Search the hub
Showing results for tags 'Investigation'.
-
News Article
'My baby died after I was ignored' - families call for NHS maternity inquiry
Patient Safety Learning posted a news article in News
When Tassie Weaver went into labour at full term, she thought she was hours away from holding her first child. But by the time she was giving birth, she knew her son had died. Doctors had previously told Tassie to call her local maternity unit immediately, she says, as she was considered high risk and needed monitoring, due to high blood pressure and concerns about the baby's growth. But a midwife told her to stay at home. Three hours later she called again, worried because now she couldn't feel her baby moving. Again, she was told to stay at home, the same midwife saying that this was normal because women can be too distracted by their contractions to feel anything else. "I was treated as just a kind of hysterical woman in pain who doesn't know what's going on because it's their first pregnancy," the 39-year-old tells us. When she called a third time, a different midwife told her to come to hospital, but when she arrived it was too late. His heart had stopped beating. Tassie and her husband John believe Baxter's stillbirth at the Leeds General Infirmary (LGI), four years ago, could have been prevented - and a review by the trust identified care issues "likely to have made a difference to the outcome". The couple are among 47 new families who have contacted the BBC with concerns about inadequate maternity care at Leeds Teaching Hospitals (LTH) NHS Trust between 2017 and 2024. As well as the new families, three new whistleblowers - two who still work for the trust - have shared concerns about the standard of care at its two maternity units - at the LGI and St James' University Hospital. This is in addition to the two we spoke to in the initial BBC investigation. Read full story Source: BBC News, 17 June 2025- Posted
-
- Baby
- Patient death
- (and 6 more)
-
Content Article
A year after the Infected Blood Inquiry’s final report, serious transfusion risks persist. Trusts must act now to improve safety, reduce waste, and address inequality, warns Cheng Hock Toh in this HSJ article. In May 2024, the UK Infected Blood Inquiry (IBI) published its final report into the devastating failures that led to approximately 30,000 people in the UK being infected with HIV or hepatitis C through transfused blood and blood products. This tragedy has so far claimed more than 3,000 lives. One year on, the UK government has formally accepted all 12 of the report’s recommendations, either in full or in principle. Although rigorous testing has made blood itself safer, serious risks around transfusion practice remain. The government rightly acknowledges that more must be done to prevent future harm. There are already troubling signs, and trusts and commissioners must act urgently to assess and improve the quality, safety, and equity of blood transfusion care across the system.- Posted
-
- Blood / blood products
- Patient harmed
- (and 2 more)
-
News Article
Questions after three disabled children at same care home die
Patient Safety Learning posted a news article in News
Three disabled children died in similar circumstances at the UK's largest brain rehabilitation centre for children despite warnings about care failings, The Independent can reveal. Five-year-old Connor Wellsted died in 2017 at The Children's Trust’s (TCT) Tadworth unit in Surrey, having suffocated when a cot bumper became lodged under his chin. Six years later, in 2023, Raihana Oluwadamilola Awolaja, 12, died after her breathing tube became blocked, and Mia Gauci-Lamport, 16, died after she was found unresponsive in her bed. Inquests into all three deaths uncovered a litany of failings and identified common problems in the children's care at the home where multiple senior directors earn six-figure salaries. Now, police have launched a fresh investigation into Connor’s death. Coroners who investigated their deaths criticised staff for failing to adequately monitor the children – all of whom had complex disabilities and needed one-to-one care – and for not sharing the full circumstances of how they died with authorities. The families of the children, who were all under the care of their local council, are demanding that the government and the regulator, the Care Quality Commission (CQC), take action. Speaking to The Independent, Connor’s father, Chris Wellsted, said: “How many more children are going to die because of their incompetence? CQC failed, NHS England failed. The government failed. Every organisation that should have been investigating the children's trust. It’s a disgrace.” Read full story Source: The Independent, 10 June 2025- Posted
-
- Disability
- Children and Young People
- (and 4 more)
-
News Article
Nottingham maternity scandal hospital data was ‘maliciously’ deleted, police say
Patient Safety Learning posted a news article in News
