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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

The family of a baby who died after errors in her care have criticised the failure of the NHS to learn lessons. Elizabeth Dixon died due to a blocked breathing tube shortly before her first birthday and a subsequent independent investigation found a 20-year cover-up. A year on, Elizabeth's mother Anne told the BBC: "My daughter has not been a catalyst for change." The Department of Health said it was working on the report's recommendations and will publish "a full response". Elizabeth Dixon, known as Lizzie, was born prematurely at Frimley Park Hospital, in Surrey, in December 2000. But a series of errors by the hospital and by Great Ormond Street Hospital, which took over her care shortly after birth, left Elizabeth with brain damage and needing to breathe through a tracheostomy. She was further let down by Nestor Primecare, a private nursing agency, which was hired to support her parents when Elizabeth returned home. She died 10 days before her first birthday. An official investigation, published last year, found a "20 year cover-up" by health workers, with some of those involved described as "persistently dishonest". "I would have expected them to take it seriously," Mrs Dixon said in response to the lack of action. She believes that if a similar incident happened today, there would be a danger it would also be covered up. "That's the default option - if its bad enough, they'll cover up," she said. Read full story Source: BBC News, 1 December 2021

GPs are set to be balloted on industrial action over controversial reforms proposed by health secretary Sajid Javid. The “outraged” doctors in England have voted unanimously to reject the government’s plans at a British Medical Association (BMA) meeting. The government wants to see GP surgeries ranked in league tables to “name and shame” those that do not carry out enough face-to-face appointments with their patients. From early November, GPs will have to have their names and wages published if they earn an NHS salary of more than £150,000. The BMA says that forcing GPs to publish their earnings “provides no benefit to patients or their care, yet will potentially increase acts of aggression towards GPs, will damage morale amongst the profession, and only worsen practices’ ability to recruit and retain GPs”. GP surgeries will not be eligible for new funding if they fail to provide an “appropriate” number of in-person consultations. Patients will also be asked to rate their GPs via text message. Mr Javid has insisted that his plans would improve patients’ access to primary care – but the union representing the GPs says it has been “left with no alternative” but to ballot over whether to take industrial action. Read full story Source: The Independent, 22 October 2021

Clinical trials run in the UK will be automatically registered from 2022, the country’s Health Research Authority has announced. The new system seeks to ensure that every single clinical trial with be listed on a trial registry from the outset. UK researchers have been formally required to register trials since 2013, but that rule was never enforced, and many trials remained unregistered. Trial registration is a key pillar of clinical trial transparency. It helps scientists to gain an overview of who is currently researching which treatments, preventing needless duplication of medical research efforts . In addition, because investigators have to specify in advance what exactly they will be measuring, trial registration supports research integrity by discouraging post hoc statistical shenanigans and evidence distortion. While there are various rules and regulations around trial registration, no other country currently enforces these nationwide. The new trial registration system forms part of the wider UK national Make it Public strategy, which aims to ensure that every single clinical trial run in the UK is registered and makes its results public. The strategy was developed in the wake of a 2018-2019 parliamentary enquiry into clinical trial transparency. Read full story Source: TranspariMED, 20 October 2021

