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Content ArticleChildren being subjected to lethal medical experiments sounds like the plot of a dystopian horror film. Yet that is exactly what happened in the UK in the 1970s and 80s. New documents seen last week by the BBC reveal the extent to which children with haemophilia and other blood clotting disorders were enrolled in clinical trials, often without their parents’ consent. Most of them were infected with HIV or hepatitis C as a result of being treated with blood products that doctors knew could kill them. At one boarding school for boys with haemophilia used by the doctors conducting these trials, Treloar College in Hampshire, 75 out of the 122 pupils who attended between 1974 and 1987 have died as a result of their HIV or hepatitis C infections. The independent inquiry on the contaminated blood scandal estimated that 1,250 people contracted both HIV and hepatitis C as a result of these agents, and between 2,400 and 5,000 people hepatitis C alone. Others contracted these viruses after receiving blood transfusions following surgery or childbirth; it is thought that up to 100 people were infected with HIV this way, and 27,000 people with hepatitis C. Around 2,900 people have died so far. One gets a sense of the horrific trauma the state inflicted on people by reading the evidence those affected gave the inquiry.
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News Article
Surgeon at NHS hospital promoted despite allegedly assaulting staff
Patient Safety Learning posted a news article in News
Managers at a hospital where police are investigating dozens of deaths promoted a consultant surgeon months after they allegedly assaulted junior doctors during surgery, the Guardian can reveal. Two female registrars at the University Hospitals Sussex NHS trust in Brighton sent written statements to the trust’s chief medical officer in March 2022 detailing how they were allegedly assaulted by the surgeon in separate incidents as they helped to operate on patients, leaked documents reveal. The incidents were not reported to the police and are not part of a separate Sussex police investigation into allegations of medical negligence and cover-up at the trust’s surgery and neurosurgery departments, involving at least 40 deaths and more than 60 incidents of patient harm. The consultant surgeon was alleged to have slapped one of the registrars across her face with the back of a hand. The other registrar claimed she was slapped on the hand and had surgical instruments snatched from her by the same person. The trust said its investigation found the surgeon’s actions were inappropriate but did not constitute assault and were taken in the interest of patient safety. The surgeon apologised to the registrars. The investigation concluded that, in the first incident, the registrar’s visor was blocking the consultant’s field of vision during surgery, causing them to instinctively push the visor away. In the second incident, it concluded that an instrument was taken from the registrar’s hand during a procedure for patient safety purposes. After these events, other registrars threatened to refuse to go into theatre with the consultant and pointed to other alleged examples of their bullying, sources claim. They had expected the consultant to be disciplined, given time off work and supported in changing their behaviour, the sources added. Instead, within a year of the complaints, the consultant was given a leadership role in the surgery department, despite the trust’s stated policy of zero tolerance for violence and aggression. Read full story Source: The Guardian, 22 April 2024 -
News Article
Infected blood scandal: Children were used as 'guinea pigs' in clinical trials
Patient Safety Learning posted a news article in News
The true scale of the number of medical trials using infected blood products on children in the 1970s and 80s has been revealed by documents seen by BBC News. They reveal a secret world of unsafe clinical testing involving children in the UK, as doctors placed research goals ahead of patients' needs. They continued for more than 15 years, involved hundreds of people, and infected most with hepatitis C and HIV. The trials involved children with blood clotting disorders, when families had often not consented to them taking part. The majority of the children who enrolled are now dead. Documents also show that doctors in haemophilia centres across the country used blood products, even though they were widely known as likely to be contaminated. Luke O'Shea-Phillips, 42, has mild haemophilia - a blood clotting disorder that means he bruises and bleeds more easily than most. He caught the potentially lethal viral infection hepatitis C while being treated at the Middlesex Hospital, in central London, which was administered because of a small cut to his mouth, aged three, in 1985. Documents seen by the BBC suggest he was deliberately given the blood product - which his doctor knew might have been infected - so he could be enrolled in a clinical trial. Read full story Source: BBC News, 18 April 2024 -
News Article
Met investigates 'stem-cell autism cure' claim
