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Found 98 results
  1. News Article
    Hundreds more cases of potentially avoidable baby deaths, stillbirths and brain damage have emerged at an NHS trust, raising concerns about a possible cover-up of the true extent of one the biggest scandals in the health service’s history. The additional 496 cases raise further serious concerns about maternity care at Shrewsbury and Telford hospital NHS trust since 2000. The cases involving stillbirths, neonatal deaths or baby brain damage, as well as a small number of maternal deaths, have been passed to an independent maternity review, led by the midwifery expert Donna Ockenden. They bring the total number of cases being examined to 1,862. They will also be passed to West Mercia police, which last month launched a criminal investigation into the trust’s maternity services. Detectives are trying to establish whether there is enough evidence to bring charges of corporate manslaughter against the trust or individual manslaughter charges against staff involved. The extra 496 cases had not emerged until now because an “open book” initiative led by the NHS in 2018 asked only for digital records of cases identified as a cause for serious concerns. The vast majority of the 496 further cases were recorded only in paper documents. Read full story Source: The Guardian, 21 July 2020
  2. News Article
    African American children are three times more likely than their white peers to die after surgery despite arriving at hospitals without serious underlying conditions, the latest evidence of unequal outcomes in health care, according to a study published in the journal Pediatrics, “We know that traditionally, African Americans have poorer health outcomes across every age strata you can look at,” said Olubukola Nafiu, the lead researcher and an anaesthesiologist at Nationwide Children’s Hospital in Columbus, Ohio. “One of the explanations that’s usually given for that, among many, is that African American patients tend to have higher comorbidities. They tend to be sicker.” But his research challenges that explanation, he said, by finding a racial disparity even among otherwise healthy children who came to hospitals for mostly elective surgeries. Out of 172,549 children, 36 died within a month of their operation. But of those children, nearly half were black – even though African Americans made up 11% of the patients overall. Black children had a 0.07% chance of dying after surgery, compared with 0.02% for white children. Postoperative complications and serious adverse events were also more likely among the black patients and they were more likely to require a blood transfusion, experience sepsis, have an unplanned second operation or be unexpectedly intubated. Read full story Source: The Independent, 20 July 2020
  3. Content Article
    Episodes include: BeginningsApprenticeFlying SoloDetourBalanceNight ShiftMotherhood Part 1Motherhood Part 2ContinuityHomebirthCaesareanFlexibleMistakes DadsGuidelines
  4. News Article
    Babies are at risk of dying from common treatable infections because NHS staff on maternity wards are not following national guidance and are short-staffed and overworked, an investigation has revealed. The Healthcare Safety Investigation Branch (HSIB), a national safety watchdog, has warned that NHS staff on maternity wards face sometimes conflicting advice on treating women who are positive for a group B streptococcus (GBS) infection. They are also making errors in women’s care because of the pressure of work and a lack of staff, with antibiotics not being administered when they should be. HSIB’s specialist investigators examined 39 safety incidents in which GSB had been identified, and found that the infection had contributed to six baby deaths, six stillbirths and three cases of babies being left with severe brain damage. In its report, the watchdog warned that the problems on maternity wards meant that even in cases where mothers were known to be positive for GBS infection, this wasn’t shared with the mother or noted in the record, resulting in the standard care and antibiotics not being provided. It added: “The identification and escalation of care for babies who show signs of GBS infection after birth was missed. This has resulted in severe brain injury and death for some of the affected babies.” Read full story Source: The Independent, 19 July 2020
  5. Content Article
    The Healthcare Safety Investigation Branch (HSIB) published ‘Summary of themes arising from the Healthcare Safety Investigation Branch maternity programme (April 2018-December 2019)’ in February 2020. This described eight themes for further exploration in order to highlight opportunities for system-wide learning; one of these themes was group B streptococcus (GBS). This report, Severe brain injury, early neonatal death and intrapartum stillbirth associated with group B streptococcus infection, highlights a number of patient safety concerns and recommends that maternity care providers should consider the findings and make necessary changes to their local systems to ensure that mothers and babies receive care in line with national guidance. The Healthcare Safety Investigation Branch will keep the theme of group B streptococcus under review and consider a future national investigation to explore this subject further.
