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Content ArticleSafety recommendations It is recommended that the British Association of Urological Surgeons, in collaboration with other relevant specialties (such as the Royal College of Radiologists and British Transplant Society), develops national standards which support electronic and paperbased systems for stent logging/ tracking. These standards should include guidance on monitoring and human oversight. It is recommended that the British Association of Urological Surgeons works with the Patient Information Forum to review its stent patient information leaflet. This should include accessibility and clinical considerations, especially with regards to side effects and complications, and advice on the action to take should concerns arise. It is recommended that the British Association of Urological Surgeons provides guidance for staff working within the stone care pathway to promote consistent advice to patients as part of discharge planning. It is recommended that the British Association of Urological Surgeons encourages members to include information in discharge letters and other communication sent to GPs and patients regarding patients’ stent status, potential complications and the possibility of a retained stent. Safety observations The NHS Summary Care Records (SCR) system is being developed to allow for specific patient groups to be flagged. It may be beneficial for the British Association of Urological Surgeons to liaise with NHSX should opportunities arise in the future to use SCR to flag patients with ureteric stents to aid communication with primary/urgent care services. The National Institute for Health and Care Excellence (NICE) guidance for the management of urinary tract infections does not include ureteric stents as a cause of urinary symptoms which could mimic a urinary tract infection. It may be beneficial for this potential complication to be considered in the next review of this and other clinical practice guidance.
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News ArticleThe staff-side committee of a major hospital trust has stopped working with its leadership, with its chair alleging an ‘endemic’ culture of ‘racism, discrimination and bullying’. Irene Pilia, staff-side committee chair at King’s College Hospital Foundation Trust, told colleagues that the decision was taken “in the interests of staff”, especially black, Asian and minority ethnic workers, and expressed concerns about the organisation’s disciplinary procedures. She said the decision had the backing of staff committee officers and delegates. Ms Pilia, who is also the senior KCHFT Unite representative, said she was open to resuming partnership working again, but told trust executives: “I have lost trust and confidence in the ability of [KCHFT] to conduct fair, impartial and no-blame investigations. “Until there is tangible and credible evidence that racist behaviour at all levels is proactively eliminated, such that perpetrators face real consequences (including to the detriment of their careers) for their actions and are no longer allowed to behave in racist ways with impunity, I take a stand for the hundreds, possibly thousands of KCHFT staff whose voices are not being heard." Read full story (paywalled) Source: HSJ, 22 October 2020
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Content ArticleI believe all clinicians should read this latest report. There is so much to be learned and so many changes in clinical practice that can be made right away. Since 2018, I have been teaching using Oliver's tragic story to promote reflection on best practice in prescribing and in implementing the Mental Capacity Act. I could write a lot here; however, I believe this is a report all clinicians, and especially all prescribers, need to read in full. A summary of how I see this (or indeed how any individual sees it) it will not be adequate.
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News ArticleAn independent review found that commissioners’ investigation of a young boy’s death was ‘mismanaged’, and heard allegations that the person who coordinated it was bullied over the contents. The independent review, commissioned by NHS England, has published its final report following an investigation into Bristol, North Somerset and South Gloucestershire clinical commissioning group’s LeDer review into the death of Oliver McGowan. Chaired by Fiona Ritchie, the independent review was commissioned last year after evidence emerged that the CCG had rewritten earlier findings of the review, removing suggestions his death at North Bristol Trust in 2016 was avoidable. Oliver died in November 2016 after being given anti-psychotic medication against his own and his parents’ wishes and despite medical records showing he had an intolerance to anti-psychotics. He developed severe brain swelling because of the drugs and died.A local LeDer review — part of a programme aimed at improving care based on deaths among people with learning disabilities — was launched in 2017, seven months after his death, by the CCG (then operating as three separate organisations), then published in 2018. In 2018, a coroner concluded Oliver’s care prior to his death was “appropriate” and made no recommendations. His death is also currently the subject of a police investigation. The lead reviewer (Ms A) stated in her panel interview that during the time she was undertaking this LeDeR she had felt bullied, overworked and overly stressed by the demands placed on her by the various correspondences with solicitors and her line management. The fact that Ms A believed she was isolated and unsupported during this review illustrates evident failures in the CCG assurance and management processes at the time. In a final report by the subsequent independent review, published today, the panel led by Ms Ritchie “unanimously” agreed Oliver’s death was “potentially avoidable”. Read full story (paywalled) Source HSJ, 20 October 2020