Patient Safety Learning posted a news article in News
The Met Police has launched an investigation over concerns about stem-cell injections being offered to children as a cure for autism. The Royal Borough of Greenwich told BBC London it was aware of concerns surrounding "experimental procedures" on autistic children. The Met said it was investigating "a reported fraud relating to the provision of medical services". The National Autistic Society said there was no "cure" for autism. Greenwich Council said it issued a warning to schools and nurseries in the borough after it became aware of concerns. A spokesperson said the authority had recently been made aware of concerns that "an individual claiming to be a doctor plans to visit the UK to offer dangerous, experimental procedures on children with autism". "We understand that this person is proposing the transfer of bone marrow and spinal fluid to the brain by injection," the spokesperson said. "This unlicensed procedure poses a significant threat to life and there is no evidence of any benefits. "The safety and welfare of our children and young people is of the utmost importance." Read full story Source: BBC News, 17 April 2024 -
News Article
Seven more avoidable sepsis deaths spark coroner warnings
Patient Safety Learning posted a news article in News
Preventable deaths of seven people from sepsis – including four children – have prompted coroners to flag major concerns about NHS services’ management of the condition. Since the start of March, six English coroners have sent formal warnings to trusts, NHS England and the government warning of systemic failures to spot sepsis and delays in administering antibiotic treatments. It comes after an HSJ investigation in February uncovered more than 30 avoidable deaths from sepsis, and undertook analysis of internal figures revealing repeated failures by NHS trusts to provide prompt treatment. Coroner warnings since March include: Two notices were sent this week by Nottingham assistant coroner Elizabeth Didcock to Sherwood Forest Hospitals Foundation Trust, raising concerns over its ability to provide safe paediatric care following the deaths of 10-week-old Tommy Gillman and five-year-old Meha Carneiro from sepsis; A warning from earlier in April criticising University Hospitals Birmingham FT for its failure to treat 56-year-old Tracey Farndon’s sepsis and low blood pressure. Read full story (paywalled) Source: HSJ, 17 April 2024 -
News Article
GPs and patients invited to share views on legal ‘duty of candour’
Patient Safety Learning posted a news article in News
The Government is inviting views on how well GP practices and other NHS organisations are complying with their legal duty of candour when things go wrong. Patients and health professionals are being asked whether the statutory duty is well understood and adequately regulated by the CQC. Under the statutory duty of candour, introduced for all CQC-registered providers in 2015, GP practices must be open and honest with their patients when something goes wrong and has caused harm. In December, the Department of Health and Social Care (DHSC) announced a review into whether healthcare providers are following the duty of candour rules. This was in response to concerns that the duty is not always being met and that there is variation in how the rules are being applied. The DHSC has published its ‘call for evidence’ to gather views on how well the duty of candour obligation is working for both patients and health professionals. Patients have been asked whether GP practices and other providers ‘demonstrate meaningful and compassionate engagement’ with patients who have been affected by an incident. The call for evidence also asks for views on whether the criteria for triggering the duty are appropriate and well understood by staff. Read full story Source: Pulse, 16 April 2024 -
Content ArticleThose who use any type of health or social care service have a right to be informed about all elements of their care and treatment. Health and social care providers have that fundamental responsibility to be open and honest with those who are under their management and care. In particular, when things go wrong during the provision of care and treatment, patients and service users and their families or caregivers expect to be informed honestly about what happened, what can be done to deal with any harm caused, and to know what will be done to prevent a recurrence to someone else. In November 2014, the government introduced a statutory (organisational) duty of candour for NHS trusts and NHS foundation trusts via Regulation 20 of the Health and Social Care Act 2008. In essence, the duty places a direct obligation upon trusts to be open and honest with patients and service users, and their families, when something goes wrong that appears to have caused or could lead to moderate harm or worse in the future (known as a ‘notifiable safety incident’). The Department of Health and Social Care (DHSC) are seeking views on the statutory duty of candour for health and social care providers in England. This call for evidence closes at 11:59 pm on 29 May 2024.
