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Showing results for tags 'Legal issue'.
Found 103 results
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NHS Resolution: Manual handling (19 October 2020)
Patient Safety Learning posted an article in Patient management
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Private hospital in Bradford placed in special measures over patient safety
Patient Safety Learning posted a news article in News
A hospital for men with learning disabilities has been placed in special measures after the Care Quality Commission (CQC) identified “serious risks to patient safety”. The CQC said it had also suspended its current rating of “good” for caring for Cygnet Woodside, Bradford, West Yorkshire, following an inspection in September. The commission said it carried out the unannounced inspection following allegations of abuse by staff towards a patient, which are subject to an ongoing police investigation. The hospital said it was “disappointed” with the CQC’s assessment, stressing that the inspection was triggered by its own management notifying the commission of a concern it had identified. It said the report “does not provide an entirely accurate representation” of the hospital. Dr Kevin Cleary, the CQC deputy chief inspector of hospitals and lead for mental health, said: “Our latest inspection of Cygnet Woodside found that the hospital was not ensuring its patients’ safety.” Cleary added: “The service showed warning signs that increased the likelihood of a closed culture developing. This would have put people at serious risk of coming to harm if we didn’t take action.” He said care was compromised because there was not always the right number or skill level of staff looking after patients. Read full story Source: Guardian, 23 December 2020 -
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RSM: In Conversation Live with Sir Robert Francis QC
Patient Safety Learning posted a calendar event in Community Calendar
untilSir Robert Francis QC, Retired Barrister (specialising in medical law) and Queen’s Counsel. Before his retirement from full-time practice earlier this year, Sir Robert sat as a Recorder (part-time Crown Court judge) and as a Deputy High Court Judge. Sir Robert will be joining Professor Roger Kirby (RSM President) for an interesting discussion on his wide-ranging legal career, including previous inquiries such as the Freedom to Speak Up Review. He will also be talking about patient quality and care in the UK, and his view on the COVID-19 pandemic. Register -
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Hospital may have broken law by failing to reveal errors led to boy’s death
Patient Safety Learning posted a news article in News
Great Ormond Street Hospital may have broken the law by failing to share information with parents that showed its errors had contributed to their son’s death, The Independent understands. The care watchdog is speaking to Great Ormond Street about its handling of an expert report into five-year-old Walif Yafi in 2017. It showed that the hospital’s failure to share results that showed a deadly infection had played a role in Walif’s death. But the boy’s parents were only told about the findings after inquiries by The Independent – months after settling a lawsuit with Great Ormond Street in which the trust denied responsibility. The Care Quality Commission is looking at concerns relating to duty of candour regulations, which require hospitals to be open and honest with families about mistakes made that result in serious harm to patients. Breaching the regulations is a criminal offence and can lead to prosecution. Read full story Source: The Independent, 7 December 2020 -
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Rebuilding Shattered Lives
Patient Safety Learning posted an article in Legal matters
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Great Ormond Street Hospital admits errors led to boy’s death
Patient Safety Learning posted a news article in News
Mistakes by Great Ormond Street contributed to the death of a five-year-old boy, the children’s hospital has admitted – just months after it concluded a legal case with his family in which it denied responsibility. The world-renowned children’s hospital failed to flag results of a crucial blood test, showing that Walif Yafi had a dangerous infection, to doctors at King’s College Hospital where he had been receiving treatment. He died a few weeks later, in September 2017. In September this year, Walif’s parents agreed an out-of-court settlement with Great Ormond Street, which admitted negligence but denied liability for the boy’s death. However, this week the hospital admitted an expert had reviewed the case ahead of the settlement and concluded its actions did contribute to Walif’s death. The hospital said it had been under no duty to share these results with Walif’s parents at the time. Walif had a liver transplant in 2012 after suffering cancer shortly after his birth, and was being overseen by Great Ormond Street as an outpatient, as well as by the transplant team at King’s College Hospital, in south London. On 24 August 2017, he had a routine blood test at Great Ormond Street, which showed he had an adenovirus infection – something that is common in children whose immune system is being suppressed by drugs, as Walif’s was because of his transplant. If untreated, the infection can be deadly. But the blood test result was not communicated to the team at King’s College Hospital. Shortly afterwards, Walif’s health deteriorated and he was admitted to hospital. He was transferred to King’s College Hospital a week later, and it was not until 7 September that the infection was confirmed. By this stage, he was severely unwell and, though he began anti-viral therapy, Walif suffered multiple organ failure from the spread of the infection. On 30 September, he suffered cardiac arrest and died. It was only when approached by The Independent this week that the trust revealed its expert had, in the course of negotiating the settlement with Walif’s parents, determined the hospital did materially contribute to the child’s death. Read full story Source: The Independent, 29 November 2020 -
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Demand for public inquiry into NHS mental health deaths to be debated by MPs