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Content Article
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Content ArticleWhat is root cause analysis? Root cause analysis (RCA) is a structured method used to analyse serious adverse events. Initially developed to analyse industrial accidents, RCA is now widely deployed as an error analysis tool in healthcare. The RCA approach is the current methodology to investigate why and how serious incidents have happened in healthcare and to assure the Trust, Clinical Commissioning Group (CCG) and the patient/family that lessons have been learned and that the incident will not happen again. This methodology is soon to change next year as set out in the new Patient Safety Incident Response Framework. What happens to the report? Once written, the RCA report will be sent to the CCG, other outside bodies and the patient/family, alongside an action plan on how practices will change. What type of incident is RCA used for? Many Trusts will perform an RCA on incidents which are deemed to have greater learning for the Trust despite the degree of harm, moderate harm and above, and never events. Most Trusts use a modified RCA for ‘local’ investigations – these incidents may include pressure damage, falls and medication errors. What is the process? The current process of undertaking and processing a serious incident is laid out below. This is taken from the NHS Serious Incident Framework. Many Trusts will provide RCA training to anyone undertaking the lead role in an investigation – this could be a patient safety lead or a clinician. How long does it take to complete an RCA? This can depend on the experience of the investigator, the capacity of the department involved to collect statements, a timeline and information. If the incident has been declared to the CCG, the report will need to be completed within 60 days. A local RCA should take no longer than 4 weeks. How many RCAs are completed each year in the UK? During 2018 there were nearly 62,500 incidents that were reported as moderate harm or above. The majority of these would require an RCA. This figure does not include incidents that were not reported on to the Strategic Executive Information System (StEIS) but were investigated using the root cause analysis locally. Currently, patient safety teams up and down the country are drowning in writing RCA reports. We are caught up in a process of investigating harm that has already happened. Hours, days, months are spent having meetings mulling over the RCA. Looking at timelines, thinking of why the incident happened and whether there was any way for it to have been prevented. The cost of undertaking an RCA must be in the thousands of pounds. The team often includes the patient’s consultant, head of nursing, governance leads, patient safety managers and clinical staff. This group may meet up at several different occasions to make sure that all facts are correct and that the RCA is written well and meet a standard that the CCG will accept. Multiple drafts are written before submitting the final report. Action plans are found at the bottom of the RCA – once the root causes have been found, that is when the actions can be formulated. These actions will need to be carried out in the department/area where the incident took place or across the Trust if it was a system failure. Once written and signed off by the Trust and the CCG – the RCA is complete. What happens next? The end of the RCA should be the beginning of either a quality improvement initiative, a new policy, a change in practice or change in process. This part of the process is often poor – ‘reminding staff’, ‘education’ and ‘reflection’, assuming it must be human error and must be ‘fixed’ by telling people how to do it better. There is little training in setting appropriate actions or a centralised place to evidence that the action is now imbedded. The Care Quality Commission (CQC) can call on these actions and the evidence of these actions at any time. At present there is not a robust, standardised approach across the NHS to gather evidence that actions have been put in place post incident. One of the reasons for this is a lack of capacity and capability due to the industry we have made of writing the RCA and lack of quality improvement training or time provided to all staff throughout the NHS. Final words Have we forgotten the purpose of our role within patient safety? Figuring out what went wrong systemically is only one part of our role; however, assuring the family and patient that we have put new systems in place and that we are striving for this incident to never happen again is equally, if not more, important – so why is there not a standard process/industry for this? If we focussed more on the prevention we could get off the hamster wheel of investigating recurrent harm. It is hoped that the new serious incident framework will address this issue and allow us the time and the capability to put in measures to stop recurrent harm happening to patients and the public. What are your solutions to action plans and gathering the evidence for these plans? Have you a system that is easy to keep track of RCA reports and follow up? I would also be interested in the patient/public view of investigation reports and whether this type of approach is what they want?
