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News Article
Wynter Andrews: Trust faces fine in baby death prosecution
Patient_Safety_Learning posted a news article in News
A hospital trust is facing a fine in a criminal prosecution over the death of a baby. The Care Quality Commission (CQC) is prosecuting Nottingham University Hospitals (NUH) NHS Trust over the death of Wynter Andrews. Wynter died 23 minutes after she was born by Caesarean section in September 2019 at the Queen's Medical Centre. The prosecution is one of only two the CQC has brought against an NHS maternity unit. The trust is due to face sentencing at Nottingham Magistrates' Court later. Read full story Source: BBC News, 25 January 2023 -
News Article
Harlow hospital suspends gas and air over nitrous oxide levels
Patient Safety Learning posted a news article in News
A hospital has stopped using gas and air in its maternity unit to "protect our midwifery and medical team". The Princess Alexandra Hospital in Harlow, Essex, said the decision followed tests on nitrous oxide levels. It said it would temporarily suspend the use of Entonox while additional safety equipment was installed. Giuseppe Labriola, director of midwifery, said: "There is no risk to mothers, birthing people, their partners and babies." Other hospitals have previously temporarily suspended the use of gas and air in recent months including Basildon and Ipswich. Read- Posted
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- Oxygen / gas / vapour
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News Article
Shrewsbury maternity scandal: Pay out over boy's brain injury
Patient Safety Learning posted a news article in News
The health trust behind the worst maternity scandal in NHS history has accepted responsibility for a boy's brain injury. Adam Cheshire, 11, contracted a Group B Strep (GBS) infection following his birth at the Royal Shrewsbury Hospital in 2011. A High Court judge approved a pay out from Shrewsbury and Telford Hospitals NHS Trust (SaTH) to provide special care for the rest of his life. His case was examined as part of senior midwife Donna Ockendon's investigation into SaTH which found catastrophic failures might have led to the deaths and life-changing injuries of hundreds of bab- Posted
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News Article
‘Insufficient leadership’ as maternity unit drops two ratings to ‘inadequate’
Patient Safety Learning posted a news article in News
Inspectors raised serious concerns around leadership and safety at Lister Hospital in Stevenage, run by East and North Hertfordshire Trust, when they visited in October. The maternity service was also rated inadequate for leadership. The CQC also raised concerns about staffing shortages, infection prevention control, care records, cleanliness, waiting times and training. The inspection did, however, find staff worked well together, managers monitored the effectiveness of the service and findings were used to make improvements. Carolyn Jenkinson, the CQC’s head of hospital inspec- Posted
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Content Article
The Independent Medicines and Medical Devices Safety (IMMDS) Review examined the response of the healthcare system in England to the harmful side effects of three medical interventions: hormone pregnancy tests, sodium valproate and pelvic mesh implants. These interventions have resulted in a truly shocking degree of avoidable harm to patients over a period of decades, with the Review describing the healthcare system’s response to this as “disjointed, siloed, unresponsive and defensive."[1] Over two years on from the publication of the IMMDS Review’s report, First Do No Harm, the Health an- Posted
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Content Article
This report follows on from an evidence session held by the Select Committee on the 13 December 2022 to assess the Government’s progress against recommendations made in the Independent Medicines and Medical Devices Safety (IMMDS) report, First Do No Harm. This featured contributions from the Government Minister Maria Caulfield MP, patients and patient groups, and representatives from NHS England and the Medicines and Healthcare products Regulatory Agency (MHRA). Summary of the reports recommendations The Government should: Urgently ensure that the accepted recommendations 6 an- Posted
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- Medical device
- Medication
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News Article
Basildon Hospital maternity staff exposed to 30 times legal gas limit
Patient Safety Learning posted a news article in News
Staff at a maternity unit were exposed to almost 30 times the legal workplace exposure limit for nitrous oxide, documents have shown. Testing at Basildon Hospital revealed the levels more than 16 months before colleagues were informed. The Royal College of Midwives said its members there were considering legal action. Routine testing of the maternity suite in June 2021 revealed nine staff members had been exposed to excess nitrous oxide levels during the course of their shifts. Three had readings of more than 1,000 parts per million (ppm) of the gas, while a fourth recorded- Posted
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News Article
Patient experiences of maternity care in England 'deteriorating'
Patient Safety Learning posted a news article in News
Fewer women who gave birth in NHS maternity services last year had a positive experience of care compared to 5 years ago, according to a major new survey. The Care Quality Commission’s (CQC) latest national maternity survey report reveals what almost 21,000 women who gave birth in February 2022 felt about the care they received while pregnant, during labour and delivery, and once at home in the weeks following the arrival of their baby. The findings show that while experiences of maternity care at a national level were positive overall for the majority of women, they have deteriorated in- Posted