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News ArticleA regulator overseeing 340,000 professionals breached a psychologist’s human rights by letting their fitness-to-practise case go on for a decade, amid widespread very long delays, it has emerged. A judgment from the Health and Care Professions Tribunal said the “lamentable” situation for the registrant was down to the “disgraceful… manner in which the Healthcare Professions Council dealt with their case”. The HCPC oversees professional standards for several groups including radiographers, paramedics, physiotherapists, occupational therapists, and operating department practitioners. If a complaint is made about a registrant, it can investigate and refer them to the tribunal, which can strike them off. The Society of Radiographers said the current speed of cases was “simply unacceptable” and its director of industrial strategy Dean Rogers added: “Our members spend too long working — and living — under the intense scrutiny of their regulator, often under the control of an interim order restricting or even preventing their practise while investigations drag on.” Read full story (paywalled) Source: HSJ, 17 April 2024
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Content ArticleWe know from several reports, reviews, and inquiries over recent years that the patient and family voice has not been heard. These voices are essential to learning and improvement because of their unique insight into how care is delivered. To improve safety we must understand its reality as experienced by patients. In a blog for the Patient Safety Commissioner website, Rosie Benneyworth, interim chief executive officer of the Health Services Safety Investigations Body (HSSIB), explains how HSSIB involves families in its investigations.
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Content ArticleWhen operating on a patient, a surgeon may put swabs (pieces of gauze that come in a range of types, shapes and sizes) into the patient’s body to absorb bodily fluids such as blood. The operating theatre team count the swabs in and out, using a process known as reconciliation, to ensure all swabs are accounted for at the end of the operation. However, sometimes a swab can be unintentionally retained (left inside a patient’s body). This type of patient safety incident is known as a ‘Never Event’ – that is, an event that NHS England considers to be wholly preventable. This report is intended for healthcare organisations, policymakers, and the public to help improve patient safety in relation to retained swabs following invasive procedures.
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News Article
Causes of death to be scrutinised in revamp of death certificates
Patient Safety Learning posted a news article in News
Public protection and support for bereaved families are at the heart of a government overhaul of how deaths are certified. From September, medical examiners will look at the cause of death in all cases that haven’t been referred to the coroner in a move designed to help strengthen safeguards and prevent criminal activity. They will also consult with families or representatives of the deceased, providing an opportunity for them to raise questions or concerns with a senior doctor not involved in the care of the person who died. The changes demonstrate the government’s commitment to providing greater transparency after a death and will ensure the right deaths are referred to coroners for further investigation. Health Minister, Maria Caulfield said: Reforming death certification is a highly complex and sensitive process, so it was important for us to make sure we got these changes right. At such a difficult time, it’s vital that bereaved families have full faith in how the death of their loved one is certified and have their voices heard if they are concerned in any way. The measures I’m introducing today will ensure all deaths are reviewed and the bereaved are fully informed, making the system safer by improving protections against rare abuses. From 9 September 2024 it will become a requirement that all deaths in any health setting that are not referred to the coroner in the first instance are subject to medical examiner scrutiny. Welcoming the announcement today, Dr Suzy Lishman CBE, Senior Advisor on Medical Examiners for Royal College of Pathologists, said: “As the lead college for medical examiners, the Royal College of Pathologists welcomes the announcement of the statutory implementation date for these important death certification reforms. “Medical examiners are already scrutinising the majority of deaths in England and Wales, identifying concerns, improving care for patients and supporting bereaved people. The move to a statutory system in September will further strengthen those safeguards, ensuring that all deaths are reviewed and that the voices of all bereaved people are heard.” Read full story Source: Gov.UK, 15 April 2024 -
