    A mental health hospital in Suffolk has been closed after inspectors found it was failing to protect patients from harm and abuse. St John's House in Palgrave, near Diss, was previously rated inadequate by the Care Quality Commission (CQC). A further inspection of the 49-bed hospital found the care was "unacceptable" and "insufficient progress had been made regarding patient safety". The company that runs the hospital, Partnerships in Care, part of the Priory Group, has now decided to close the site. Stuart Dunn, CQC head of inspection for mental health and community services, said: "Our latest inspection of St John's House found an unacceptable service where insufficient improvements had been made to protect patients from harm and abuse and the number of safety incidents remained high." "Staff weren't responding appropriately to patients who were self-harming, with one patient not being sent to hospital quickly enough after swallowing a foreign object, despite complaining of abdominal pain. "We reviewed CCTV footage and found staff were sometimes asleep when they should have been observing patients to make sure they were safe. This was all the more concerning as we identified this as a concern during the previous two inspections of this service, demonstrating a lack of improvement to keep patients safe. "Incidents of restraint remained high and not all staff had the right training to carry it out safely. In addition, staff were not following hospital policy when using soft handcuffs with patients during safety incidents." Read full story Source: ITV News, 17 September 2021
  25. News Article
    Young people cared for by an NHS mental health service "came to harm" because of its failings, inspectors said. The care provided by Essex Partnership University NHS Foundation Trust (EPUT) has been rated "inadequate" by the Care Quality Commission (CQC). It has now been stopped from admitting new patients after inspectors found "serious concerns" in the children and adolescent mental health services. EPUT said it had increased staffing levels and had been coaching staff. The inspection was prompted by a serious incident and concerning information received about safety and quality, the CQC said. Inspectors visited, unannounced, in May and June and looked at the Larkwood and Longview wards at the St Aubyn Centre in Colchester and the Poplar Adolescent Unit at Rochford Hospital. The CQC found observations were not always carried out safely and patients "had been harmed as a result of the poor practices", which included patients self-harming. It said these incidents were not always reported or dealt with appropriately. Read full story Source: BBC News, 15 September 2021
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