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Found 684 results
  1. News Article
    NHS England is investigating a “potential serious incident” in its flu programme following concerns that people aged 65 and over are being given a vaccination jab known to be ineffective for this age group. Details of the investigation were set out in a letter by NHS England’s South East regional team. The letter, seen by HSJ, said: “The NHS regional direct commissioning team are investigating reported administration of QIVe flu vaccine to patients aged 65 years or older by a number of primary care providers (primary care and pharmacy) across the region. QIVe is not recommended for use in this age group due to its poor effectiveness.” It said officials were contacting practices and pharmacists directly where there was a record of QIVe vaccine having been given to the older age cohort to identify whether this is a recording coding error, or a genuine administration of QIVe. Initial investigations “suggest a mixture of both”, it said. The letter added: “If any patient 65 or over has received QIVe, we will be asking the practice or pharmacist to treat this as an incident. Patients will need to be contacted, informed of the error, its potential implications and offered the opportunity to receive a vaccine which is appropriate for their age group." It is unclear how many patients have been given the wrong jab. Read full story Source: HSJ, 8 November 2022
  2. News Article
    Safety inspectors have ordered a mental health trust to make immediate improvements after visiting two inpatient wards where three patients died inside six months. The Care Quality Commission this week warned Devon Partnership Trust it would take “urgent action” over “serious concerns about patients” unless the trust made the required improvements swiftly. The watchdog inspected the trust’s Delderfield and Moorland wards in June following concerns about three patient deaths in September, October and March, along with “a number of” patient safety incidents - including ligature incidents. The CQC also highlighted poor patient observation routines and a lack of learning from previous incidents, amid delays in completing investigations into safety incidents. Read full story Source: HSJ, 21 August 2020
  3. News Article
    High-risk women at a maternity unit were not monitored closely enough and there was a "lack of learning" from a mother's death, inspectors found. A Care Qualtiy Commission (CQC) report rated the unit at Basildon University Hospital as inadequate with "failings" found in six other serious cases. Inspectors carried out unannounced checks in June after a whistleblower voiced fears about patient safety. The unit was criticised following the deaths of baby Ennis Pecaku in September 2018 and mother Gabriela Pintilie, 36, in February 2019. The CQC previously carried out an inspection of the department the month Mrs Pintilie died and said the unit, which had once been rated outstanding, required improvement. Inspectors returned for the surprise "focused" inspection after being contacted by an anonymous whistleblower. The report found babies were born in a poor condition and then transferred for cooling therapy, which can be offered for newborn babies with brain injury caused by oxygen shortage during birth. During their visit, inspectors found: High-risk women giving birth in a low-risk area. Not enough staff with the right skills and experience. "Dysfunctional" working between midwives, doctors and consultants, which had an impact on the "increased number of safety incidents reported". Concerns over foetal heart monitoring. Women being referred to by room numbers instead of their names. A "lack of response by consultants to emergencies" resulting in delays The CQC also referred to issues relating to the death of Mrs Pintilie, who was not named in the report, and said five serious incidents "identified the same failings of care". Read full story Source: BBC News, 18 August 2020 "This demonstrated there had been a lack of learning from previous incidents and actions put in place were not embedded."