News Article
Adult transgender clinics in England face inquiry into patient care
Patient-Safety-Learning posted a news article in News
Adult transgender clinics in England are facing a Cass-style inquiry into how they treat patients after whistleblowers raised concerns about the care they provide. NHS England has announced that it is setting up a review of how the seven specialist services operate and deliver care after past and present staff shared misgivings privately during a previous investigation. As a first step, NHS England will send “external quality improvement experts” into each of the clinics to gather evidence about how they care for patients, to help guide the inquiry’s direction. The move follows the publication on Wednesday of a landmark review by Dr Hilary Cass, a former president of the Royal College of Paediatrics and Child Health, which recommended sweeping changes in the way that the health service treats under-18s who are unsure about their gender identity. In a letter responding to Cass’s report, which NHS England sent on Tuesday to the seven trusts that host adult gender dysphoria clinics (GDCs), it told them: “We will be launching a review into the operation and delivery of the adult GDCs, alongside the planned review of the adult gender dysphoria service specification.” Robbie de Santos, director of campaigns and human rights at Stonewall, an LGBT rights charity, said: “Gender healthcare for adults in the UK is, simply put, not fit for purpose. Many trans adults are being forced to go private at great personal expense to avoid waiting lists in excess of half a decade. We would welcome a review aimed at tackling this unacceptable state of affairs and building capacity into the system.” Read full story Source: Guardian, 10 April 2024 -
News Article
Deaths inquiry extended to last three years
Patient-Safety-Learning posted a news article in News
A statutory inquiry into deaths of mental health patients will now cover fatalities that took place as late as December 2023. The inquiry’s investigations are focused “on the trusts which provide NHS mental health inpatient care in Essex”. This includes: “Essex Partnership University Foundation Trust, and the North East London Foundation Trust and their predecessor organisations, where relevant.” NELFT was not specifically mentioned in the original terms of reference although the inquiry told HSJ it had been within the original scope. The inquiry will also now cover deaths of NHS patients from Essex who died when under the care of private sector providers. The inquiry’s previous terms of reference covered a period ending in 2020. However, the inquiry’s chair, Baroness Kate Lampard, proposed extending the inquiry’s scope last year due to “ongoing concerns” over services at EPUFT. Read full story (paywalled) Lampard Inquiry: Terms of reference Source: HSJ, 11 April 2024 -
Content Article
Lampard Inquiry: terms of reference (10 April 2024)
Mark Hughes posted an article in Other reports and inquiries
The Lampard Inquiry will seek to understand the events that led to the tragic deaths of mental health inpatients under the care of NHS trusts in Essex between 2000 and 2023. This document outlines the terms of reference set following consultation with the chair of the inquiry, Baroness Lampard. -
News Article
Man suffered psychosis after Trust failed to inform him of steroids side-effects
Patient Safety Learning posted a news article in News
A man who suffered a psychotic episode which lasted for weeks was not fully informed about potential extreme side-effects of taking steroids medication, England’s health service Ombudsman has found. Andrew Holland was prescribed steroids in early January 2022 by Manchester Royal Eye Hospital after losing vision in his left eye and suffering a severe infection in his right eye. The 61-year-old from Manchester was given the medication as treatment for eye inflammation, but soon began suffering from disrupted sleep and severe headaches. These side-effects developed into more serious ones, including becoming aggressive, psychotic, and inexplicably wandering the street at different times of the day and night. After several hospital visits due to his symptoms, Andrew attended Manchester University NHS Foundation Trust’s emergency department in mid-January with a severe headache and later became an inpatient. He was diagnosed with steroid induced psychosis, with symptoms including hallucinations, insomnia and behaviour changes. Though no failings were found with Manchester University NHS Foundation Trust in prescribing Andrew with steroids for the eye condition, the Ombudsman discovered a missed opportunity to fully inform him of potential extreme side-effects. He was therefore unable to make a fully informed decision about whether to take them or not. The Trust apologised for an ‘unsatisfactory experience’. However, the Ombudsman found relevant guidelines were not followed. Moreover, there had been no acknowledgement of mistakes in communication about the side-effects. Nor was any attempt made to correct them. Read full story Source: PSHO, 10 April 2024 -