  6. News Article
    Only two out of 23 recommendations from a royal college review into a trust’s troubled maternity services can be shown to be fully implemented, a new investigation has revealed. A learning and review committee, set up by East Kent Hospitals University Foundation Trust, found that 11 more of the recommendations from a 2016 review by the Royal College of Obstetricians and Gynaecologists (RCOG) were “partially” implemented. But it said there was either no evidence the remaining 10 had been delivered, or there was evidence they were not implemented. The original RCOG review looked at a number of cases where babies had died as well as broader issues within the maternity service at the trust. The committee was set up after an inquest into the death of Harry Richford, who died a week after his birth in 2017 at the trust’s Queen Elizabeth, the Queen Mother, Hospital in Thanet. Many of the issues which came to light at his inquest echoed those from the RCOG report. Committee chair Des Holden, medical director of Kent Surrey Sussex Academic Health Science Network, highlighted the difficulties in tracking evidence and action plans during a time when the trust had significant changes in leadership. But he said the committee felt cases where evidence could not be found or the standard of evidence gave concern, the recommendations could not be said to be met. Derek Richford, Harry’s grandfather, said on behalf of the family: “We are saddened and shocked to find that over four years after the RCOG found fundamental systemic failings and made 23 recommendations, only two have been completed. It is not good enough for them to now say ‘leadership has changed’. The main board must take responsibility and be held to account.” Read full story (paywalled) Source: HSJ, 13 July 2020
  7. Content Article
    Recommendations The Government should immediately issue a fulsome apology on behalf of the healthcare system to the families affected by Primodos, sodium valproate and pelvic mesh. The appointment of a Patient Safety Commissioner who would be an independent public leader with a statutory responsibility. The Commissioner would champion the value of listening to patients and promoting users’ perspectives in seeking improvements to patient safety around the use of medicines and medical devices. A new independent Redress Agency for those harmed by medicines and medical devices should be created based on models operating effectively in other countries. The Redress Agency will administer decisions using a non-adversarial process with determinations based on avoidable harm looking at systemic failings, rather than blaming individuals Separate schemes should be set up for each intervention – HPTs, valproate and pelvic mesh – to meet the cost of providing additional care and support to those who have experienced avoidable harm and are eligible to claim. Networks of specialist centres should be set up to provide comprehensive treatment, care and advice for those affected by implanted mesh; and separately for those adversely affected by medications taken during pregnancy. The Medicines and Healthcare products Regulatory Agency (MHRA) needs substantial revision particularly in relation to adverse event reporting and medical device regulation. It needs to ensure that it engages more with patients and their outcomes. It needs to raise awareness of its public protection roles and to ensure that patients have an integral role in its work. A central patient-identifiable database should be created by collecting key details of the implantation of all devices at the time of the operation. This can then be linked to specifically created registers to research and audit the outcomes both in terms of the device safety and patient reported outcomes measures. Transparency of payments made to clinicians needs to improve. The register of the General Medical Council (GMC) should be expanded to include a list of financial and non-pecuniary interests for all doctors, as well as doctors’ particular clinical interests and their recognised and accredited specialisms. In addition, there should be mandatory reporting for pharmaceutical and medical device industries of payments made to teaching hospitals, research institutions and individual clinicians. The Government should immediately set up a task force to implement this Review’s recommendations. Its first task should be to set out a timeline for their implementation. Response from Patient Safety Learning Patient Safety Learning welcomes the publication of the First Do No Harm report today from the Independent Medicines and Medical Devices Safety Review. The Chair of the review, Baroness Julia Cumberlege, highlighted in this that they found the healthcare system to be "disjointed, siloed, unresponsive and defensive" to the patients effected by these issues. She also noted that: ‘The system is not good enough at spotting trends in practice and outcomes that give rise to safety concerns. Listening to patients is pivotal to that’ The report highlighted some key themes consistent with other major patient safety failures: Patients not being engaged in their care: Lacking the information required to make informed choices, awareness of how to report problems and their experiences not being recognised. Ineffective reporting: Data not being utilised to identify and address patient safety issues. Existing reporting systems not being effective enough to capture this information and share learning widely. Blame culture: Persistent failure to acknowledge when things go wrong for fear of blame, reducing the ability to address threats to patient safety. Patient Safety Learning considers that patient safety is currently treated as one of many priorities to be weighed against each other. We think it is wrong that safety is negotiable. Patient safety must be core to the purpose of healthcare, reflected in everything that it does.
  8. News Article
    Parents of babies who died at a hospital trust at the centre of a maternity inquiry say a police investigation has come "too late". West Mercia Police said it was looking at whether there was "evidence to support a criminal case" at Shrewsbury and Telford NHS Hospital Trust. An independent review, contacted by more than 1,000 families, said it was working with police to identify relevant cases. "It's bittersweet," one mother said. "It's come too late for my daughter, she should still be here," said Tasha Turner, whose baby, Esmai, died four days after she was born at Royal Shrewsbury Hospital in 2013. Ms Turner's case is part of the Ockenden Review, an independent investigation into avoidable baby deaths at the trust, which runs Royal Shrewsbury Hospital and Telford's Princess Royal. LaKamaljit Uppal, 50, from Telford, who is also part of the review following the death of her son Manpreet in April 2003 at Royal Shrewsbury Hospital, said she hoped the police inquiry would bring some closure. "The trust put me through hell, someone should be held accountable," she said. Read full story Source: BBC News, 1 July 2020
  9. Content Article
    The audit consists of 3 elements: 1. A survey of the organisation of maternity care in England, Scotland and Wales will provide an up-to-date overview of maternity care provision, women’s access to recommended services and options available to them. 2. A continuous prospective clinical audit of a number of key interventions and outcomes to identify unexpected variation between service providers or regions. 3. A flexible programme of periodic audits on specific topics (‘sprint audits’) within a focused time frame.
  10. News Article
    A hospital trust under the spotlight over avoidable baby deaths provided inadequate antenatal care, with inexperienced junior midwives working alone and doctors not always available to assess high risk women, the Care Quality Commission (CQC) has found. The latest CQC report on maternity services at East Kent Hospitals University Foundation Trust follows a report last month by the NHS Healthcare Services Investigation Branch on 24 maternity care investigations at the trust. Read full story (paywalled) Source: BMJ, 28 May 2020
  11. News Article
    The coroner investigating the botched birth of a baby boy who died from hypoxia has strongly criticised the Healthcare Service Investigation Branch (HSIB) over its report on his death. Karen Henderson, who conducted the inquest into the death of baby Theo Young in May 2018 at East Surrey Hospital said that the HSIB had asked Surrey and Sussex Healthcare NHS Trust not to undertake its own investigation, “effectively preventing the recognition of causes of concern and therefore being unable to undertake any immediate and necessary remedial action at the earliest opportunity to prevent future deaths.” Read full story (paywalled) Source: BMJ, 19 May 2020
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