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

Patient Safety Learning Press Release 10th December 2020 Today the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust published its first report on its findings.[1] The report made recommendations for actions to be implemented by the Trust and “immediate and essential actions” for both the Trust and the wider NHS. The Review was formally commissioned in 2017 to assess “the quality of investigations relating to new-born, infant and maternal harm at The Shrewsbury and Telford Hospital NHS Trust”.[2] Initially it was focused on 23 cases but has been significantly expanded as families have subsequently contacted the review team with their concerns about maternity care and treatment at the Trust. The total number of families to be included in the final report is 1,862. These initial findings are drawn from 250 cases reviewed to date. This is another shocking report into avoidable harm. We welcome the publication of these interim findings and the sharing of early actions that have been identified to make improvements to patient safety in NHS maternity services. We commend the ambition for immediate responses and action. Reflecting on the report, there are a number of broad patient safety themes, many of which have been made time and time again in other reports and inquiries. A failure to listen to patients The report outlines serious concerns about how the Trust engaged and involved women both in their care and after harm had occurred. This was particularly notable in the example of the option of having a caesarean section, where there was an impression that the Trust had a culture of wanting to keep the numbers of these low, regardless of patients’ wishes. They commented: “The Review Team observed that women who accessed the Trust’s maternity service appeared to have little or no freedom to express a preference for caesarean section or exercise any choice on their mode of deliver.” It also noted a theme in common with both Paterson Inquiry and Cumberlege Review relating to the Trusts’ poor response to patients raising concerns.[3] The report noted that “there have also been cases where women and their families raised concerns about their care and were dismissed or not listened to at all”. The need for better investigations Concerns about the quality of investigations into patient safety incidents at the Trust is another theme that emerges. The review reflected that in some cases no investigation happened at all, while in others these did take place but “no learning appears to have been identified and the cases were subsequently closed with it deemed that no further action was required”. One of the most valuable sources for learning is the investigation of serious incidents and near misses. If these processes are absent or inadequate, then organisations will be unable to learn lessons and prevent future harm reoccurring. Patient Safety Learning believes it is vital that Trusts have the commitment, resources, and frameworks in place to support investigations and that the investigators themselves have the right skills and training so that these are done well and to a consistently high standard. This has not formed part of the Report’s recommendations and we hope that this is included in their final report. Lack of leadership for patient safety Another key issue highlighted by the report is the failure at a leadership level to identify and tackle the patient safety issues. Related to this one issue it notes is high levels of turnover in the roles of Chief Executive, executive directors and non-executive directors. As part of its wider recommendations, the Report suggests trust boards should identify a non-executive director who has oversight of maternity services. Good leadership plays a key role in shaping an organisations culture. Patient Safety Leadership believes that leaders need to drive patient safety performance, support learning from unsafe care and put in place clear governance processes to enable this. Leaders need to be accountable for patient safety. There are questions we hope will be answered in the final report that relate to whether leaders knew about patients’ safety concerns and the avoidable harm to women and their babies. If they did not know, why not? If they did know but did not act, why not? Informed Consent and shared decision-making The NHS defines informed consent as “the person must be given all of the information about what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment does not go ahead”.[4] The report highlights concerns around the absence of this, particularly on the issue of where women choose as a place of birth, noting: “In many cases reviewed there appears to have been little or no discussion and limited evidence of joint decision making and informed consent concerning place of birth. There is evidence from interviews with women and their families, that it was not explained to them in case of a complication during childbirth, what the anticipated transfer time to the obstetric-led unit might be.” Again this is another area of common ground with other recent patient safety reports such as the Cumberlege Review.[5] Patient Safety Learning believes it is important that patients are not simply treated as passive participants in the process of their care. Informed consent and shared decision making are vital to respecting the rights of patients, maintaining trust in the patient-clinician relationship, and ensuring safe care. Implementation for action and improved patient safety In its introduction, the report states: “Having listened to families we state that there must be an end to investigations, reviews and reports that do not lead to lasting meaningful change. This is our call to action.” Responding with an official statement in the House of Commons today, Nadine Dorries MP, Minister for Mental Health, Suicide Prevention and Patient Safety, did not outline a timetable for the implementation of this report’s recommendations. In 2020 we have seen significant patient safety reports whose findings have been welcomed by the Department of Health and Social Care but where there has subsequently been no formal response nor clear timetable for the implementation of recommendations, most notably the Paterson Inquiry and Cumberlege Review. Patient Safety Learning believes there is an urgent need to set out a plan for implementing the recommendations of the Ockenden Report and these other patient safety reports. Patients must be listened to and action taken to ensure patient safety. [1] Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Emerging findings and recommendations form the independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, 10 December 2020. https://www.ockendenmaternityreview.org.uk/wp-content/uploads/2020/12/ockenden-report.pdf [2] Ibid. [3] The Right Reverend Graham Jones, Report of the Independent Inquiry into the Issues raised by Paterson, 2020. https://assets.publishing.serv...; The Independent Medicines and Medical Devices Safety Review, First Do No Harm, 8 July 2020. https://www.immdsreview.org.uk/downloads/IMMDSReview_Web.pdf [4] NHS England, Consent to treatment, Last Accessed 16 July 2020. https://www.nhs.uk/conditions/consent-to-treatment/ [5] Patient Safety Learning, Findings of the Cumberlege Review: informed consent, Patient Safety Learning’s the hub, 24 July 2020. https://www.pslhub.org/learn/patient-engagement/consent-and-privacy/consent-issues/findings-of-the-cumberlege-review-informed-consent-july-2020-r2683/