A computer file containing the details of cases linked to the NHS’s largest maternity scandal was “intentionally” and “maliciously” deleted, a police investigation has found. Nottinghamshire Police launched a probe earlier this year after records held by Nottinghamshire University Hospitals Foundation Trust (NUH) and linked to the alleged maternity failings were temporarily lost. The data was later recovered and 300 more cases are expected to be added to the inquiry into the scandal after a discrepancy was noted by a coroner. NUH is currently being investigated for potential corporate manslaughter after The Independent revealed babies had died or suffered serious injuries at its maternity units. The investigation into the deleted hospital data is not related to the corporate manslaughter probe. The trust is also the subject of an inquiry led by top midwife Donna Ockenden, who is investigating the cases of 2,400 families who experienced maternity care at the trust, including deaths and injuries. Read full story Source: The Independent, 10 June 2025 -
News Article
Australia: Monash IVF admits second bungled embryo implant
Patient Safety Learning posted a news article in News
A second bungled embryo implant at Monash IVF has sparked a new investigation and the expansion of a review into the first incident, which led to a woman unknowingly giving birth to a stranger’s baby. Monash IVF said in a statement on Tuesday that in June “a patient’s own embryo was incorrectly transferred to that patient, contrary to the treatment plan which designated the transfer of an embryo of the patient’s partner”. “Monash IVF has extended its sincere apologies to the affected couple, and we continue to support them,” the fertility company said. The first error was announced in April. In that case, a patient at one of its Queensland clinics had an embryo incorrectly transferred to her, meaning she gave birth to a child of an unrelated woman. The mistake was blamed on human error. Monash IVF asked senior counsel Fiona McLeod to investigate. Lawyers described the incident as a legal and ethical nightmare while Monash IVF said it was confident it was an isolated incident. The latest incident happened in a Victorian laboratory. The state’s health minister, Mary-Anne Thomas, confirmed the Victorian health regulator was investigating. Read full story Source: The Guardian, 10 June 2025 -
News Article
Police investigate heart deaths at NHS hospital
Patient Safety Learning posted a news article in News
Police have launched an investigation into the deaths of patients following heart operations at an NHS hospital, the BBC has learned. Documents seen suggest patients suffered avoidable harm - and that in some cases their death certificates failed to disclose that the procedure contributed to their deaths. One woman's operation at Castle Hill Hospital near Hull - that should have taken no more than two hours - has been described as a "disaster" by one medic. She spent six hours in surgery and lost five litres of blood - all while under local anesthetic. But none of this was mentioned on her death certificate, which recorded her as dying from pneumonia. Her family were also not told what had happened. The documents raise concerns about the care that 11 patients received during a TAVI - Transcatheter Aortic Valve Implant - a procedure to replace a damaged valve in the heart, similar to adding a stent. The department's TAVI mortality rate at the time was three times higher than the UK average, something patients and families were also unaware of. The NHS body that runs Castle Hill, the Humber Health Care Partnership, told the BBC it had delivered improvements suggested by the Royal College of Physicians (RCP). In a statement, it said it was happy to directly answer any questions from the patients' families. Read full story Source: BBC News, 4 June 2025- Posted
-
- Investigation
- Police
-
(and 2 more)
Tagged with:
-
News Article
Manslaughter case launched into Nottingham baby deaths
Patient Safety Learning posted a news article in News
A corporate manslaughter investigation has been opened into failings that led to hundreds of babies dying or being injured at maternity units in Nottingham. Nottinghamshire Police said it was examining whether maternity care provided by the Nottingham University Hospitals (NUH) NHS trust had been grossly negligent. The trust is at the centre of the largest maternity inquiry in the history of the NHS, with about 2,500 cases of neonatal deaths, stillbirths and harm to mothers and babies being examined by independent midwife Donna Ockenden. The police investigation will centre on two maternity units overseen by the trust, which runs the Queen's Medical Centre and Nottingham City Hospital. NUH said it was "deeply sorry for the pain and suffering caused", and it was "absolutely right" that accountability was taken. In a statement on the force's website, Det Supt Matthew Croome, from the investigation team, said corporate manslaughter was a "serious criminal offence". He said: "The offence relates to circumstances where an organisation has been grossly negligent in the management of its activities, which has then led to a person's death. "In such an investigation we are looking to see if the overall responsibility lies with the organisation rather than specific individuals and my investigation will look to ascertain if there is evidence that the Nottingham University Hospitals NHS Trust has committed this offence." The force said its investigation into deaths and serious injuries related to NUH's maternity care - called Operation Perth - had seen more than 200 family cases referred to it so far. Read full story Source: BBC News, 2 June 2025- Posted