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- Maternity
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Content Article
CQC: Maternity survey 2022
Patient Safety Learning posted an article in Maternity
At a national level the 2022 maternity survey shows that people's experiences of care have deteriorated in the last 5 years. Positive results Hospital discharge Since 2017, there has been a positive upward trend for women and other people who had recently given birth reporting that there was no delay with their discharge from hospital, from 55% to 62% in 2022. Mental health support Support for mental health during pregnancy is improving, although there remains room for further improvement. Nearly three-quarters of women and other pregnant people (71%) said -
News Article
Alarm raised at decline in women’s maternity experiences in England
Patient-Safety-Learning posted a news article in News
The Care Quality Commission (CQC) has sounded the alarm over a “concerning decline” in women’s experiences with maternity services. Fewer women feel they always got the help they needed during labour and birth, many were disappointed at the amount of time their partners could stay with them after the delivery of their babies, and a significant number reported that they did not feel listened to when they raised concerns. The CQC said it has noticed a “deterioration” over the last five years in the ratings women gave their care. It came as a major new national poll showed a “stat -
News Article
Five million children worldwide die before fifth birthday, says UN
Patient-Safety-Learning posted a news article in News
Five million children worldwide died before their fifth birthday in 2021, with almost half (47%) dying during their first month, according to new UN figures. Most of the deaths could have been prevented with better healthcare, say campaigners, adding that deaths among newborn babies haven’t reduced significantly since 2017. Children born in sub-Saharan Africa are 15 times more likely to die in childhood than children in Europe and North America. UN figures also show that 1.9 million babies were stillborn during 2021, more than three-quarters (77%) in sub-Saharan Africa and in so- Posted
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- Children and Young People
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Content Article
Key findings Almost everywhere in the world, a child born today has a better chance at surviving to age 5 than in 1990, but inequities persist among and within countries Divergent chances of survival start from the earliest ages Globally and across all regions, the probability of dying between the ages of 5 and 24 is lower than for children under 5 years old, yet more than 2 million children, adolescents and youth aged 5—24 died in 2021 -
Content Article
January 2023 - Dementia friendly ward, National Audit for Inpatient Falls (NAIF), investigation training, CQUINS, ePMA, Health Visitor teams. patient-safety-newsletter-janaury2023.pdf December 2022 - Supporting hydration (HCSW Innovation Idea project), deteriorating patient thematic review, investigation training, checking the right saline, Professional Nurse Advocacy, Medical Device Safety Lead. patient-safety-newsletter-december2022.pdf November 2022 - Reducing the use of fall alarms, wound photography, defining levels of assistance when moving patients, Duty of Candour.- Posted
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- Healthcare
- Falls
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News Article
'Keep mums and babies safe by improving digital medical records'
Patient Safety Learning posted a news article in News
With the distressing spate of news reports about mums and babies who weren’t kept safe in hospital, an initiative in the Midlands to improve patient safety in maternal and acute care settings comes as a relief. The newly announced Midlands Patient Safety Research Collaboration will bring together NHS trusts, universities and private business to evaluate how digital tools can help clinical decision making and reduce danger for patients. Problems can arise if communication is poor between medics when patients move between departments. Professor Alice Turner of Birmingham Univers -
Content Article
Coroner's concerns During the course of the investigation the evidence revealed matters giving rise to concern. If the coroner is inhibited from being in a position to confirm the cause of death of a baby, there is a risk that future deaths will occur unless action is taken. Matters of Concern The placenta, a key organ required for a full paediatric post mortem in an early neonatal death, has been interfered with such that the Paediatric Pathologist, is limited in his conclusion as to the likely cause of death. In some ways the placenta is akin to an organ for the purposes of a- Posted
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- Baby
- Patient death
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Content Article
Addressing these safety challenges must be a key priority for the new Prime Minister and Health Secretary. This report makes five recommendations, highlighting the vital role that the intelligent collection and monitoring of patient safety data, and the rapid response to any concerns they raise, can play in the continuous improvement of patient safety. Underpinning all of these recommendations is the principle that, first and foremost, patient safety needs to be seen and truly understood from the patient’s perspective. Recommendations: The breadth of patient safety data needs to in- Posted
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- Patient harmed
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Content Article