The NHS is under pressure to publish a delayed review into a bullying scandal at Matt Hancock’s local hospital that involved senior clinicians being asked to provide fingerprint samples in a “witch-hunt” for a whistleblower. The “rapid review” into West Suffolk hospital, which Hancock had to recuse himself from because of his friendship with the boss at the trust, was ordered in January and had been due for completion in April. Its publication was put back to this month because of the coronavirus pandemic. But it is now not expected until spring. The Doctors’ Association UK suspects the conclusions are being sat on because they make embarrassing reading for the trust’s chief executive, Steve Dunn, described by Hanock as a “brilliant leader”. A consultant who chairs the hospital’s medical staff committee wrote to the NHS’s regional director for the east of England, Ann Radmore, last week warning that senior medics felt the hospital could not move on until the review was published. The NHS East insists the review will be published as soon as possible, but a source confirmed this is likely to be “spring next year”.

The lateral flow devices used in the community testing pilot in Liverpool only picked up half the COVID-19 cases detected by polymerase chain reaction (PCR) tests and missed 3 out of 10 cases with higher viral loads, according to the government’s own policy paper. Given the low sensitivity of the Innova lateral flow devices when used in the field, experts are questioning how they can be used to allow care home residents to have contact with relatives over Christmas safely or for students to know for certain that they are not infected before returning home. The information can only be found by looking in annex B of the document, Community testing: a guide for local delivery, which was published on 30 November. This is the first publicly available information about the field evaluation of the Innova tests in Liverpool which has been criticised for its lack of transparency, accuracy of the tests used, and costs and potential harms. Read full story Source: BMJ, 4 December 2020

Regulators have apologised to a health manager who went through “five years of hell” while being investigated for misconduct, before being told there was no case to answer. Debbie Moore was a senior manager at the former Liverpool Community Health Trust, where there was a major care scandal in the early 2010s. As head of healthcare at HMP Liverpool, where many of the most serious failings were identified, Ms Moore was suspended in 2014 and referred to the Nursing and Midwifery Council. She was accused of multiple failures to take action or escalate concerns, of failing to investigate deaths, and discouraging staff from reporting incidents. However, in a first public interview about her experience, she told HSJ she was “scapegoated” for the problems at the prison, where she says she worked tirelessly to address the issues and had repeatedly flagged concerns to the LCH management team. External inquiries have found the trust would routinely downgrade risks escalated by divisional managers, as it sought to make drastic cost savings in pursuit of foundation trust status. Read full story (paywalled) Source: HSJ, 30 November 2020

The death of a premature baby in 2001 led to a "20-year cover-up" of mistakes by health workers, an independent inquiry has found. Elizabeth Dixon, from Hampshire, died due to a blocked breathing tube shortly before her first birthday. The government, which ordered the inquiry in 2017, said the mistakes in her care were "shocking and harrowing". The inquiry report by Dr Bill Kirkup said some of those involved had been "persistently dishonest". Elizabeth, known as Lizzie, died from asphyxiation after suffering a blockage in her tracheostomy tube while under the care of a private nursing agency at home. Dr Bill Kirkup, who was appointed by the government to review the case, said her "profound disability and death could have been avoided". He said: "There were failures of care by every organisation that looked after her, none of which was admitted at the time, nor properly investigated then or later." "Instead, a cover-up began on the day that she died, propped up by denial and deception." Read full story Source: BBC News, 26 November 2020 Patient Safety Learning's statement on the Dixon Inquiry report

Former health secretary and chair of the Commons health committee Jeremy Hunt has criticised Great Ormond Street Hospital after it was accused of covering up errors that may have led to the death of a toddler. Writing for The Independent, Mr Hunt, who has set up a patient safety charity since leaving government, said it was “depressing” to see how the hospital had responded to the case of Jasmine Hughes, which has now been taken to the Parliamentary Health Service Ombudsman for a new investigation. Mr Hunt said the hospital had chosen to issue a “classic non-apology apology of which any politician would be proud” and added he was left angry over the hospital’s “ridiculous decision” to stop talking to Jasmine’s family and the refusal to apologise for what went wrong. The MP for South West Surrey said the case was symbolic of a wider problem in the health service of a blame culture that prevents openness and transparency around mistakes. Read full story Source: The Independent, 24 November 2020

