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Found 213 results
  1. Content Article
    This article in the Journal of Minimally Invasive Gynaecology provides an interpretation of the 2014 US Food and Drug Administration (FDA) statement on power morcellation, a gynaecological procedure in which a device is used to slice up fibroid tissue for extraction through small incisions. Although use of power morcellation makes surgery less invasive, it has been shown to spread cancer if it exists within the patient's tissues. This article looks at the legal impact of the FDA statement, which warns against using laparoscopic power morcellators in the majority of women undergoing hysterectomy or myomectomy for uterine fibroids.
  2. Content Article
    This is a joint blog by Patient Safety Learning and Sling the Mesh, highlighting key areas of concern included in their recent response to the Royal College of Obstetricians and Gynaecologists consultation on a new Mesh Complications Management Training Pathway.
  3. Content Article
    'The Theatre: Surgical Learning & Innovation Podcast' is a podcast by the Royal College of Surgeons of England. This episode features a panel discussion on the nature of “human factors” in surgery, presented by Peter Brennan, consultant oral and maxillofacial surgeon, Louise Cousins, trainee general surgeon, Neil Tayler, British Airways pilot and trainer, and Graham Shaw, also a British Airways pilot and Director of Critical Factors, a consulting and training service for professionals operating in safety-critical environments.
  4. Event
    until
    As one of the largest gatherings of perioperative professionals in the UK, the AfPP Annual Conference is essential for anyone working in the perioperative field. This year’s theme is ‘A Profession To Be Proud Of’. What better way to celebrate this incredible profession than by listening to fantastic speakers, asking exhibitors your burning questions and getting dressed up at our Gala Dinner! Join us at the University of York from 10 – 13 August. If you’re joining us for the entire conference or just for a day, there will be something for everyone. Virtual tickets are also available if you can’t make it to York. Our Annual Conference boasts a full programme of education, networking, hands-on workshops and entertainment. You’ll leave feeling informed, challenged and inspired. If you’re not proud of your profession when you arrive, you will be by the time you leave! Register
  5. Event
    Future Surgery, brings together surgeons, anaesthetists and the whole perioperative team. Designed specifically to meet the training needs, promote networking and develop a stronger voice for all surgical professionals and their multidisciplinary teams in perioperative care. Our CPD accredited speaker programme explores disruptive technology, connectivity, human factors, training and research to support the transformation of the profession and the improved care and safety of patients. Future Surgery is the biggest gathering of surgical and operating theatre teams with over 110 expert speakers – in keynote sessions, panel discussions and workshop sessions, covering all that is new in the field of surgery. Register
  6. Community Post
    Subject: Looking for Clinical Champions (Patient Safety Managers, Risk Managers, Nurses, Frontline clinical staff) to join AI startup Hello colleagues, I am Yesh. I am the founder and CEO of Scalpel. <www.scalpel.ai> We are on a mission to make surgery safer and more efficient with ZERO preventable incidents across the globe. We are building an AI (artificially intelligent) assistant for surgical teams so that they can perform safer and more efficient operations. (I know AI is vaguely used everywhere these days, to be very specific, we use a sensor fusion approach and deploy Computer Vision, Natural Language Processing and Data Analytics in the operating room to address preventable patient safety incidents in surgery.) We have been working for multiple NHS trusts including Leeds, Birmingham and Glasgow for the past two years. For a successful adoption of our technology into the wider healthcare ecosystem, we are looking for champion clinicians who have a deeper understanding of the pitfalls in the current surgical safety protocols, innovation process in healthcare and would like to make a true difference with cutting edge technology. You will be part of a collaborative and growing team of engineers and data scientists based in our central London office. This role is an opportunity for you to collaborate in making a difference in billions of lives that lack access to safe surgery. Please contact me for further details. Thank you Yesh yesh@scalpel.ai
  7. Content Article
    In this blog post, Kath Sansom, founder of the Sling the Mesh campaign, looks at the issue of payments being made to doctors and lobby groups by pharma and medical tech companies. She argues that these payments are a patient safety concern as it can lead to doctors displaying bias in advising treatments, with benefits being overstated and risks downplayed. This is especially concerning when industry money is given to consultants or researchers trialling new treatments. Kath highlights an investigation carried out by the Observer into the issue and explains why Sling the Mesh have lobbied the UK Government for a UK Sunshine style payment act, which would allow the public to look up the names of doctors, surgeons and researchers to see if they have taken money from industry.