-
- Legal issue
- Criminal behaviour
- (and 5 more)
-
News Article
External reviews ordered over trust’s baby death rates
Mark Hughes posted a news article in News
Two external reviews are being commissioned into maternity and neonatal care at the trust with the highest perinatal mortality rates. Leeds Teaching Hospitals Trust has claimed its extended perinatal mortality rate – which measures stillbirths and neonatal deaths – is within the expected range, considering it takes many high-risk pregnancies, including some where babies are not expected to survive, as a specialist centre. However, a report to its board meeting today reveals it is commissioning an external review of the issue. The review would examine mortality data. Read full article (Paywalled) Source: Health Service Journal, 29 May 2025- Posted
-
- Baby
- Patient death
-
(and 2 more)
Tagged with:
-
News Article
Streeting apologises to families for six-month delay on maternity plan
Patient Safety Learning posted a news article in News
Wes Streeting has apologised to families harmed by poor maternity care for taking six months to get back to them, and claimed he is pressing NHS England for a “more comprehensive and stronger set of actions” to improve safety. The health and social care secretary had previously met with a group of campaigners for improved standards in December. But in a letter to them this week he admitted: “It has taken far longer than anticipated to come back to you with concrete plans for the actions we will take….I also realise that the lack of any update may have inadvertently implied that it was not a priority for me. This had never been my intention.” The letter, seen by HSJ, added: ”I was keen that they were sufficiently ambitious to reflect the scale of the challenge with maternity and neonatal care… I have asked NHS England to continue working up a more comprehensive and stronger set of actions that will deliver the change we need – and subject to your views would like to ask them to work directly with yourselves.” The delay in contact since December has caused some disquiet among families affected by recent maternity scandals, who felt they had been promised swifter action. Some groups favour a public inquiry into maternity nationally – which Mr Streeting is thought unlikely to offer – while other families hope for a “maternity czar” to drive forward change. In his letter this week, the MP said “on behalf of the Department, I offer my sincere apologies” for the delay in his response and action, and asked to meet the families again to discuss his plans, which include a set of immediate actions as well as longer-term plans to tackle entrenched issues. Read full story (paywalled) Source: HSJ, 28 May 2025- Posted
-
- Maternity
- Investigation
-
(and 1 more)
Tagged with:
-
News Article
Warning over unlicensed weight-loss jabs after woman left in intensive care
Patient Safety Learning posted a news article in News
A woman was left fighting for her life after using a so-called “weight loss jab” sourced from a salon with police making three arrests. The woman suffered internal injuries earlier after using an injection earlier this month. She has since been discharged. Two other people also become unwell. North Yorkshire Police has launched an investigation into the supply of the injections as they arrested three women from the Selby area. Medical professionals in North Yorkshire and the Medicines and Healthcare Products Regulatory Agency (MHRA) issued a warning against using weight loss medicines bought from private clinics or online. They warned that buying products from unregulated suppliers “significantly increases the risk of getting a product which is either falsified or not licensed for use in the UK and can pose a direct danger to health”. NHS Humber and North Yorkshire Integrated Care Board (ICB) Chief Pharmacy Officer, Laura Angus, said: “There has been a lot of attention in the media and on social media about these so-called ‘skinny jabs’, but as with any medicines bought outside of legitimate supply chains, the contents may not match the ingredients on the label. “If you use such products you could be putting your health at serious risk. “If you are thinking of buying a weight-loss medicine, please talk to a healthcare professional first. The only way to guarantee you receive a genuine weight-loss medicine is to obtain it from a legitimate pharmacy – including those trading online – using a prescription issued by a healthcare professional.” Read full story Source: The Independent, 25 May 2025- Posted
-
- Obesity
- Medication
- (and 6 more)
-
News Article