  4. News Article
    A GP practice serving one of Greater Manchester’s most deprived communities has been banned from operating for four months after regulators uncovered a catalogue of basic failures - including failing to follow up on a child reporting breathing difficulties for three days. Jarvis Medical Practice in Glodwick has had its registration with the Care Quality Commission (CQC) suspended after ‘serious concerns’ passed to the body led to a snap inspection last month. Inspectors found the practice, based at Glodwick Primary Care Centre, was failing 20 separate standards, many of them relating to patient safety. It noted ‘poor quality’ and conflicting records that were sometimes impossible to properly understand and urgent home visits delayed or not carried out at all. In one case a patient with a lump apparently received no physical examination and was not referred for tests or scans ‘due to Covid-19’. Inspectors also found examples of patients with breathing difficulties, including a child, who were not dealt with for days after they got in touch. In one case no further contact was made for 11 working days, with no explanation provided in the patient's notes. The practice, which serves more than 5,000 patients in the Oldham neighbourhood of Glodwick, has now been suspended by the CQC until October 11. Read full story Source: Manchester Evening News, 17 July 2020
  5. News Article
    A hospital trust at the centre of Britain’s largest ever maternity scandal has widespread failings across departments and is getting worse, the care regulator has warned as it calls for NHS bosses to take urgent action. Ted Baker, chief inspector of hospitals, urged NHS England to intervene over the “worsening picture” at Shrewsbury and Telford Hospital Trust, which is already facing a criminal investigation. There are as many as 1,500 cases being examined after mothers and babies died and were left with serious disabilities due to poor care going back decades in the trust’s maternity units. Now, in a leaked letter seen by The Independent, Prof Baker has warned national health chiefs that issues are still present today across wards at the trust – with inspectors uncovering poor care in recent visits that led to “continued and unnecessary harm” for patients. He raised the prospect that the Care Quality Commission (CQC) could recommend the trust be placed into special administration for safety reasons, which has only been done once in the history of the NHS – at the former Mid Staffordshire NHS Trust, where a public inquiry found hundreds of patients suffered avoidable harm and neglect because of widespread systemic poor care. In a rarely seen intervention, Prof Baker’s letter to NHS England’s chief operating officer, Amanda Pritchard, warned there were “ongoing and escalating concerns regarding patient safety” and that poor care was becoming “normalised” at the trust, which serves half a million people with its two hospitals – the Royal Shrewsbury and Telford’s Princess Royal. Read full story Source: The Independent, 16 July 2020
  6. News Article
    London’s Nightingale hospital recorded 144 patient safety incidents during its 29 days treating 54 patients, it has emerged. There were two serious incidents at the field hospital, a doctor told a Royal Society of Medicine webinar. Dr Andrew Wragg, consultant cardiologist and director of quality and safety at Barts Health NHS Trust, said a study of the long-term outcomes of the 54 patients was ongoing, as 20 of those treated at the ExCel conference centre site were still recovering in hospitals across London. Johanna Cade, a nurse at Guy’s and St Thomas’ NHS trust and who worked at the Nightingale, said: “We had quite high incident reporting at 144 incidents reported and I think that demonstrates that Nightingale really did well at building a no blame safety culture for resolution and learning. This system manifested itself and staff were really striving to make things better continually. We knew who to report to and how to escalate things.” She showed data revealing the largest number of safety incidents involved medical devices. There were 25 incidents that included the ventilators used to keep patients alive. Staffing issues and medication, as well as pressure ulcer and communication incidents, were also among the highest numbers. Read full story Source: The Independent, 27 June 2020
  7. News Article
    A High Court judge has ruled that an NHS trust was negligent in failing to consider early enough that a toddler with fever, lethargy, and vomiting might have had a serious bacterial infection and to give her intramuscular antibiotics. Mr Justice Johnson said that doctors from University Hospital Southampton NHS Foundation Trust should have ordered a lumbar puncture on the 15 month old girl on the day she was first seen or the next day. The girl, referred to in court as SC, was sent by her GP to the hospital by ambulance on 26 January 2006 with a note describing his findings on examination and ending “?meningitis.” The GP, Mark Dennison, had given her intramuscular penicillin. Read full story (paywalled) Source: BMJ, 22 June 2020