  8. Community Post
    I’ve just been listening to the 10 o’clock news tonight and it has been covering the report into Paterson, the breast surgeon who may have needlessly operated on thousands on women. One of the recommendations is that patient safety should be a ‘top priority’ across the NHS (again!!). Another interesting recommendation is that the NHS (and private healthcare providers) need to be better at sharing information about medical staff. Currently, medical staff seem to be able to be investigated in one hospital, and then move to another without any of their history following them. Maybe we need some sort of central system, like Doctify for employers? What do you think?
  9. Content Article
    Dr Liz O’Riordan is a breast cancer surgeon who has battled against social, physical and mental challenges to practise at the top of her field. Under the Knife charts Liz’s incredible highs: performing like a couture dressmaker as she moulded and reshaped women’s breasts, while saving their lives; to the heart-breaking lows of telling ten women a day that they had cancer. But this memoir is more than just an eye-opening look at the realities of training to be a female surgeon in a man’s world. In addition to this high-powered, high-pressured role, Liz faced her own breast cancer diagnosis, severe depression and suicidal thoughts, in tandem with commonplace sexual harassment and bullying. And by revealing how she coped when her life crashed around her, she demonstrates there is always hope.
  10. Content Article
    This series of blog posts is written by a patient who experienced life-changing complications after surgery went wrong. In her posts, they explore the psychological needs of patients following healthcare harm, which are often overlooked during physical rehabilitation. "I believe that the emotional support given to the patient during those first few weeks can make a significant difference to their long term quality of life. That’s why I decided to write this blog, to give constructive feedback to help medical professionals learn from my experiences."
  11. News Article
    Barts Health NHS Trust has been told to take action to prevent future deaths after an elderly woman was unlawfully killed at one of its hospitals. East London acting senior coroner Graeme Irvine sent a report to the trust in which he raised concerns over the death of 78-year-old Surekha Shivalkar in 2018. The report follows an inquest into Mrs Shivalkar's death, which reached a narrative conclusion incorporating a finding of unlawful killing. A Barts spokesperson said the trust had made a number of changes after carrying out an investigation. Mrs Shivalkar underwent hip replacement revision surgery at Newham Hospital on September 28, 2018 in a procedure estimated to last between four and five hours, the coroner wrote. She had a number of serious conditions, including ischaemic heart disease, osteoporosis and chronic obstructive pulmonary disorder. But Mr Irvine said an inaccurate risk of death of less than 5% was given, as no formal risk assessment tool was used. The surgery took longer than seven and a half hours, during which time Mr Irvine said Mrs Shivalkar sustained a "prolonged and dangerous" period of hypotension, or low blood pressure. He said the anaesthetist failed to communicate this to the surgical team and agreed to prolong surgery at the six hour point. Mr Irvine said: "Poor communication between the orthopaedic surgical team and the anaesthetist during surgery led to a collective failure to identify a critically ill patient." Read full story Source: Newham Recorder, 17 January 2022
  12. News Article
    A surgeon who burned his initials on to the livers of two patients during transplant surgery has been struck off the medical register. Simon Bramhall, 57, admitted using an argon beam – used to stop livers bleeding during operations and to highlight an area to be worked on – to sign “SB” into his patients’ organs in 2013 while working at Birmingham’s Queen Elizabeth hospital. On Tuesday, a review by the Medical Practitioners Tribunal Service (MPTS) concluded Bramhall’s actions were “borne out of a degree of professional arrogance” and that they “undermined” public trust in the medical profession. Bramhall, of Tarrington, Herefordshire, was first suspended from his post as a consultant surgeon in 2013 after another surgeon spotted the initials during follow-up surgery on one of his patients. A photograph of the 4cm-high branding was taken on a mobile phone. During his sentencing hearing in 2018, Bramhall was told one of the victims suffered serious psychological harm as a result of the branding. The surgeon later told police he branded the organs to relieve operating theatre tensions following difficult and long transplant operations. Read full story Source: The Guardian, 11 January 2022
  13. News Article