A coroner has warned of a "culture of cover-up" at a care home where neglect contributed to the death of a disabled 12-year-old girl. Raihana Awolaja, who required 24-hour one-to-one care, died of cardiac arrest in 2023 after her breathing tube became clogged while she was left alone at Tadworth Court in Surrey, a residential care facility operated by The Children’s Trust. Now a senior coroner looking into her death, Professor Fiona Wilcox, has written to the Trust's chief executive, warning there could be further deaths at the home if improvements aren't made. Prof Wilcox raised several serious concerns about the home, including that severely disabled children may not be receiving the level of care needed to keep them safe and more staff training was required. She also warned there "may be culture of cover up at Tadworth Children’s Trust". She added: "They carried out a flawed investigation after this incident, pushing blame onto an innocent individual and thereby avoiding highlighting systemic failures and learning and thus risking lessons that should be learned are lost that could prevent future deaths." Read full story Source: ITV News, 21 May 2025- Posted
-
- Coroner
- Investigation
- (and 5 more)
-
Content Article
Operational guidance to support health boards boards undertaking perinatal adverse event reviews incorporating the additional reporting required of maternity services. See also Maternity and neonatal (perinatal) adverse event review process for Scotland: Operational guidance to supplement the HIS national framework- Posted
-
- Scotland
- Patient safety incident
-
(and 2 more)
Tagged with:
-
News Article
Two men with paranoid schizophrenia stabbed members of the public in separate attacks weeks before Valdo Calocane's killings in Nottingham – and all were under the care of the same NHS trust, the BBC has found. Josef Easom-Cooper and Junior Dietlin injured six men in the stabbings in Nottinghamshire in 2023. Within weeks, Calocane - who also has paranoid schizophrenia - stabbed to death Barnaby Webber, Grace O'Malley-Kumar and Ian Coates on 13 June 2023. Nottinghamshire Healthcare NHS Trust has been criticised over its care of Calocane, and in response to the BBC's findings, apologised to those "affected for any aspects of our care that were not of the high standard our patients deserve". On 9 April 2023, Easom-Cooper stabbed a worshipper who was leaving an Easter Sunday service at St Stephen's Church in Sneinton. Easom-Cooper's mother, Shelly Easom, said that as a teenager, her son was under the care of child and adolescent mental health services (CAMHS) in Nottingham. She said the stabbing could have been prevented if her son's paranoid schizophrenia had been taken more seriously. "It's disgusting that it takes someone to either lose their life or be stabbed before somebody thinks 'oh, hang on a minute, maybe we need to do something here'. "The mental health services in Nottingham have routinely and systematically let him down and also the victim," she added. Read full story Source: BBC News, 23 May 2025- Posted
-
- Violence/ abuse
- Investigation
- (and 2 more)
-
News Article
NHS facing another national maternity services review
Patient Safety Learning posted a news article in News
Another major inquiry into patient safety within NHS maternity departments is being considered, HSJ has learned, this time by the Health Services Safety Investigations Body. HSJ has previously reported about concerns that trusts have been swamped with “overwhelming reporting requirements” and unclear regulation and standards on maternity as the result of a series of high profile reviews undertaken in recent years. HSSIB carries out thematic reviews of safety issues which do not apportion blame. It has not looked into maternity since it was launched in 2023. Chief executive Rosie Benneyworth told HSJ: “There are national issues in maternity… it was increasingly hard for us to explain why we were not looking at maternity as it appears to meet our criteria.” These criteria include systemic failings in multiple providers. Dr Benneyworth continued: “We are very keen that we don’t duplicate other work. The focus for us is making recommendations into national bodies. But we are very aware with maternity there has been an enormous amount of work.” The HSSIB investigation could examine why recommendations from other bodies and inquiries have not been implemented. It may also examine “risk management” and whether learning has been shared after incidents. It could lead to a series of reports published over a year. Read full story (paywalled) Source: HSJ, 20 May 2025- Posted
-
- Maternity
- Organisation / service factors
-
(and 1 more)
Tagged with:
-
News Article
Senior doctor accused of failures in case that gave rise to Martha’s rule
Patient Safety Learning posted a news article in News