The Department of Health and Social Care (DHSC) has been criticised by the national health ombudsman for the ‘maladministration’ of a 2018 review into the death of a teenage girl under the care of one of England’s top specialist hospitals, HSJ can reveal. The Parliamentary and Health Service Ombudsman (PHSO) came to the conclusion after investigating a DHSC review into the 1996 death of 17-year-old Krista Ocloo which had been requested by her mother. Krista died at home of acute heart failure in December 1996. She had been admitted to the Royal Brompton Hospital with chest pains in January of that year. The PHSO report states her mother was told “there was no cause for concern” and that another appointment would be scheduled in six months. This follow-up appointment did not happen. The young woman’s death was considered by the hospital’s complaints process, an independent panel review and an inquiry into the hospital’s paediatric cardiac services. They concluded the doctor involved was not responsible for Krista’s death – though the paediatric services inquiry criticised the hospital for poor communication. A coroner declined to open an inquest into the case. Civil action against the hospital, brought by Ms Ocloo, found Krista’s death could not have been prevented. However, a High Court judge found that the failure to arrange appropriate follow-up by the RBH was “negligent”. A spokeswoman for PHSO said: “Our investigation found maladministration by the Department for Health and Social Care, which should have been more transparent in its communication. The department’s failure to be open and clear compounded the suffering of a parent who was already grieving the loss of her child.” A DHSC spokeswoman said: “We profoundly regret any distress caused to Ms Ocloo. “[The PHSO] report found that in communicating with Ms Ocloo the department’s actions were – in places – not consistent with relevant guidance. The department has writen to Ms Ocloo to apologise for this and provide further information about the review.” Read full story (paywalled) Source: HSJ, 12 November 2020

An NHS trust is to appear in court today charged with breaking the law on being open and transparent after a woman’s death in the first ever court case of its kind. The Care Quality Commission (CQC) has brought a criminal prosecution against University Hospitals Plymouth Trust which will appear at Plymouth Magistrates Court tomorrow morning. The trust is charged with breaching the duty of candour regulations under the Health and Social Care Act 2008 which require hospitals to be honest with families and patients after a safety incident or error in their care. Hospitals are legally required to notify patients or families and investigate what has happened and communicate the findings to families and offer an apology. The case relates to how the Plymouth trust communicated with a woman’s family after her death which happened after she underwent an endoscopy procedure at Derriford Hospital in December 2017. The trust was required by law to communicate in an open and transparent way. The CQC has accused the trust of failing to do this. Read full story Source: The Independent, 22 September 2020

Yesterday marked the second World Patient Safety Day, and this year’s theme shined a light on health worker safety – those on the frontline of the pandemic have been selfless in their sacrifices to care for an ailing global population. What has become ever clearer is that a health system is nothing without those who work within it and that we must prioritise the safety and wellbeing of health workers, because without safe health workers we cannot have safe patients. Improving maternity safety has been a priority for some time – although rare, when things go wrong the consequences are unthinkable for families and the professionals caring for them. Maternity negligence makes up 50% of the total value of negligence claims across all NHS sectors, according to the latest NHS Resolution annual report and accounts. It states there were claims of around £2.4 billion in 2019/20, which is in the region of £6.5 million a day. This cost says nothing of the suffering families and professionals associated. However, without investing in the maternity frontline we cannot hope to make integral systemic changes to improve maternity safety and save mothers’ and babies’ lives, writes Sara Ledger, head of research and development at Baby Lifeline in the Independent. "We owe it to every mother and baby to rigorously and transparently scrutinise the safety of maternity services, which will be in no small way linked to the support staff receive." Read full story Source: The Independent, 17 September 2020