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Event
Investigation and learning from deaths in NHS Trusts
Patient Safety Learning posted a calendar event in Community Calendar
The NHS is the world’s first health organisation to publish data on avoidable deaths. The National Guidance on Learning from Deaths has driven a strengthening of systems of mortality case review with emphasis on learning. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. This virtual conference focuses on improving the investigation and learning from deaths in NHS Trusts following the National CQC and NQB guidance, and Department of Health reporting requirements. The conference will also discuss the role of Medical Examiners which were introduced in April 2019, providing a national system of medical examiners will be introduced to provide much-needed support for bereaved families and to improve patient safety. Register hub members can receive a 20% discount by quoting HCUK20psl when booking -
News ArticleThe parents of a three-year-old boy whose death was part of an alleged NHS cover-up have won a six year battle for the truth about how he died. Shropshire coroner John Ellery backed the parents of three-year-old Jonnie Meek in a second inquest into his death on Thursday and rejected evidence from nurses about what happened at Stafford Hospital in August 2014. Jonnie, who was born with rare congenital disability De Grouchy syndrome, died two hours after being admitted to hospital to trial a new feed which was being fed directly into his stomach. His parents, John Meek and April Keeling, from Cannock in Staffordshire, have always maintained their son died after a reaction to the milk feed caused him to vomit and suffocate. But they have been forced to battle what they believe was an attempt to hide what happened after they discovered attempts to alter their son’s medical history with claims he had experienced several cardiac arrests requiring resuscitation which never happened. In 2015, healthcare assistant Lauren Tew, who was with Jonnie and his mother when he died, told the HSJ that a statement in her name submitted to a child death overview panel stating Jonnie had died from a sudden cardiac arrest was false and she had never made such a statement. Another statement said Jonnie had been admitted to hospital for three weeks months before his death which also never happened. After his parents exposed the false statements an independent inquiry was launched, with three independent experts agreeing with Jonnie’s parents, and in April last year the High Court quashed the original inquest verdict that Jonnie died of natural causes and pneumonia. Speaking to The Independent Jonnie’s father said: “This does bring us some peace after six years. For the coroner to say he believes April over the nurses after all this time is a big weight lifted off her. “The hospital definitely decided to try and cover up what happened to Jonnie. We have always said we knew what happened and this has been a massive waste of resources. I am still very concerned about how these things can happen in the first place.” Read full story Source: The Independent, 15 October 2020
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EventuntilThe Westminster Health Forum is a division of Westminster Forum Projects, an impartial and cross-party organisation which has no policy agenda of its own. Forums operated by Westminster Forum Projects enjoy considerable support from within Parliament and Government. The agenda: The impact of investigations in the NHS and the priorities of the Healthcare Safety Investigation Branch Progress of improving patient safety in the NHS Maintaining patient safety during COVID-19 - rapid learning to respond to the virus, continuity of care, and adapting care delivery practices Delivering safe care in the NHS - preventing errors, utilising data and technology, supporting the workforce, and promoting high quality leadership Learning from the voice of parents and families How to improve patient safety by reducing unwarranted variation and learning from clinical negligence claims The role of technology in reducing errors, enhancing care, and ensuring safety in remote healthcare and telemedicine Taking forward the National Patient Safety Syllabus and supporting the workforce to deliver care safely during the presence of COVID-19 Learning from harm, reducing the cost of litigation in the NHS, and the impact of COVID-19 Assessing findings from the Independent Medicines and Medical Devices Safety Review The role of the regulator in reducing avoidable harm and informing future practice Register