A senior doctor has been accused of wrongly failing to escalate the care of a 13-year-old girl whose death led to the adoption of Martha’s rule, which gives the right to a second medical opinion in hospitals. At a disciplinary tribunal in Manchester, Prof Richard Thompson was also said to have provided a colleague with “false and misleading information” about the condition of Martha Mills. Martha died on 31 August 2021 at King’s College hospital (KCH) in south London after contracting sepsis. In 2022, a coroner ruled that she would most likely have survived if doctors had identified the warning signs of her rapidly deteriorating condition and transferred her to intensive care earlier, which her parents had asked doctors to do. Thompson, a specialist in paediatric liver disease, and the on-duty consultant – although he was on call at home – on 29 August 2021, is accused by the General Medical Council (GMC) of misconduct that impairs his fitness to practise. Opening the GMC’s case at the Medical Practitioners Tribunal Service on Monday, Christopher Rose said, based on a review of the case by Dr Stephen Playfor, a medical examiner at Manchester Royal Infirmary, Thompson: Should have taken more “aggressive intervention” between noon and 1pm on 29 August, including referring Martha to the paediatric intensive care unit (PICU). Should have gone into the hospital from about 5pm to carry out an in-person assessment of a rash Martha had developed. Gave “false, outdated and misleading information” in a phone call at approximately 9.40pm to Dr Akash Deep in the PICU team. Read full story Source: The Guardian, 19 May 2025- Posted
-
- Doctor
- Patient / family involvement
- (and 5 more)
-
Content Article
Presentation from David Osborn, health and safety consultant and member of the Covid Airborne Transmission Alliance (CATA), to the Safer Healthcare Biosafety Network. You can watch the video of the presentation and download the pdf presentation slides below. David Osborn, health and safety consultant and member of the Covid Airborne Transmission Alliance (CATA), has given an account of CATA’s journey through the Covid-19 Public Inquiry to the Safer Healthcare Biosafety Network (SHBN). This has been in two parts: His first presentation was delivered on 3 December 2024, just as the public hearings for module 3 (impact of the pandemic on healthcare systems) were drawing to a close. In this second presentation (28 March 2025) David updates the group on CATA's current position and summarises their final submissions to Baroness Hallett. The detail in CATA’s closing submissions to the Inquiry may be found in its written statement at this link. Links are provided in the last two slides of the attached PDF file to CATA’s letters to the Chief Nursing Officers and Ministers. 2025-03-28 SHBN Presentation.pdf It should be noted that, as at 19 May 2025: No reply has been received from the Chief Nursing Officers to CATA’s letter of 4 March. No reply has been received from the Minister (Rt Hon Ashley Dalton MP) to CATA’s letter of 18 March. CATA has therefore written again to the Rt Hon Ashley Dalton MP. The letter is attached below: cata-letter-to-ashley-dalton-mp-1-may-25 (1).pdf -
News Article
A 15-year-old boy who was operated on twice by a now unlicensed Great Ormond Street surgeon says he is living with "continuous" pain. Finias Sandu has been told by an independent review the procedures he underwent on his legs were "unacceptable" and "inappropriate" for his age. The teenager from Essex was born with a condition that causes curved bones in his legs. Aged seven, a reconstructive procedure was carried out on Finias's left leg, lengthening the limb by 3.5cm. A few years later, the same operation was carried out on his right leg which involved wearing an invasive and heavy metal frame for months. He has now been told by independent experts these procedures should not have taken place and concerns have been raised over a lack of imaging taken prior to the operations. His doctor at London's prestigious Great Ormond Street Hospital was former consultant orthopaedic surgeon Yaser Jabbar. Sky News has spoken to others he treated. Mr Jabbar also did not arrange for updated scans or for relevant X-rays to be conducted ahead of the procedures. The surgeries have been found to have caused Finias "harm" and left him in constant pain. "Every day I'm continuously in pain," he told Sky News. "It's not something really sharp, although it does get to a certain point where it hurts quite a lot, but it's always there. It just doesn't leave, it's a companion to me, just always there." Read full story Source: Sky News. 18 May 2025- Posted
-
- Adolescent
- Surgeon
- (and 3 more)
-
News Article
CEO: TV show sparked ‘overwhelming’ regulator scrutiny
Patient Safety Learning posted a news article in News
An “overwhelming” number of regulators were involved with a trust after an undercover documentary exposed care failings, its chief executive has said. Channel 4 aired hidden camera footage from Essex Partnership University Foundation Trust mental health inpatient wards in 2022. This revealed staff sleeping on duty and concerns over use of restraints. Trust CEO Paul Scott said on Thursday: “Understandably, those with regulatory responsibilities were very interested in the Dispatches programme and our response to it. But the sheer volume of people who wanted some assurance that we were taking seriously and making improvements [was] overwhelming.” He estimated he had attended around 19 boards or equivalent structures to provide assurance from different angles. “Nineteen regulators over one organisation felt overwhelming.” Mr Scott made the comments during his evidence to the Lampard Inquiry, which is looking into thousands of mental health patient deaths in Essex between 2000 and 2023. The probe is expected to report its findings before the end of 2027. In his written submission, Mr Scott had mentioned the “complexity of the nature and oversight of regulation” facing trusts from multiple parties within health and social care. Read full story (paywalled) Source: HSJ, 16 May 2025- Posted