News Article
Thousands of children unsure of gender identity ‘let down by NHS’, report finds
Patient Safety Learning posted a news article in News
Thousands of vulnerable children questioning their gender identity have been let down by the NHS providing unproven treatments and by the “toxicity” of the trans debate, a landmark report has found. The UK’s only NHS gender identity development service used puberty blockers and cross-sex hormones, which masculinise or feminise people’s appearances, despite “remarkably weak evidence” that they improve the wellbeing of young people and concern they may harm health, Dr Hilary Cass said. Cass, a leading consultant paediatrician, stressed that her findings were not intended to undermine the validity of trans identities or challenge people’s right to transition, but rather to improve the care of the fast-growing number of children and young people with gender-related distress. But she said this care was made even more difficult to provide by the polarised public debate, and the way in which opposing sides had “pointed to research to justify a position, regardless of the quality of the studies”. “There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour. This must stop.” Read full story Source: The Guardian, 10 April 2024 -
Content ArticleDr Hilary Cass has submitted her final report and recommendations to NHS England in her role as Chair of the Independent Review of gender identity services for children and young people. The Review was commissioned by NHS England to make recommendations on how to improve NHS gender identity services, and ensure that children and young people who are questioning their gender identity or experiencing gender dysphoria receive a high standard of care, that meets their needs, is safe, holistic and effective. The report describes what is known about the young people who are seeking NHS support around their gender identity and sets out the recommended clinical approach to care and support they should expect, the interventions that should be available, and how services should be organised across the country. It also makes recommendations on the quality improvement and research infrastructure required to ensure that the evidence base underpinning care is strengthened.
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News Article
Urology inquiry: Waiting lists greatest source of harm
Patient Safety Learning posted a news article in News
A former consultant at the Southern Health Trust has told an inquiry into urology services that waiting lists are the "greatest source of patient harm". The inquiry was established in 2021 and is examining the trust's handling of urology services prior to May 2020. Aidan O'Brien became a consultant urologist in Craigavon Area Hospital in July 1992. His work is at the centre of the inquiry. Giving evidence on Monday, he said waiting list figures highlighted what "myself and my colleagues [have said] for decades" and described it as a "grossly inadequate service". "If you look at four-and-a-half years for urgent surgery, it is appalling," he told the inquiry. "I don't have a magic solution to the current situation, which is dire." Read full story Source: BBC News, 8 April 2024 -
Content Article
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Richard von Abendorff, an outgoing member of the Advisory Panel of the Healthcare Safety Investigation Branch (HSIB), has written an open letter to incoming Directors on what the new Health Services Safety Investigations Body (HSSIB) needs to address urgently and openly to become an exemplary investigatory safety learning service and, more vitally, how it must not contribute to compounded harm to patients and families. The full letter is attached at the end of this page.- Posted
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Content ArticleBatches of some products made by Legency Remedies Pvt Ltd have been found to contain a bacteria called Ralstonia pickettii (R. pickettii). All potentially affected batches are being recalled following an MHRA investigation.