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News ArticleAn NHS trust has offered an unreserved apology to an elderly patient and his family after they accused hospital staff of restraining him 19 times in order to forcibly administer treatment. East Kent Hospitals University NHS Foundation Trust admitted that care for the man, who has dementia, “fell far short” of what patients should expect. The 77-year-old had been admitted to the William Harvey Hospital last November for urinary retention problems, according to a recent BBC investigation. In February, The Independent revealed that a police investigation had been launched into an alleged assault against an elderly man at the hospital after nurses and carers were filmed by hospital security staff holding the man’s arms, legs and face down while they inserted a catheter. A whistleblower told The Independent that the incident was being covered up by the trust and staff were told: “Don’t discuss it, don’t refer to it at all.” On Wednesday, the trust said its investigation had found a failure to alert senior medics to the difficulties being experienced in caring for the patient. Changes to dementia care including ward reorganisation, training and recruitment are underway, said a spokesperson, who added: “We apologise unreservedly to the patient and his family for the failings in his care, this fell far short of what patients should expect.” Read full story Source: The Independent, 14 October 2020
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News Article
‘Babies are still being damaged’ Tory peer warns ‘evasive’ ministers
Patient Safety Learning posted a news article in News
The government has been told it is ‘not sustainable’ to continue to delay its response to a major review on patient safety as ‘babies are still being damaged’. The Independent Medicines and Medical Devices Safety Review spoke to more than 700 people, mostly women who suffered avoidable harm from surgical mesh implants, pregnancy tests and an anti-epileptic drug, and criticised “a culture of dismissive and arrogant attitudes” including the “unacceptable labelling of many symptoms as “attributable to ‘women’s problems’”. The review’s author Baroness Julia Cumberlege told HSJ that “time is marching on” for the Department of Health and Social Care to implement the recommendations of her July report, which include setting up a new independent patient safety commissioner. The Conservative peer said pressure was building on government to adopt the findings of the review, since it had been endorsed by Royal Colleges and has already been adopted by the Scottish government. She said the government had given “evasive” answers in parliament on the issue. In an exclusive interview with HSJ, Baroness Cumberlege said: There is a crowded field of regulators but “there’s a void” for a service that listens and responds to patients’ safety concerns. She feels “diminished” that women’s concerns are still being dismissed by clinicians, but said young doctors are a cause for hope. She is “very optimistic” report will be implemented – but the NHS has to have the will to make changes. Read full story (paywalled) Source: HSJ, 13 October 2020 -
Content ArticleThe HSIB investigation focused on what happens after thrombolysis treatment is given and how venous thromboembolism (VTE) risk is managed as patients recover. They identified issues such as a low rate of intermittent pneumatic compression (IPCs) being fitted despite their success in improving the survival rates of those who are not mobile after a stroke and their recommendation by NICE guidelines. As the investigation progressed, HSIB identified missed opportunities throughout the whole process of care. There is a lack of a national, stroke-specific assessment for VTE that considers the patient’s specific circumstances or determines the level of risk the patient has of blood clots forming. Even if an assessment identifies IPC as a treatment, the case examined in this report reflected a wider picture of confusion over how the devices are recorded i.e. on the patient’s chart and who then is responsible for fitting. The findings also show that national guidelines do not require a follow-up assessment or a check that the VTE preventative measure is in place. Safety recommendation As a result of the national investigation, HSIB have made one safety recommendation to facilitate the development of a stroke specific assessment, a system for the associated treatment to be recorded using a tool to ensure that the relevant information is documented and, importantly, reviewed. Dr Stephen Drage, HSIB Director of Investigations and intensive care unit consultant, said: “The time after a patient is admitted and treated for a stroke is incredibly precarious. It is important that any safety risks in the care process are mitigated to prevent life-threatening blood clots forming to give patients the best chance of making a full recovery. “A number of barriers to the most effective aftercare emerged through our investigation and the safety issues impact not only all specialist units but any wards where stroke recovery takes place in the NHS. The recommendation we have made is aimed at ensuring that VTE risk is managed in a targeted way that ensures that patients are getting the right treatment at the right time.”