-
- Regulatory issue
- Mental health
- (and 3 more)
-
Content Article
The way in which healthcare organisations are expected to respond after patient safety events in England changed significantly in August 2022 when the new Patient Safety Incident Response Framework (PSIRF) was introduced. What has actually happened is that the new processes built around the use of the Learning Response Tools in general and for After Action Review (AAR) in particular, are very varied. In this article, Judy Walker looks at the the variation in executing AARs and why this risks jeopardising the very essence of the AAR. *This article was first published in The After Action Review Newsletter May 2025 written by Judy Walker Associates Ltd. The way in which healthcare organisations are expected to respond after patient safety events in England changed significantly in August 2022 when the new Patient Safety Incident Response Framework (PSIRF) was introduced. What has actually happened is that the new processes built around the use of the Learning Response Tools in general and for After Action Review in particular, are very varied This is not surprising and is not concerning, as the PSIRF is purposefully designed to empower healthcare providers to implement in the framework in the way that suits their context best. However, I am concerned that the variation is also being manifested in the approach taken within the execution of the AAR itself, which risks jeopardising the very essence of the AAR. One of the risks is to the quality of the engagement and accountability with those who are attending the AARs. It was an excellent article published by Psychological Safety, on the Spectra of Participation which explores these concepts that gave me the idea for a framework for describing what I have observed that is a concern. Participation doesn’t guarantee engagement Looking at the IAP2 and other frameworks, the article explores the idea that participation doesn’t always guarantee engagement. The quality of engagement is a direct result of the goal of the process and the amount of psychological safety present. This analysis got me thinking about creating a scale of participation to bring to life the variety seen in AARs and is designed to help those leading AARs to be clear on the what their goals are. This table below sets out the five levels of participation that I’ve developed. Involve, Facilitate and Empower are all possible and healthy uses of the After Action Review approach. Organisational requirements will impact on how the AAR approach is deployed in each context and the full “Empower” approach where AAR participants are given full scope to act on the learning and their own recommendations, may not be appropriate for AARs taking place within a PSIRF governed process. However, it is a legitimate and valuable approach in project teams and other contexts. The continuum When you look at the continuum, you can see there is a shift from left to right of the AAR Conductor having knowledge of the event to needing to have very little. The Inform position is one where the AAR Conductor already has knowledge and is inviting participants to contribute to enrich the knowledge already held. This is not genuine engagement and along with the Consult approach, can be experienced as a tokenistic application of the AAR. The Facilitate and Empower positions, are those where the AAR Conductor needs have little knowledge prior to the AAR since the work is centred around the participants’ contributions and responses the AAR questions alone. This ensures meaningful engagement with the participants and requires skill in creating the psychological safety for honest conversations and asking the searching questions. The Empower position is different in that the aim is not to hand back the responsibility for action and reporting to the AAR Conductor, but to enable the participants to be ready to take the learning forward. Examples of the types of questions asked along the continuum Inform – “Did you have enough staff on duty?”, “ Was the NatSSIPS process followed?” Consult – “How did the patient respond?”, “Why weren’t the police called?” Involve – “What else was happening on the ward at the time?”, “What might prevent this happening again?” Facilitate – “Communication between agencies has been mentioned a few times: what might improve communication between agencies in future?” “Which of these ideas would make most impact?” Empower – “What do you want to do with this learning?” What support do you need to put this into action?” In summary As an AAR Conductor, you have to operate within your organisations’ context but it is vital to build trust in the AAR process. You will do this by ensuring your actions match your stated intentions and you are transparent about the level of participation you’re aiming for. Getting this right isn’t just about the integrity and standardisation of the AAR approach, it is also about maximising the potential for improvements in patient safety. Those AARs where Involving, Facilitating and Empowering are the goal, increase the level of accountability for change owned by the participants. We know from the research that when staff are fully engaged in the AARs they attend, their behaviour changes and patients are safer as a result.- Posted