  8. News Article
    The NHS has kept secret dozens of external reviews of failings in local services – covering possible premature deaths, unnecessary and harmful operations, and rows among doctors putting patients at risk – an HSJ investigation has found. At least 70 external reviews by medical royal colleges were carried out from 2016 to 2019, across 47 trusts, according to information provided by NHS trusts, but more than 60 of these have never been published – contrary to national guidance – while several have not even been shared with the Care Quality Commission (CQC) and other regulators. These include reviews which uncovered serious failings. Bill Kirkup’s review into the Morecambe Bay scandal in 2015 recommended trusts should “report openly” all external investigations into clinical services, governance or other aspects of their operations, including notifying the CQC. Since then the CQC has asked trusts for details of external reviews when it reviews evidence, and in July 2018 it began to ask for copies of their final reports, but HSJ’s research suggests this does not always happen. James Titcombe, the patient safety campaigner whose son’s death led to the inquiry by Bill Kirkup into the Morecambe Bay maternity care scandal, said a review was now needed of whether its recommendations had been implemented. “It is not acceptable that five years [on], there are still secretive royal college reports and patients are kept in the dark,” he said. Read full story Source: HSJ, 25 June 2020
  9. News Article
    A hospital A&E department has been rated "inadequate" after inspectors found patients at "high risk of avoidable harm". The Care Quality Commission (CQC) reported a "range of regulation breaches" and a shortage of nurses at Stepping Hill hospital's A&E unit. It also criticised maternity and children's services. Stockport NHS Foundation Trust's chief executive said the trust had taken "immediate steps" to improve. The CQC inspected Stepping Hill Hospital in January and February and found A&E performance "had deteriorated significantly" since its last inspection in 2018. Inspectors found shortcomings "relating to patient-centred care, dignity and respect, safe care and treatment, environment and equipment, good governance, and staffing". Their report said the service "could not assure itself that staff were competent for their roles" and patient outcomes "were not always positive or met expectations in line with national standards". Read full story Source: BBC News, 19 May 2020
  10. News Article
    The Care Quality Commission (CQC) has suspended its routine inspections due to the coronavirus outbreak following pressure from system leaders and NHS bosses. The decision to suspend inspections where there are no immediate safety concerns is understood to have been taken by the CQC’s executive team this morning, senior sources told HSJ. Both the NHS Confederation and The Royal College of GPs said the decision had been made. NHS Confederation called the move a “sigh of relief” for front-line staff, while the RCGPs said it would enable GPs to dedicate their time to providing care. NHS Confederation chief executive Niall Dickson said: “Front-line staff will breathe a sigh of relief that CQC has responded to our concerns and will now postpone its inspections where there is no immediate safety concern so that they can gear themselves up to prepare for the huge task ahead in dealing with the coronavirus pandemic.” Read full story Source: HSJ, 16 March 2020
  11. News Article
    An NHS trust at the centre of an inquiry into preventable baby deaths will repay money it received for providing good maternity care. In 2018, Shrewsbury and Telford NHS Trust received almost £1m, weeks before its services were rated inadequate. The BBC revealed in December the trust had qualified for the payment under the NHS's Maternity Incentive Scheme. The trust said an "incorrect submission" had been made and it had ordered an independent review. Shrewsbury and Telford NHS Trust (SaTH) is at the centre of England's largest inquiry into poor maternity care, with more than 900 families contacting a review looking into concerns over preventable deaths and long-term harm. Former health secretary Jeremy Hunt wrote to ministers questioning if improvements to the Maternity Incentive Scheme were needed in light of payments made to both Shrewsbury and Telford and East Kent Hospitals, despite both facing serious questions over the safety of maternity services. The trust in Shropshire was paid £963,391 after certifying it had met the 10 safety standards demanded by the scheme, which is run by NHS Resolution. In the letter, seen by the BBC, Mr Hunt suggested one improvement would be to link payments to CQC maternity and safety ratings. "The whole approach is likely to be discredited if trusts can meet all 10 actions and yet still be delivering poor standards of care," the letter said. Read full story Source: BBC News, 6 March 2020
  12. News Article