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News Article
Maternity scandal hospital fined for not triaging A&E patients fast enough
Patient Safety Learning posted a news article in News
An NHS hospital which has faced repeated criticism by regulators for poor standards of care has been fined £4,000 for failing to assess A&E patients quickly enough. The Shrewsbury and Telford Hospitals Trust has been fined by the Care Quality Commission (CQC) after patients were not triaged within 15 mimutes of arrival in A&E – in breach of conditions set by the regulator last year and a national target. The care of emergency patients at the hospital trust, which is also facing an inquiry into poor maternity care, has been a long running concern for the watchdog which has rated the trust inadequate and put it in special measures in 2018. Earlier this year the CQC’s chief inspector of hospitals, Professor Ted Baker, wrote to NHS England warning of a “worsening picture" at the Midlands hospital and demanding action be taken. The CQC said it had issued the fixed penalty notice to the trust because it failed to comply with national clinical guidance that all children and adults must be assessed within 15 minutes of arrival. It also failed to implement a system that ensured all children who left the emergency department without being seen were followed up. After inspections in April 2019 and November 29 the CQC imposed seven conditions on the hospital over emergency care. The regulator said it was now clear the trust had not stuck to the conditions and had breached them both at Royal Shrewsbury Hospital and Princess Royal Hospital. Professor Baker said: "The trust has not responded satisfactorily to previous enforcement action regarding how quickly patients are assessed upon entering the urgent and emergency department." “We have issued a penalty notice due to the severity of the situation and to ensure the necessary, urgent improvements are made. It is essential that patients are seen in a timely way when they arrive at an emergency department; failure to do so could result in deteriorating health, harm, or even death, which is why national guidelines exist and must be followed." Read full story Source: The Independent, 12 October 2020 -
News ArticleAn urgent investigation into blanket orders not to resuscitate care home residents has been launched amid fears some elderly people may still be affected by the “unacceptable” practice. After COVID-19 cases rose slightly in care homes in England in the last week, with 116 residences handling at least one infection, the Care Quality Commission (CQC) said it was developing the scope of its investigation “at pace” and it would cover care homes, primary care and hospitals. In March and April, there were reports that some GPs had applied “do not attempt resuscitation” (DNAR) notices to groups of care home residents that meant people would not be taken to hospital for potentially life-saving care. This was being done without their consent or with little information to allow them to make informed decisions, the CQC said. Cases emerged in care homes in Wales and East Sussex. Care homes said the blanket use of the orders did not appear to be as prevalent ahead of a possible second wave of infections and families were reporting fewer concerns, although that could be because visiting restrictions meant they had less access to the homes and were getting less information. There are also concerns that steps may not have been taken to review DNAR forms added to care home residents’ medical files, and so they could remain in place, without proper consent. The CQC review will examine the use of “do not attempt cardiopulmonary resuscitation” (DNACPR) notices, which only restrict chest compressions and shocks to the heart. Dr Rachel Clarke, a palliative care expert in Oxford, has described the CPR process as “muscular, aggressive, traumatic” and said it often resulted in broken ribs and intubation. The review will also investigate the use of broader do not resuscitate and other anticipatory care orders. “We heard from our members about some pretty horrific examples of [blanket notices] early in the pandemic, but it does not appear to be happening now,” said Vic Rayner, the executive director of the National Care Forum, which represents independent care homes. “DNAR notices should not be applied across settings and must be only used as part of individual care plans.” It will also investigate the use of broader do not resuscitate and other anticipatory care orders. Read full story Source: The Guardian, 12 October 2020
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News ArticleThe Care Quality Commission (CQC) has launched the first prosecution of an acute trust for failing to meet fundamental standards of care. East Kent Hospitals University Foundation Trust faces two charges relating to the death of Harry Richford and the risks posed to his mother during his birth. Both charges are under regulation 12 of the Health and Social Care Act 2008. The trust is accused of failing to discharge its duty under regulation 12 in that it failed to provide safe care and treatment exposing Harry and his mother Sarah to a significant risk of avoidable harm. It is only the fourth prosecution of a trust over the “fundamental standards” which were brought in following the Mid Staffordshire care scandal and are meant to be enforced by the CQC. It is also thought to be the first related to the safety of clinical care. Read full story (paywalled) Source: HSJ, 9 October 2020
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News Article
Former ministers to hold 'rapid' inquiry into government's COVID-19 response
Patient Safety Learning posted a news article in News