-
- Patient safety incident
- Investigation
- (and 4 more)
-
News Article
A surgeon was flagged as dangerous — she kept operating for ten years
Patient Safety Learning posted a news article in News
Hospital bosses were warned about an NHS surgeon almost nine years before she was eventually suspended over botched operations on children. A joint investigation by The Sunday Times and Sky News has discovered a confidential report written for managers at Cambridge University Hospitals Trust in 2016 that identified problems with the surgical technique and practice of Kuldeep Stohr, a paediatric orthopaedic surgeon. A series of recommendations were made in the report but Stohr was allowed to continue operating. Managers at the hospital told staff the investigation into Stohr had not raised any concerns. Almost a decade on, Stohr has been suspended by the trust after a new review identified at least nine children whose care “fell below the standard” expected. The trust has begun a review of 800 other patients, including around 560 children, 140 adults and 100 emergency patients, who were operated on by Stohr. It has also commissioned an investigation into what action was taken after the 2016 report. Read full story (paywalled) Source: The Times, 10 May 2025- Posted
-
- Paediatrics
- Surgeon
-
(and 2 more)
Tagged with:
-
News Article
Baby death NHS trust reaches 'turning point'
Patient Safety Learning posted a news article in News
Two maternity units in Kent have shown signs of improvements three years after a damning independent review found up to 45 babies might have survived if they had received better care, a report has said. The Care Quality Commission (CQC) report rated maternity services at William Harvey Hospital in Ashford and Queen Elizabeth The Queen Mother Hospital in Margate as good, two years after they were downgraded to inadequate. The CQC said "significant improvements" had been made at both units to safety, leadership, culture, the environment and staffing levels. Tracey Fletcher, chief executive of East Kent Hospitals University NHS Foundation Trust, said the report was "an important milestone in our continuing work to improve our services". Serena Coleman, CQC's deputy director of operations in Kent, said: "We found significant improvements and a better quality service for women, people using the service and their babies. "This turnaround in ratings across both services demonstrates what can be achieved with strong and capable leaders who focus on an inclusive and positive culture." Kaye Wilson, chief midwife for the South East at NHS England, said: "This report marks a turning point for services at East Kent and is the result of the commitment, determination and sheer hard work of midwives, obstetricians and the whole maternity team." Read full story Source: BBC News,15 May 2025 -
News Article
Charity boss slams 'reprehensible' health trusts
Patient Safety Learning posted a news article in News
Health trusts have repeatedly tried to prevent coroners from issuing Prevention of Future Death reports in order to protect their reputations, an inquiry has heard. Deborah Coles, director of the charity Inquest, told the BBC the "reprehensible" behaviour was a pattern "played out across the country" but was "exemplified" in Essex. She gave evidence at the Lampard Inquiry, which is looking into the deaths of more than 2,000 people being treated by NHS mental health services in Essex between 2000 and 2023. In her evidence to the inquiry, Ms Coles said the "lack of candour" on the part of mental health trusts in Essex was the reason a statutory public inquiry needed to be held. "It's difficult to say how traumatising that is for families when they sit in at an inquest… and then see legal representatives try and effectively stop a coroner from making a Prevention of Future Deaths report, external, which is ultimately about trying to safeguard lives in the future - and I find that reprehensible," she said. "We are talking here about trying to protect lives and also remember those who've died where those deaths were preventable." Read full story Source: BBC News, 13 May 2025- Posted
-
- Investigation
- Patient death
- (and 2 more)
-
News Article