Patient Safety Learning posted a news article in News
A mother fighting for a public inquiry into the death of her son and more than 20 other patients at an NHS mental health hospital in Essex has won a debate in parliament after more than 100,000 people backed her campaign. On Monday, MPs in the House of Commons will debate Melanie Leahy’s petition calling for a public inquiry into the death of her son Matthew in 2012, as well as 24 other patients who died at The Linden Centre, a secure mental health unit in Chelmsford, Essex, since 2000. The centre is run by Essex Partnership University NHS Trust which has been heavily criticised by regulators over the case. A review by the health service ombudsman found 19 serious failings in his care and the NHS response to his mother’s concerns. This included staff changing records after his death to suggest he had a full care plan in place when he didn’t. Matthew was detained under the Mental Health Act but was found hanged in his room seven days later. He had made allegations of being raped at the centre, but this was not taken seriously by staff nor properly investigated by the NHS. The trust has admitted Matthew’s care fell below acceptable standards. In November, it pleaded guilty to health and safety failings linked to 11 deaths of patients in 11 years. Read full story Source: The Independent, 29 November 2020 -
Content ArticleQuestions healthcare leaders should consider as they work to innovate, design, and implement action toward improvement: How are you resourcing your organization to learn from failure? How do you ensure learning happens and is applied widely from the board room to the frontline? How are you partnering within your organisation and the broader healthcare community to empower in-house leaders to achieve improvements? How are you engaging decision-makers to commit to sustained improvement? How do you demonstrate your responsibility and accountability to engage with front-line staff and patients if the momentum for improvement initiatives is lagging? How are you tracking constant, emerging, and future operational, cultural, and clinical risks to prepare for them? How are you ensuring the transparency needed to drive learning and improvement?
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When things go wrong - Doctors in the dock: I experienced medical errors
Patient Safety Learning posted a calendar event in Community Calendar
untilWhen things go wrong - doctors in the dock series provides a unique opportunity to hear real patients discuss their experience of medical errors. Well-known witnesses of clinical errors will talk about their first-hand experiences, what happened, how they and their family had to deal with them, and how they have dealt with the aftermath in the most constructive way possible. Gain more experience and insight about the best way to deal with clinical errors as professionals, and from a patient perspective, and convert them into an opportunity for improvement for all involved, even leading to very successful careers. Register -
News ArticleThe Department of Health and Social Care (DHSC) has been criticised by the national health ombudsman for the ‘maladministration’ of a 2018 review into the death of a teenage girl under the care of one of England’s top specialist hospitals, HSJ can reveal. The Parliamentary and Health Service Ombudsman (PHSO) came to the conclusion after investigating a DHSC review into the 1996 death of 17-year-old Krista Ocloo which had been requested by her mother. Krista died at home of acute heart failure in December 1996. She had been admitted to the Royal Brompton Hospital with chest pains in January of that year. The PHSO report states her mother was told “there was no cause for concern” and that another appointment would be scheduled in six months. This follow-up appointment did not happen. The young woman’s death was considered by the hospital’s complaints process, an independent panel review and an inquiry into the hospital’s paediatric cardiac services. They concluded the doctor involved was not responsible for Krista’s death – though the paediatric services inquiry criticised the hospital for poor communication. A coroner declined to open an inquest into the case. Civil action against the hospital, brought by Ms Ocloo, found Krista’s death could not have been prevented. However, a High Court judge found that the failure to arrange appropriate follow-up by the RBH was “negligent”. A spokeswoman for PHSO said: “Our investigation found maladministration by the Department for Health and Social Care, which should have been more transparent in its communication. The department’s failure to be open and clear compounded the suffering of a parent who was already grieving the loss of her child.” A DHSC spokeswoman said: “We profoundly regret any distress caused to Ms Ocloo. “[The PHSO] report found that in communicating with Ms Ocloo the department’s actions were – in places – not consistent with relevant guidance. The department has writen to Ms Ocloo to apologise for this and provide further information about the review.” Read full story (paywalled) Source: HSJ, 12 November 2020
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EventThis Westminster Health Forum conference will focus on key issues for clinical negligence in the NHS and priorities for NHS resolution. The discussion is bringing together stakeholders with a range of key policy officials who are due to attend from DHSC; the Government Legal Department; HM Treasury; the MOJ and the NAO. The discussion at a glance: a patient safety culture - assessing progress and next steps in its development in the context of the NHS Patient Safety Strategy and the publication of the first Annual progress report COVID-19 - the impact on clinical negligence risk and increased clinical negligence claims the workforce - priorities for support through a period of unprecedented pressure legal costs - options for mitigation and policy. Register