    There is a “strong association” between staff experience of senior management and whether an organisation acts on error reporting, exclusive analysis for HSJ of the staff survey data suggests. Analysis by health and social care charity Picker Institute examined statistical relationships between responses to staff survey questions regarding staff communication with managers and those relating to error reporting. The analysis, which included all trust types, looked at the relationships between statements such as “communication between senior managers and staff is effective” and “I know who the senior managers are here” to “When errors, near misses or incidents are reported, my organisation takes action to ensure they do not happen again” and other similar indicators. A high correlation to the questions does not categorically prove a direct causal relationship but the data suggested “strong associations”, Picker Institute chief statistician Steve Sizmur told HSJ. He said: “There are a number of strong associations in the latest staff survey data, to the extent that there is likely to be a link between staff experiences of senior management and their views about error reporting and whether the organisation addresses their concerns.” Read full story (paywalled) Source: HSJ, 27 February 2020
  13. News Article
    The government has announced an independent review into maternity services at an NHS trust where a number of babies have died. “Immediate actions” have also been promised and an independent clinical team has been placed “at the heart” of East Kent Hospitals University NHS Foundation Trust. It comes amid reports that at least seven preventable baby deaths may have occurred at the trust since 2016, including that of Harry Richford. Harry died seven days after his emergency delivery in a “wholly avoidable” tragedy, contributed to by neglect, in November 2017, an inquest found. Speaking in the House of Commons, the health minister Nadine Dorries confirmed the independent review would be carried out by Dr Bill Kirkup, who led the investigation into serious maternity failings at Morecambe Bay. It will look at preventable and avoidable deaths of newborns to ensure the trust learns lessons from each case and will put in place appropriate processes to safeguard families. The review is expected to begin shortly and work in partnership with affected families. Read full story Source: 13 February 2020
  14. News Article
    A GP has been given three life sentences for 90 sex assaults on female patients. Manish Shah assaulted 23 women and a 15-year-old girl while working in London - carrying out invasive examinations for his own gratification. The Old Bailey heard he used Angelina Jolie and Jade Goody as examples to frighten patients about their health. Judge Anne Molyneux described him as a "master of deception who abused his position of power". "You made up stories which got into heads and caused panic," she said. Shah, from Romford, convinced his victims to have unnecessary checks between May 2009 and June 2013. Read full story Source: BBC News, 7 February 2020
  15. News Article
    A number of doctors have claimed a service under which adolescents with gender dysphoria can be given puberty-suppressing hormone blockers is "unsafe" and must be immediately stopped, but their concerns were suppressed. The service is provided in Ireland by flying in two clinicians from an NHS trust in London to run clinics at Crumlin Children's Hospital. But the Irish Independent has learned at least three doctors working in the gender area expressed grave concerns over the service provided by the Tavistock and Portman NHS Foundation Trust at Crumlin. The concerns over standards of clinical care and governance were raised at a meeting of doctors and hospital officials in Crumlin last March. These included that children had been started on hormone treatment when they did not appear to be suitable. However, the issues raised and calls by the doctors for the service to be "terminated with immediate effect" were omitted from draft minutes of the meeting. News of their concerns comes days after it emerged a lawsuit was being taken by a former nurse, a parent, and a former patient against the trust in the London High Court. The action is challenging the clinic's practice of prescribing hormone blockers and cross-sex hormones to children under the age of 18. The trust has also been hit by a series of resignations by psychologists amid disquiet about the alleged "over-diagnosis" of gender dysphoria. Read full story Source: Irish Independent, 3 February 2020
  16. News Article
    More than half of all incidents resulting in death reported by health boards in Wales came from troubled Betsi Cadwaladr. The 53% figure from a Welsh Government safety report came to light during First Minister Questions in the Senedd yesterday. Plaid Cymru Leader Adam Price said there had been “an alarming rate” of patient safety incidents in the Betsi Cadwaladr University Health Board area and that between December 2018 and November 2019 there were 40 incidents resulting in death registered within Betsi. Between November 2017 and November 2019 there were 520 incidents within Betsi that resulted in death or serious harm - higher than all the other health boards in Wales combined. Mr Price questioned whether there is an issue with Betsi itself, or whether there is an issue of "under-reporting of serious incidents" in the rest of Wales. Defending the figures, the First Minister said that reporting incidents and learning from them has become part of the culture of a health board that they “want to see everywhere in Wales”. Read full story Source: North Wales Live, 29 January 2020