    Women who are operated on by a male surgeon are much more likely to die, experience complications and be readmitted to hospital than when a woman performs the procedure, research reveals. Women are 15% more liable to suffer a bad outcome, and 32% more likely to die, when a man rather than a woman carries out the surgery, according to a study of 1.3 million patients. The findings have sparked a debate about the fact that surgery in the UK remains a hugely male-dominated area of medicine and claims that “implicit sex biases” among male surgeons may help explain why women are at such greater risk when they have an operation. “In our 1.3 million patient sample involving nearly 3,000 surgeons we found that female patients treated by male surgeons had 15% greater odds of worse outcomes than female patients treated by female surgeons,” said Dr Angela Jerath, an associate professor and clinical epidemiologist at the University of Toronto in Canada and a co-author of the findings. “This result has real-world medical consequences for female patients and manifests itself in more complications, readmissions to hospital and death for females compared with males. “We have demonstrated in our paper that we are failing some female patients and that some are unnecessarily falling through the cracks with adverse, and sometimes fatal, consequences.” Read full story Source: The Guardian, 4 January 2022
  14. News Article
    The government has committed “in principle” to creating a public repository of consultants’ practice details that sets out their practising privileges and key performance data, including how many times they have performed a particular procedure and how recently. The commitment was part of the response to an independent national inquiry, launched in 2017, following the malpractice of rogue surgeon Ian Paterson. Now serving a 20 year prison sentence, Paterson had undertaken numerous unnecessary breast operations in both private and NHS practice, causing harm to hundreds of patients. The inquiry, published February 2020, found that Paterson was able to harm patients over more than decade because of the “dysfunctional” healthcare system. It outlined 17 recommendations for the government to respond to, mainly focusing on improving oversight and governance, as well as ensuring greater scrutiny of private providers. At the time, some saw the report as a missed opportunity to tackle the systemic patient safety risks of the private hospital business model, such as financial incentives which can lead to overtreatment. Read full story Source: BMJ, 17 December 2021
  15. News Article
    An inquest into whether a pioneering surgery technique played any role in a Gloucestershire woman's death has opened. Jacqui Kingston, from Marshfield, died on 16 March 2020 after having mesh fitted for a prolapsed bowel at Southmead Hospital in Bristol. On Monday an inquest opened at Avon Coroner's Court examining whether the surgery performed by colorectal surgeon Tony Dixon contributed to her death. It is due to run until Thursday. Pathologist Edward Sheffield told the hearing that the use of the mesh for a prolapsed bowel - which was fitted in 2016 - may have contributed to her death. The inquest heard that Mrs Kingston was a fragile patient with many underlying health conditions who developed complications. Mr Dixon was dismissed by the North Bristol NHS Trust in 2019 after dozens of his patients were told they should have been offered alternative treatment first. Read full story Source: BBC News, 13 December 2021
  16. News Article
    Several patients were harmed after leaders at an acute trust failed to act on multiple concerns being raised about a surgeon, documents obtained by HSJ suggest. The documents reveal a catalogue of governance and safety concerns over the trauma and orthopaedics department at University Hospitals of Morecambe Bay Foundation Trust in the last three years. They include an external review which described the process for investigating clinical incidents as akin to “marking your own homework” and found the T&O department at Royal Lancaster Infirmary driven by “internecine squabbles”. It comes as the trust, which is widely known for a patient safety scandal within its maternity department, also faces a major investigation into whistleblowing concerns over its urology services. Read full story (paywalled) Source: HSJ, 17 November 2020
  17. News Article
    Keyhole surgery can allow complicated procedures to be carried out with just a few access cuts, helping to reduce patient recovery times and potential risk of infection. But the remote controlled robots that can perform this type of surgery are often very large, expensive and not widely available. Now a new robo-surgeon with a modular design could be about to change that. View video Source: BBC News, 9 November 2020
  18. News Article