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News ArticleA woman has been arrested after attempting to take her 97-year-old mother out of a care home for lockdown. Qualified nurse Ylenia Angeli, 73, wanted to care for her mother, who has dementia, at home. But when she told staff at the care home, they called the police who then briefly arrested Ms Angeli. The family have not been able to see their elderly relative for nine months, and decided to act ahead of the second national lockdown. Assistant Chief Constable Chris Noble, from Humberside Police, said: "These are incredibly difficult circumstances and we sympathise with all families who are in this position." "We responded to a report of an assault at the care home, who are legally responsible for the woman's care and were concerned for her wellbeing. We understand that this is an emotional and difficult situation for all those involved and will continue to provide whatever support we can to both parties." The incident came to light on the day the government announced new rules for families wishing to visit their loved ones in care homes. Under the guidance, issued hours before lockdown, families can meet relatives through a window or in a secure outdoor setting. Visits will need to be booked in advance, but the Department of Health and Social Care advice said care homes "will be encouraged and supported to provide safe visiting opportunities". All care home residents are allowed to receive visits from friends and family during the second national lockdown. Read full story Source: Sky News, 5 November 2020
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Content ArticleThe review looked back over the period from 2013 to 2016 and catalogues a number of failings and missed opportunities to address the situation. Among its findings are: More than 100 residents had concerns raised more than once. More than 200 safeguarding alerts were made for individuals but only 16 went through to an individual adult safeguarding conference. More than 80 whistleblower or similar reports were made concerning issues that put residents at risk. 44 inspections were undertaken at Morleigh Group homes in the three-year period, the vast majority identifying breaches. There was a period of at least 12 months when four of the homes had no registered manager in place. During the three-year period reviewed the police received 130 reports relating to the care homes. In total there are 15 recommendations made by the review which have been accepted by Cornwall Council and the Safeguarding Adults Board. These include changes to contract management for the provision of care services so that they link with safeguarding and inspections. On whistleblowing the review says there needs to be a clear whistleblowing process for all staff, residents, families and professionals to follow and to ensure that information is shared across all agencies. Other recommendations include better enforcement to ensure action is taken when breaches are identified. And it calls for a “front door” for all alerts made about care providers so that there is no confusion about who should take responsibility to deal with concerns.
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Inquests, indemnity and incidents in primary care
Clive Flashman posted a calendar event in Community Calendar
untilThis Royal Society of Medicine meeting will focus on some of the key medico-legal issues that impact GPs, primary care and patient safety, with a specific emphasis on inquests, clinical negligence and incidents. This comprehensive programme will review and explore the latest legal and regulatory developments from national leaders in each of these fields. Delegates will gain an understanding of: The role of coroners and inquests, what to expect and what GPs and those working in primary care need to do to prepare and actively learn from deaths. The role of Medical Examiners and how they will impact on primary care. The support, including education and training, available to GPs in dealing with medico-legal issues and how to access practical support (e.g. via the Medical Defence Organisations) when necessary. The role of NHS Resolution and the Clinical Negligence Scheme for GPs (CNSGP) and their impact upon GPs and patient safety. Developments in learning from incidents in primary care, including feedback from the CQC regarding best practice and areas for improvement. Book here -
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 ArticleA major acute trust has confirmed the health service inspectorate has begun a criminal investigation into three incidents at its hospitals. University Hospitals Birmingham FT told HSJ the Care Quality Commission (CQC) has started a criminal investigation into incidents involving potential errors around the provision of anti-coagulant medication. The trust received a letter from the CQC this month informing it that the regulator has begun the investigation under regulation 22 of the Health and Social Care Act 2008 (regulated activities) regulations 2014. The incidents happened at Queen Elizabeth Hospital in Birmingham and Good Hope Hospital — the trust’s two main sites. Regulation 22 says: “In order to safeguard the health, safety and welfare of service users, the registered person must take appropriate steps to ensure that, at all times, there are sufficient numbers of suitably qualified, skilled and experienced persons employed for the purposes of carrying on the regulated activity.” The CQC launched a prosecution into East Kent Hospitals University FT this month for failing to meet fundamental standards of care. The regulator also successfully prosecuted University Hospitals Plymouth Trust in September after it pleaded guilty to breaching the duty of candour. Read full story (paywalled) Source: HSJ, 23 October 2020
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RSM. Consenting safely: Can the consultation room survive the court room?
Patient Safety Learning posted a calendar event in Community Calendar
Whether your role is in the NHS or in private healthcare, it is vitally important to take consent for any intervention safely. This webinar brings together clinical and legal perspectives, advising healthcare professionals of all levels how to take consent safely to avoid litigation and improve patient safety. Receive guidance from NHS Consultant, Michael Kelly, who has provided expert witness evidence at Court, combined with input from Andrew Bershadski, a highly experienced Barrister who has proceeded to Trial and won for the medical profession on a number of separate informed consent cases. Ed Glasgow, a Partner specialising in Healthcare Law, will Chair the event, which it is hoped will provide valuable practical insight.