  17. News Article
    Calls for immediate compensation for thousands of victims contaminated by infected NHS blood have been rejected by ministers at a meeting with campaigners and survivors – but more health support may be made available. Despite one person dying every four days on average from HIV, hepatitis C or other conditions, the government on Tuesday turned down a request for a national compensation scheme. There are estimated to be between 5,000 and 7,000 victims still alive who acquired viral infections through transfusions from the health service. Many are haemophiliacs who need regular transfusions to help their blood clot. Products supplied by the NHS in the 1970s and 1980s came from the US using blood obtained from prisoners and drug addicts who were paid for their donations. Imported products were inadequately screened. Read full story Source: The Guardian, 28 January 2020
  18. News Article
    The government has ordered an urgent inquiry into the local hospital of the health secretary, Matt Hancock, after the Guardian revealed its unprecedented “witch-hunt” for a whistleblower. The Department of Health and Social Care (DHSC) has told NHS England to commission a “rapid review” of the actions of bosses at West Suffolk hospital. They are under fire for demanding that staff give fingerprints and samples of their handwriting to help identify who wrote to a family alerting them to failings in care that contributed to a patient’s death. Unusually, the investigation has been instigated by Edward Argar, a junior minister at the DHSC, because Hancock and another health minister, Jo Churchill, are both local MPs who have close ties to the hospital. Argar has made clear to NHS England that the inquiry must be undertaken by independent experts, given those existing relationships. Announcing the review, Argar made clear that he wanted hospital personnel to speak openly. “I want all staff to feel that they can speak up and have the confidence that anything they raise will be taken seriously,” he said. Read full story Source: The Guardian, 28 January 2020
  19. News Article
    The failure to pass a damning report about a scandal-hit hospital trust to the care watchdog has been criticised by the man who led the inquiry into baby deaths at Morecambe Bay. On Friday, a coroner ruled that the death of baby Harry Richford in 2017 resulted from neglect in the maternity unit of East Kent Hospitals NHS Trust. A report by the Royal College of Obstetrics and Gynaecologists (RCOG) completed a year earlier had warned of issues that contributed to Harry’s death, including senior doctors not showing up for their shifts. However, the report was never passed on to the Care Quality Commission (CQC), despite the recommendation of the Morecambe Bay inquiry in 2015 that relevant external reviews should be passed on to the watchdog. Bill Kirkup, who chaired the inquiry into deaths of mothers and babies at Furness General Hospital in Barrow-in-Furness, told The Independent: “When there is sufficient concern about a service to prompt an external review, the report must be available immediately to those responsible for assuring the quality of the service. That was the reason for the recommendation of the Morecambe Bay investigation, and it is disappointing that the Care Quality Commission apparently had no sight of this report until now.” Read full story Source: 26 January 2020
  20. News Article
    England's care watchdog has carried out a no-notice inspection of an NHS trust at the centre of concerns over the possible preventable deaths of babies. The Care Quality Commission (CQC) is investigating East Kent Hospitals NHS Trust but has not yet decided whether to prosecute. It comes as the trust is likely to be heavily criticised at an inquest into the death of baby Harry Richford. On Thursday, the BBC revealed significant concerns have been raised about maternity services at the trust, and a series of preventable baby deaths may have occurred there. On Wednesday and Thursday this week, the trust's maternity services were subject to an unannounced inspection from the CQC. On Thursday night, East Kent Hospitals University NHS Foundation Trust said in a statement: "We are truly sorry for the death of baby Harry and our thoughts and deepest sympathies go out to Harry's family. We accept that Harry's care fell short of the standard that we expect to offer every mother giving birth in our hospital and we are fully cooperating with the CQC's investigation into Harry Richford's death." Read full story Source: BBC News, 24 January 2020
  21. News Article