A pair of Conservative former ministers have announced they are to lead a rapid, cross-party investigation into the UK’s handling of the coronavirus crisis, amid worries a government inquiry will take too long for lessons to be learned in time. In a rare set of joint hearings, the Commons health committee, led by ex-health secretary Jeremy Hunt, and the science committee, chaired by Greg Clark, who was business secretary, are to hear from witnesses in the hope of producing a report by the spring. Announcing the plan, Hunt and Clark said the inquiry would aim to produce interim recommendations along the way. It will hold weekly joint sessions, with early witnesses set to include Chris Whitty, the chief medical officer for England, and Patrick Vallance, the government’s top scientific adviser. Hunt said he would expect the inquiry to cover the need for regular, large-scale coronavirus testing, an issue he has repeatedly raised in parliament, and whether this could help people visit loved ones in care homes. The hearings begin next Tuesday with a session on social care. Other promised areas of examination include the efficacy of lockdown measures; how well modelling and statistics have been used; the efficacy of government messaging; wider preparedness for a pandemic; and the impact on BAME communities. Read full story Source: The Guardian, 8 October 2020 -
News Article
Baby died on maternity unit months after staff warned it was unsafe
Patient Safety Learning posted a news article in News
A baby died during birth because of systemic errors in one of Britain's largest NHS hospitals, months after staff had warned hospital chiefs that the maternity unit was “unsafe”, an inquest has found. A coroner ruled that neglect by staff at Nottingham University Hospitals Trust contributed to the death of baby Wynter Andrews last year. She was delivered by caesarean section on 15 September after significant delays. Her umbilical cord was wrapped around her neck and leg, resulting in her being starved of oxygen. In a verdict on Wednesday, assistant coroner Laurinda Bower said Wynter would have survived if action had been taken sooner, criticising the units “unsafe culture” and warning that her death was not an isolated incident. Wynter’s mother, Sarah Andrews, called on the health secretary, Matt Hancock, to investigate the trust’s maternity unit. She said: “We know Wynter isn’t an isolated incident; there have been other baby deaths arising because of the trust’s systemic failings. She was a victim of the trust’s unsafe culture and practices.” Read full story Source: The Independent, 7 October 2020 -
News Article
Care watchdog to target NHS maternity units after baby death scandals
Patient Safety Learning posted a news article in News
The Care Quality Commission (CQC) is to target poorly performing NHS maternity units after a series of maternity scandals. It is drawing up plans to spot high-risk maternity units and will use data on their patient outcomes and culture to draw up a list of facilities for targeted inspection. The watchdog has voiced concerns over the wider safety of maternity units in the NHS after a number of high-profile maternity scandals in the past year. Almost two-fifths of maternity units, 38%, are rated as “requires improvement” by the CQC for their safety. The Independent has joined with charity Baby Lifeline to call on the government to reinstate a national maternity safety training fund for doctors and midwives. The fund was found to be successful but axed after just one year. On Tuesday, the CQC’s chief inspector of hospitals, Professor Ted Baker, told MPs on the Commons Health and Social Care Committee that he was concerned about the safety of mothers and babies in some maternity units which had persistent problems. “Those problems are of dysfunction, poor leadership, of poor culture, of parts of the services not working well together,” he said. “This is not just a few units; this is a significant cultural issue across maternity services.” Now the CQC has confirmed it is planning to draw up a list of poor-performing units or hospitals where it suspects there could be safety issues. The new inspection programme will specifically look at issues around outcomes and teamworking culture although the full methodology has yet to be decided. Read full story Source: The Independent, 4 October 2020 -
News ArticleSending thousands of older untested patients into care homes in England at the start of the coronavirus lockdown was a violation of their human rights, Amnesty International has said. A report says government decisions were "inexplicable" and "disastrous", affecting mental and physical health. More than 18,000 people living in care homes died with COVID-19 and Amnesty says the public inquiry promised by the government must begin immediately. According to Amnesty's report, a "number of poor decisions at both the national and local levels had serious negative consequences for the health and lives of older people in care homes and resulted in the infringement of their human rights" as enshrined in law. Researchers for the organisation interviewed relatives of older people who either died in care homes or are currently living in one; care home owners and staff, and legal and medical professionals. Amnesty said it received reports of residents being denied GP and hospital NHS services during the pandemic, "violating their right to health and potentially their right to life, as well as their right to non-discrimination". It adds that care home managers reported to its researchers that they were "pressured in different ways" to accept patients discharged from hospital who had not been tested or had COVID-19. Amnesty says the public inquiry into the pandemic should begin with an "interim phase". "The pandemic is not over," it added. "Lessons must be learned; remedial action must be taken without delay to ensure that mistakes are not repeated." Read full story Source: BBC News, 4 October 2020
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Community PostHi The new Patient Safety Incident Response Framework is due for publication this month for early adopters and as 'introductory guidance' for everyone else: https://improvement.nhs.uk/resources/about-new-patient-safety-incident-response-framework/ I wondered if there is anyone who is involved in an organisation that is an early adopter who can share what has happened so far and also would be willing to share any local learning as the new framework is implemented? Also, more generally wondered if anyone has any initial comments on the proposals which were mentioned in the NHS patient safety strategy and any things in particular which they think will bring benefit or could represent significant challenges or issues?