A Northern Ireland nurse failed to properly manage a dying patient's pain on the last night of her life, a tribunal has heard. Veteran staff nurse Bernard McGrail has been issued with a four-month suspension order over his failings in dealing with an end-of-life care resident while on a night shift at a Spa Nursing Homes Group facility in July, 2021. A Nursing and Midwifery Council fitness to practice panel said Mr McGrail's misconduct had caused "emotional distress" to the family of the woman, identified as Resident A. It added: "There was a real risk of harm to Resident A through the inadequate management of their pain on their last evening." A remorseful and apologetic Mr McGrail admitted a series of allegations including: a failure to appropriately manage Resident A’s pain; failure to investigate whether Resident A’s syringe driver was working correctly and a failure to escalate that the alarm on Resident A’s syringe driver sounded repeatedly. Mr McGrail also admitted that without clinical justification, he administered a 5mg doses of Apixiban to Resident B on three dates on October 2020. And on occasions between April 2020 and May 2022 failed to administer and/or record the administration of named medications to six other residents. Read full story (paywalled) Source: Belfast Telegraph, 12 May 2025- Posted
-
- End of life care
- Medicine - Palliative
- (and 4 more)
-
News Article
A former health ombudsman has condemned mental health services for their handling of two vulnerable young men who died in their care. Sir Rob Behrens, who was parliamentary and health service ombudsman (PHSO) from 2017 to 2024, spoke at the Lampard Inquiry, which is examining the deaths of more than 2,000 people under mental health services in Essex over a 24-year period. Sir Rob said it was "a disgrace" how Essex Partnership University NHS Foundation Trust (EPUT) had failed in its care of 20-year-old Matthew Leahy, who died in 2012, and a 20-year-old man referred to as Mr R, who died in 2008. "This was the National Health Service at its worst and needed calling out," Sir Rob said. Sir Rob referred in his inquiry appearance to several reports made during his tenure, including "Missed Opportunities", which looked into the circumstances surrounding the deaths of Mr Leahy and Mr R. Mr Leahy was found unresponsive at the Linden Centre in Chelmsford. He reported being raped there just days before he died. Sir Rob told the inquiry the PHSO identified "19 instances of maladministration" in Mr Leahy's case by North Essex Partnership University NHS Foundation Trust - a predecessor to EPUT - including that his care plan was falsified. The former ombudsman said there had been "a near-complete failure of the leadership of this trust, certainly before it was merged" with South Essex Partnership Trust to become EPUT. "This was an indictment of the health service," he added. Read full story Source: BBC News, 6 May 2025- Posted
-
- Investigation
- Organisational Performance
- (and 3 more)
-
Content Article
Expectations of patient and family involvement in investigations of healthcare harm are becoming conventional. Nonetheless, how people should be involved, is less clear. Therefore, the “Learn Together” guidance was co-designed, aiming to provide practical and emotional support to investigators, patients and families. This study evaluated the use of the Learn Together guidance in practice—designed to support patient and family involvement in investigations of healthcare harm. Findings The guidance supported the systematic involvement of patients and families in investigations of healthcare harm and informed them how, why, and when to be involved across settings. However, within hospital Trusts, investigators often had to conduct “pre-investigations” to source appropriate details of people to contact, juggle ethical dilemmas of involving vs. re-traumatising, and work within contexts of unclear organisational processes and responsibilities. These issues were largely circumvented when investigations were conducted by an independent body, due to better established processes, infrastructure and resources, however independence did introduce challenge to the rebuilding of relationships between families and the hospital Trust. Across settings, the involvement of patients and families fluctuated over time and sharing a draft investigation report marked an important part of the process—perhaps symbolic of organizational ethos surrounding involvement. This was made particularly difficult within hospital Trusts, as investigators often had to navigate systemic barriers alone. Organisational learning was also a challenge across settings. Conclusions Investigations of healthcare harm are complex, relational processes that have the potential to either repair, or compound harm. The Learn Together guidance helped to support patient and family involvement and the evaluation led to further revisions, to better inform and support patients, families and investigators in ways that meet their needs (https://learn-together.org.uk). In particular, the five-stage process is designed to centre the needs of patients and families to be heard, and their experiences dignified, before moving to address organisational needs for learning and improvement. However, as a healthcare system, we call for more formal recognition, support and training for the complex challenges investigators face—beyond clinical skills, as well as the appropriate and flexible infrastructure to enable a receptive organisational culture and context for meaningful patient and family involvement. Related reading on the hub: The Learn Together programme (part A): co-designing an approach to support patient and family involvement and engagement in patient safety incident investigations- Posted
-
- PSIRF
- Patient safety incident
- (and 5 more)