    The surgeon at the centre of a body parts scandal operated on patients who were dangerously sedated so that their procedures could be carried out simultaneously, according to a leaked investigation seen by The Independent. Renowned hip surgeon Derek McMinn and two anaesthetists at Edgbaston Hospital, Birmingham, were accused of putting “income before patient safety” in the internal investigation for BMI Healthcare, which runs the hospital. It comes after a separate review found that McMinn had hoarded more than 5,000 bone samples from his patients without a licence or proper permission to do so over a period of 25 years, breaching legal and ethical guidelines. Police are investigating a possible breach of the Human Tissue Act. According to the report on sedation by an expert from another hospital, the two anaesthetists, Imran Ahmed and Gauhar Sharih, sedated patients for so long that their blood pressure fell to dangerous levels in order to allow McMinn to carry out near-simultaneous surgery. It found this meant long delays in the operations starting, with one sedated patient being subjected to prolonged anaesthesia for longer than one hour and 40 minutes – recommended best practice is 30 minutes. Another patient was apparently "abandoned" for an hour and 26 minutes after their surgery was only partially completed while McMinn began operating on another patient. The report’s author, expert anaesthetist Dr Dhushyanthan Kumar of Coventry’s University Hospital, said this was unsafe practice by all three doctors and urged BMI Healthcare to carry out a review of patients to see if any had suffered lasting brain damage. Both anaesthetists work for the NHS – Ahmed at Dudley Group of Hospitals, Sharih at University Hospitals Birmingham – without restrictions on their ability to practise. Read full story Source: The Independent, 30 September 2020
  19. News Article
    For more than two decades, Derek McMinn harvested the bones of his patients, according to a leaked report – but it was not until last year that anyone challenged the renowned surgeon. The full scale of his alleged collection was apparently kept from the care regulator until just days ago, and thousands of those who went under his knife for hip and knee treatment still have no idea that their joints may have been collected in a pot in the operating theatre, and stored in the 67-year-old’s office or home. Clinicians and managers at the BMI Edgbaston Hospital, where McMinn carried out the majority of his operations, actively took part in the collection of bones and – even after alarms were raised – the hospital did not immediately act to stop the tissue being taken away, according to a leaked internal report seen by The Independent. An investigation found operating theatre staff at the private hospital left dozens of pots containing joints removed from patients femurs during hip surgery in a storage area, in some cases for months. According to the report, there had been warnings about their responsibilities under the Human Tissue Act when an earlier audit between 2010 and 2015 identified the storage of femoral heads, the joints removed in the procedure. The internal report said there was no evidence McMinn had carried out any research or had been approved for any research work – required by the Human Tissue Authority to legally store samples. It said one member of staff told investigators the samples were being collected for research on McMinn’s retirement. Although the Care Quality Commission knew about claims that a small number of bones being kept by McMinn, it is understood that the regulator received a copy of the BMI Healthcare investigation report only last Friday, after The Independent had made initial inquiries about the case. That report suggests a minimum of 5,224 samples had been taken by McMinn. The regulator confirmed to The Independent it had not been aware of the extent of McMinn’s supposed actions. An insider at BMI Healthcare accused the company of “covering up”, adding: “Quite senior staff at the hospital went along with it and just handed the pots over to his staff when they came to collect them.” Read full story Source: The Independent, 30 September 2020
  20. News Article
    A private healthcare provider has been ordered to pay £20,000 after failing to disclose errors in the treatment of patients under the care of a surgeon. Spire Healthcare was prosecuted today in what the Care Quality Commission (CQC) said was “the first prosecution of its kind against an independent provider of healthcare”. The CQC said concerns around the treatment of four patients were initially raised by Leeds Clinical Commissioning Group, several physiotherapists at the hospital and another surgeon. The patients had surgical procedures carried out by Michael Walsh, a shoulder surgeon who held practising privileges at Spire Leeds until his suspension in April 2018. The procedures resulted in the patients suffering prolonged pain and requiring further remedial surgery. The CQC said it brought the prosecution after Spire failed to share details of what happened to the patients who were being treated by Mr Walsh, in line with their duty of candour responsibilities to be transparent and provide timely apologies when serious incidents occur. Read full story (paywalled) Source: HSJ, 29 April 2021
  21. News Article
    An RAF veteran has been left with life-changing injuries after being “mutilated” by an NHS surgeon during what should have been a routine procedure. Paul Tooth, 64, has been permanently left with tubes going in and out of his body which he needs to continually recycle bile produced by his liver. The previously fit and active father-of-two has lost five stone in weight and can barely leave his house after the surgery last year. It was supposed to be a routine gall bladder removal, but the surgeon inexplicably took out Paul’s bile duct and hepatic duct, which link the liver to the intestines, as well as damaging the liver itself, making a repair impossible. Although he has won his legal battle against the Norfolk and Norwich University Hospital Foundation Trust, Paul believes what happened to him raises bigger safety questions for the trust after he learned he was one of three patients harmed by the same surgeon just days apart. The alarm was first raised by Addenbrooke’s Hospital in Cambridge where the three patients were transferred for specialist care after their initial operations. The Norfolk and Norwich trust has now admitted liability for the errors and standard of care Paul received. Read full story Source: The Independent, 25 April 2021