    The Care Quality Commission (CQC) has raised concerns about the treatment of patients at mental health units run by Cygnet. It follows inspections in the wake of a BBC Panorama investigation about alleged abuse at Wharlton Hall in County Durham. The CQC found that patients under the firm's care were more likely to be restrained. Higher rates of self-harm were also noted by inspectors who quizzed managers and analysed records at the company's headquarters. The regulator also found a lack of clear lines of accountability between the executive team and its services. It said directors' identity and disclosure and barring service checks had been carried out, butd that required checks had not been made to ensure that directors and board members met the "fit and proper" person test for their roles. Systems used to manage risk were also criticised, while training for intermediate life support was not provided to all relevant staff across services where physical intervention or rapid tranquilisation was used. Cygnet runs more than 100 services for vulnerable adults and children, caring for people with mental health problems, learning disabilities and eating disorders. The CQC says Cygnet must now take immediate action to address the concerns raised. Cygnet said a number of the services highlighted have since been improved, but "we are not complacent and take on board recommendations where we must improve". Read full story Source: BBC News, 14 January 2020
  22. News Article
    The Healthcare Safety Investigation Branch (HSIB) has launched an investigation looking at nasogastric tubes and how previously identified safety improvements for the placement of these tubes are put into practice. Nasogastric (NG) tubes are used to deliver fluid, food and medication to patients via a tube that passes through the nose and down into the stomach. There is a risk of serious harm and risk to life if NG tubes are incorrectly placed into the lungs, rather than the stomach, and feed is passed through them. HSIB has started this investigation after they were notified of a patient who inadvertently had a nasogastric tube inserted into his lung. Further information Source: HSIB, 7 January 2020
  23. News Article
    Only 14% of pharmacy professionals are worried about criminal prosecution when reporting a patient safety incident, compared with 40% in 2016, survey results have showed. The results of the 2019 ‘Patient safety culture survey’ of 917 pharmacy professionals, carried out by the Community Pharmacy Patient Safety Group (PSG) in April and May 2019 came after the introduction of a legal defence for dispensing errors in 2018. The survey also showed that 22% of pharmacy professionals would not report a patient safety incident inside their organisation owing to fears of criminal prosecution. This is compared with 40% of 623 respondents saying in 2016 that they would not report a patient safety incident because of the possibility of criminal prosecution. Janice Perkins, chair of the PSG, said the results “demonstrate that there have been significant positive improvements since 2016”. “Nurturing an open and honest safety culture in community pharmacies is vital. It requires everyone to feel confident in openly sharing when things go wrong to learn from errors and prevent them occurring again,” she added. Read full story Source: The Pharmaceutical Journal. 19 December 2019
  24. News Article
    Hospitals will face penalties if staff do not notify patients of serious adverse incidents under proposed new legislation. Due to be brought to Cabinet by the Minister for Health Simon Harris in early December, it will provide for mandatory open disclosure of patient safety issues. It is understood that the new Bill would mean that where a hospital or health service provider was satisfied that a notifiable patient safety incident had occurred, information in its possession on the issue should be disclosed. A doctor or practitioner would be obliged to inform the patient and hospital of the incident. Under the proposals, failure to comply with this requirement on disclosure would mean the health service provider would be penalised. The nature or extent of the proposed penalties is unknown. The department is preparing a list of notifiable patient safety incidents for the mandatory open disclosure proposals. Read full story Source: The Irish Times, 25 November 2019
  25. News Article
    A GP who gave wrongly dated and misleading medical notes to police inquiring into the death of a 12 year old boy from undiagnosed Addison’s disease has been suspended from the UK medical register for nine months. Ryan Morse died in the early hours of 8 December 2012, hours after his mother rang the local Blaenau Gwent surgery twice in a day, reporting high temperature, extreme drowsiness, and involuntary bowel movement. The second time, she spoke to GP Joanne Rudling, telling her that the boy’s genitals had turned black. But Rudling failed to check the notes of the first call or give adequate weight to the fact that the mother was calling again, the tribunal found. She failed to obtain an adequate history or reach an appropriate conclusion about the change in genital colour. Read full story (paywalled) Source: BMJ, 25 November 2019
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