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News ArticleThe NHS 111 service has permanently stopped nurses and other healthcare professionals in a clinical division handling calls with people suspected of having COVID-19 after an audit of recorded calls found more than 60% were not safe. The audit was triggered in July after many of the medical professionals recruited to work in that clinical division of the 111 service sounded the alarm, saying they did not feel “properly skilled and competent” to fulfil such a critical role. An investigation was launched into several individual cases after the initial review found that assurances could not be given “in regard to the safety of these calls”, according to an email, seen by the Guardian, from the clinical assurance director of the National Covid-19 Pandemic Response Service. In a further email on 14 August, she told staff that after listening to a “significant number” of calls “so far over 60% … have not passed the criteria demonstrating a safe call”. A number of “clinical incidents” were being investigated, she said, because some calls “may have resulted in harm”. One case had been “escalated as a serious untoward incident with potential harm to the patient”. NHS England declined to answer questions about any aspect of these apparent safety failings, saying it was the responsibility of the South Central ambulance service (SCAS), which set up a section of NHS 111 called the Covid-19 Clinical Assessment Service (CCAS). Read full story Source: The Guardian, 1 October 2020
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News ArticleAs she lay dying in a Joliette, Que., hospital bed, an Atikamekw woman clicked her phone on and broadcast a Facebook Live video appearing to show her being insulted and sworn at by hospital staff. Joyce Echaquan's death on Monday prompted an immediate outcry from her home community of Manawan, about 250 kilometres north of Montreal, and has spurred unusually quick and decisive action on the part of the provincial government. The mother of seven's death will be the subject of a coroner's inquiry and an administrative probe, the Quebec government said today. A nurse who was involved in her treatment has been dismissed. But that dismissal doesn't ease the pain of Echaquan's husband, Carol Dubé, whose voice trembled with emotion as he told Radio-Canada his wife went to the hospital with a stomach ache on Saturday and "two days later, she died." Echaquan's relatives told Radio-Canada she had a history of heart problems and felt she was being given too much morphine. In the video viewed by CBC News, the 37-year-old is heard screaming in distress and repeatedly calling for help. Eventually, her video picks up the voices of staff members. One hospital staff member tells her, "You're stupid as hell." Another is heard saying Echaquan made bad life choices and asking her what her children would say if they saw her in that state. Dubé said it's clear hospital staff were degrading his wife and he doesn't understand how something like this could happen in 2020. Read full story Source: CBC News, 29 September 2020
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News ArticleThe 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
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Content ArticleHealth and Social Care Select Committee This is a cross-party body that is responsible for scrutinising the work of the Department of Health and Social Care and its associated public bodies in the UK. It is composed of MPs and examines government policy, spending and administration on behalf of the electorate and the House of Commons.[1] Safety of maternity services in England The Committee opened an inquiry into the Safety of maternity services in England on the 24 July 2020. The intention of this inquiry is to examine evidence relating to ongoing concerns around recurring failings in maternity services, with MPs considering whether clinical negligence and litigation processes need to be changed to improve the safety of maternity services, as well as the extent to which a “blame culture” affects medical advice and decision-making.[2] Formal meeting (oral evidence session) - Tuesday 29 September 2020 In this video of the first oral evidence session of this inquiry, the Committee heard from: Michelle Hemmington, Co-founder at Campaign for Safer Births Dr Bill Kirkup, Chairman at Morecambe Bay maternity investigation and East Kent maternity investigation Professor Ted Baker, Chief Inspector of Hospitals at Care Quality Commission Professor Jacqueline Dunkley Bent, Chief Midwifery Office at NHS England and NHS Improvement Dr Matthew Jolly, National Clinical Director for Maternity and Women's Health at NHS England and NHS Improvement References UK Parliament, Health and Social Care Committee, Last Accessed 1 October 2020. UK Parliament, Safety of Maternity Services in England, Last Accessed 1 October 2020.
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News ArticleFor 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