Today, the nonpartisan nonprofit Patient Safety Movement Foundation will lead a demonstration in the nation’s capital to raise awareness for the patient safety crisis that claims more than 200,000 lives annually in the U.S. due to preventable medical harm. The demonstration begins from Freedom Plaza and participants will walk down Pennsylvania Avenue to the Capitol Lawn, where they will hold a remembrance of loved ones lost needlessly to preventable medical errors. The demonstrators will also demand the creation of a National Patient Safety Board to implement data-driven standards, transparency, accountability, and aligned incentives. “COVID-19 has exposed the safety gaps in our healthcare system that already cause 200,000 deaths a year,” said Dr. David B. Mayer, CEO of the Patient Safety Movement Foundation. “Many of us also have very personal stories of loss and tragedy related to preventable medical harm. Now is the time for change and improvement as we work toward zero preventable patient deaths by 2030.” Read full story Source: Patient Safety Movement

Nearly 90% of organisations representing doctors agree that the UK should have a mandatory and public register of doctors’ interests, a survey by The BMJ has found. Last year the Independent Medicines and Medical Devices Safety Review, chaired by Julia Cumberlege, called for the General Medical Council (GMC) to expand its register to include a list of financial and non-pecuniary interests for all doctors. That review investigated harmful side effects caused by the hormone pregnancy test Primodos, the anti-epileptic drug sodium valproate, and surgical mesh. One of its key conclusions was that patients had a right to know if their doctor had financial or other links with pharmaceutical or medical device companies. The BMJ wrote to six faculties, 14 royal medical colleges, and the Academy of Medical Royal Colleges about such a register. It received responses from two faculties, 12 colleges, and the academy, a 71% response rate. Of the organisations that responded, 13 (87%) agreed that there should be a mandatory and public register of doctors’ interests in the UK. Read full story Source: BMJ. 8 April 2021

Labour is to push for key changes to the government’s NHS reforms, with new laws on transparency in the NHS and a demand for safe staffing levels on hospital wards, following a series of scandals relating to failures in patient care. Amendments to the government’s Health and Care Bill will also include plans for the investigation of stillbirths by medical examiners, and for limits on the power of the health secretary to interfere in investigations. Labour’s shadow health secretary Jonathan Ashworth believes the changes – which also include giving local NHS regions the ability to object to some spending limits if they consider them to pose a risk to patient safety – will attract the support of Conservative MPs. In an exclusive interview with The Independent ahead of the Labour Party conference in Brighton, Mr Ashworth said it was vital that the NHS learned from mistakes and improved its record on safety, which he said could only be achieved through greater transparency. “Patient safety has been forgotten in this bill. The patient voice has been ignored. Patients are like the ghosts in the machine,” he said. “The bill is going through parliament, and we are putting down amendments to improve it as best we can. We want to put in the bill a framework to deliver greater patient safety, because after all, it should be the golden thread running through every aspect of healthcare delivery." Read full story Source: The Independent, 26 September 2021

An NHS trust has become the first in the country to individually contact every family of patients who caught coronavirus while they were in hospital in a large-scale bid to be transparent over the scale of infections. Bosses at the Queen Elizabeth Hospital Kings Lynn NHS Trust have set up a team to work through hundreds of cases where patients caught coronavirus in hospital. At least 99 patients are known to have died after becoming infected with more cases still to review. In a unique approach to transparency the trust is sending a letter by recorded delivery to every affected patient or family where it is thought the patient picked up the virus within the hospital. The letter offers an apology for what happened and is followed by a phone call with a nurse and a meeting with officials if families have more concerns. Some families have asked to meet the nurses who cared for their loved ones. Read full story Source: The Independent, 6 June 2021

Hospitals have been accused of “unnecessary secrecy” for refusing to disclose how many of their patients died after catching Covid on their wards. The Patients Association, doctors’ leaders and the campaign group Transparency International have criticised the 42 NHS acute trusts in England that did not comply fully with freedom of information request for hospital-acquired Covid infections and deaths. The Guardian revealed on Monday that up to 8,700 patients lost their lives after probably or definitely becoming infected during the pandemic while in hospital for surgery or other treatment. That was based on responses from 81 of the 126 trusts from which it sought figures. The British Medical Association, the main doctors’ trade union, said the 42 trusts that did not reveal how many such deaths had occurred in their hospitals were denying the bereaved crucial information. “No one should come into hospital with one condition, only to be made incredibly ill with, or even die from, a dangerous infectious disease,” Dr Rob Harwood, chair of the BMA’s hospital consultants committee, said. “Families, including those of our own colleagues who died fighting this virus on the frontline, deserve answers. We will only get that if there is full transparency." Read full story Source: The Guardian, 25 May 2021