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News Article
Trust appoints chair to lead independent suicides review
Patient Safety Learning posted a news article in News
A trust has appointed a chair to lead an independent review into dozens of suicides that was sparked by allegations of record tampering. Following questions from HSJ about the review’s chair and terms of reference, Cambridgeshire and Peterborough Foundation Trust said Ellen Wilkinson, a former medical director at Cornwall Partnership FT and its current chief clinical information officer, would chair the review. The trust, which is looking for a substantive CEO following Anna Hills’ departure earlier this year, said the review “will not examine individual patient deaths but will take a thematic approach and look at the learnings we can take from these tragic incidents”. The trust told HSJ the terms of reference for the review of more than 60 cases of patients who died by suicide since 2017 were still being finalised. The decision not to investigate individual cases has been criticised by the whistleblower whose concerns prompted the review in the first place, as HSJ reported in October. While an employee of the trust, Des McVey, a consultant nurse and psychotherapist, carried out an investigation in July 2021 into the case of 33-year-old Charles Ndhlovu, who died by suicide in 2017. Mr McVey told HSJ his review found Mr Ndhlovu’s patient record had been tampered with and “his care plans were created on the day after his death” – a conclusion he stands by. Read full story (paywalled) Source: HSJ, 3 April 2024 -
News Article
NHS watchdog to review patient safety at Glasgow A&E department
Patient Safety Learning posted a news article in News
Patient safety in the Accident & Emergency unit at the Queen Elizabeth University Hospital in Glasgow will be reviewed by an NHS watchdog. Healthcare Improvement Scotland (HIS) was first contacted by 29 A&E doctors in May 2023 warning that safety was being "seriously compromised". HIS last month apologised for not fully investigating their concerns. The review will consider leadership and operational issues and how they may have impacted on safety and care. In the letter to HIS, the 29 consultants highlighted treatment delays, "inadequate" staffing levels and patients being left unassessed in unsuitable waiting areas. They claimed this resulted in "preventable patient harm and sub-standard levels of basic patient care". The doctors also said critical events had occurred including potentially avoidable deaths. The consultants said repeated efforts to raise the issues with health board bosses "failed to elicit any significant response". Read full story Source: BBC News, 4 April 2024 -
News Article
Catherine died on the operating table. Now police are investigating
Patient Safety Learning posted a news article in News
Catherine O’Connor was 17 when she died, having lost 14 litres of blood during high-risk surgery on her back. At her inquest, the surgeon who operated on her, John Bradley Williamson, told the coroner the procedure at Salford Royal Hospital in Greater Manchester had “progressed uneventfully” and “the blood loss was perhaps a little higher than one would usually anticipate but was certainly not extreme”. The coroner recorded a verdict of death by misadventure. Now Greater Manchester police are examining O’Connor’s death, in February 2007, and whether Williamson misled the coroner during the inquest in September that year. Catherine's family are now demanding a new inquest into her death in 2007. This is because in the days after O’Connor’s death, Williamson sent an internal letter to the head of the hospital’s haematology department, Simon Jowitt, describing the surgery as “difficult” and having involved “a catastrophic haemorrhage”. Williamson had also ignored advice to have a second surgeon present during the operation. Officers led by Detective Inspector Michael Sharples have commissioned two expert reports and sought advice from the Crown Prosecution Service ahead of a meeting with the coroner, who has been asked to consider reopening O’Connor’s inquest. Read full story (paywalled) Source: The Times, 31 March 2024 -
News ArticleFamilies have been told they will have to prove liability for the harm caused to mothers and children at East Kent Hospitals University Foundation Trust before getting compensation. This is despite the inquiry having examined each case in detail and concluding 45 babies could have survived, while 12 who sustained brain damage could have had a different outcome. It also determined 23 women who either died or suffered injuries might have had better outcomes had care been given to “nationally recognised” standards. However, NHS Resolution – which handles claims for clinical negligence – now says families must prove causation and a breach of duty of care before any compensation can be made. This stipulation has been made even in cases where the inquiry found different treatment would have been reasonably expected to make a difference to the outcome. The investigation into the trust’s maternity care led by Bill Kirkup reported 18 months ago. Speaking to HSJ, its author said: “I am disappointed that East Kent families are facing these problems after everything that has happened to them. Of course, it is true that the independent investigation panel was not in a position to rule on negligence, but we did provide a robust clinical assessment of each case. “I would have hoped that this could be taken into account in deciding to offer early settlement instead of a protracted dispute. It seems sad that a more compassionate approach has not been adopted.” Read full story (paywalled) Source: HSJ, 2 April 2024
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Content ArticleAs Rob Behren steps down as the Parliamentary and Health Service Ombudsman (PHSO) he records an episode of Radio Ombudsman, reflecting on his seven years in office. He also tells us about his early life, his career before PHSO and shares his future plans.
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