What is an Adjournment Debate? There is a 30 minute Adjournment Debate at the end of each day's sitting of the House of Commons. They provide an opportunity for an individual backbench MP to raise an issue and receive a response from the relevant Minister. Unlike many other debates, these take place without a question which the House of Commons must then make a decision on. Foetal valproate spectrum disorder: Fatalities Caroline Nokes, MP for Romsey and Southampton North, opened this debate by talking about the case of Jake Alcroft, a 21-year-old who died in April this year after- Posted
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- Epilepsy
- Patient harmed
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Content Article
Commissioned by the Department of Health and Social Care (DHSC) in February 2020, the Independent Investigation into East Kent Maternity services published its report last month highlighting patient safety failings in maternity and neonatal care services from 2009–2020 at two hospitals: Queen Elizabeth The Queen Mother Hospital at Margate and the William Harvey Hospital in Ashford. This is another devastating report detailing cases of serious avoidable harm and preventable deaths in the NHS, stating that it found that: “... those responsible for the services too often provided clinic- Posted
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- Investigation
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News Article
Hospital apologises after hiding surgeon's error for seven years
Patient Safety Learning posted a news article in News
A hospital trust has apologised to a woman for failing to admit a surgeon had been responsible for a massive haemorrhage that almost killed her after a Caesarean section. For seven years, East Kent Hospitals Trust maintained the size of Louise Dempster's baby was to blame. "It was just continuous lies," the 34-year-old told BBC News. East Kent Hospitals chief executive Tracy Fletcher promised "to ensure lessons are learned". Louise Dempster gave birth in May 2015 but the surgeon's error only emerged during an inquiry into poor maternity care at East Kent Hospitals Trust whi- Posted
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- Patient harmed
- Labour
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News Article
NHSE cuts £1bn from cancer, maternity and primary care funds
Patient Safety Learning posted a news article in News
NHS England is raiding a national fund earmarked for improvements in cancer, maternity care and other priority services by up to £1bn this year, to pay for deficits elsewhere, and will cut it by a similar amount in 2023-24, HSJ has learned. The “service development fund” is allocated at the beginning of the year for priority service areas also including primary care, community health, mental health, learning disabilities and health inequalities. Several NHSE directors said it was being tightly squeezed this year, amid major cost pressures from inflation, a pay deal unfunded by govern- Posted
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Content Article
Findings For healthcare staff, carrying out a robust assessment of risk factors for VTE is challenging, particularly in the complex and busy environment of antenatal clinics, the labour ward and on postnatal wards. Multiple competing demands, exacerbated by distractions and interruptions, mean healthcare professionals are constantly having to balance risk and safety for the pregnant women/pregnant people they care for and are trading off the thoroughness of assessments to improve efficiency. Midwives are asked to complete a number of risk assessments and screening tools to a- Posted
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- Deep vein thrombosis
- Pregnancy
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Content Article
Episode 1 Coproduction is Everywhere Paul is on the trail to discovering the knowledge, skills and habits that help coproduce healthcare. It begins by becoming better observers when coproduction occurs Listen to or download Episode 1, "Coproduction is everywhere" Running time: 18 minutes 31 seconds Episode 2 The person will see you now Understanding the lived reality of persons we sometimes call “patients” is useful if we seek insight into how they might take action for their own health, utilizing their own supports and resources Listen to or download Epis- Posted
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- Patient engagement
- Maternity
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News Article
Thousands of referrals for sick babies turned down due to lack of beds
Patient Safety Learning posted a news article in News
More than 1,000 referrals to admit very sick or premature babies to neonatal units were rejected in the last year due to a lack of beds, data obtained by HSJ has revealed. Nineteen trusts turned down a total of 2,721 requests to admit a baby to their level three neonatal intensive care unit – those for the most serious cases – specifically due to a lack of a bed, between 2019-20 and 2021-22, with 1,345 such refusals taking place in 2021-22. Experts told HSJ the issue – which appears to have led to families having to travel very long distances from their homes – was due to a shortage- Posted
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News Article
The NHS could be facing its largest maternity scandal to date as the review into services in Nottingham is now expected to exceed 1,500 cases, The Independent has learned. The probe began in 2021 after this newspaper revealed dozens of babies had died or been left with serious injuries or brain damage as a result of care at NUH, which runs Nottingham’s City Hospital and Queen’s Medical Centre (QMC). But the scope of the investigation has more than doubled, with Nottingham University Hospitals NHS Trust sending more than 1,000 letters to families to contact the independent inquiry, af- Posted
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- Maternity
- Investigation
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