  22. News Article
    New victims of rogue breast surgeon Ian Paterson are being blocked from using lawyers with experience of the scandal to bring fresh compensation claims against the private hospital where he worked, The Independent has learned. Under the terms of a legal settlement for £37m in 2017, 40 law firms are barred from bringing any new claims against Spire Healthcare for 20 years – meaning that former patients who have learned since then that they were victims of the surgeon, who was jailed for carrying out needless surgeries on women, face having to find lawyers with no prior knowledge of the case. When the deal was signed, it was thought that most of Paterson’s victims had been contacted by the hospital company, but an inquiry published in 2020 heavily criticised its failure to reach affected patients and accused the company of seeking to protect its reputation rather than the interests of patients. In response, Spire Healthcare launched a mass recall of 5,500 former patients, with independent clinicians reviewing their medical records. Some are learning for the first time that they had needless surgery at the hands of the surgeon. Read full story Source: The Independent, 11 April 2021
  23. News Article
    Following the statement from Nadine Dorries MP, Minister for Patient Safety, providing an update on the Paterson Inquiry, Matt James, Chief Executive of the Private Healthcare Information Network, said: “Although we were expecting the Government’s full response by now, it’s reassuring to know that this is still firmly on the agenda. The updates provided today are all welcome, but perhaps most telling is what remains to be addressed – most notably whole-practice information and better information for patients (recommendations one and three). “While it’s disappointing not to see more specifics, it is crucial that the recommendations are implemented properly and with the right consideration, resisting the temptation to create new systems from scratch and instead build on the excellent progress made by organisations such as NHS Digital, GIRFT, NCIP and PHIN. “We will continue to work with our partners across the NHS and private sector to make positive changes which improve transparency, accountability and information for patients. We will continue to liaise with the Department of Health and Social Care when invited to do so.” Press release Source: PHIN, 23 March 2021
  24. News Article
    Racism, sexism, and homophobia is widespread in hospital operating theatres across England, according to an independent report. In a damning verdict on the atmosphere in some surgical teams, Baroness Helena Kennedy QC said the ‘old boys’ network of alpha male surgeons was preventing some doctors from rising to the top and had fuelled an oppressive environment for women, ethnic minorities and trainee surgeons. The report was commissioned by the Royal College of Surgeons and lays bare the "discrimination and unacceptable behaviour" taking place in some surgical teams. Baroness Kennedy told The Telegraph the field of surgery was "lagging behind" society, adding: "It is driven by an ethos which is very much alpha male, where white female surgeons are often assumed to be nurses and black women surgeons mistaken for the cleaner. And this is by the management. Read full story Source: The Independent, 18 March 2021
  25. News Article
    NHS England has ordered an independent review into patient safety and governance concerns at an acute trust which had been resisting calls to take this step, HSJ has learned. The intervention at University Hospitals of Morecambe Bay Foundation Trust comes after pressure from staff and local MPs, who believe more extensive investigation is required into cases of patient harm within the trauma and orthopaedics division. The broad issues were first revealed by HSJ in November, with documents suggesting several patients were harmed after leaders failed to act on multiple concerns being raised about a surgeon. The trust has already commissioned one external review. This reported last year and found the service to be riven by “internecine squabbles”. However, the review was overseen by trust executives and the terms of reference were focused on incident reporting and culture within the department. It is understood that some consultants have since been pushing for further investigation into specific cases where patients were harmed, as well as concerns that managers or clinicians who were accused of failing to tackle the issues have since been promoted to more senior positions. Read full story (paywalled) Source: HSJ, 2 March 2021
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