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Found 387 results
  1. News Article
    The family of a man who bled to death during kidney dialysis treatment at Royal Shrewsbury Hospital have said they believe lessons have been learned. Mohammed Ismael Zaman, known as Bolly, died after hospital staff failed to check the connection on his dialysis machine, despite it sounding an alarm after the catheter had become disconnected. During Mr Zaman’s treatment at the Royal Shrewsbury Hospital on October 18, 2019, his dialysis machine set off a venous pressure alarm. An unidentified member of staff reset the alarm without checking that the connection was still secure. As a result of the reset, Mr Zaman bled out for seven minutes losing 49% of his blood circulating volume. He was found unconscious in a pool of blood and despite resuscitation attempts, died two hours later. The coroner, Mr John Ellery concluded that the death was due to systems failure and individual neglect on the part of the unidentified staff member. Read full story Source: Shropshire Star, 16 January 2021
  2. Content Article
    In the two weeks before his death Robbie was seen seven times by five different GPs. The child was seen by three different GPs four times in the last three days when he was so weak and dehydrated he was bedbound and unable to stand unassisted. Only one GP read the medical records, six days before death, and was aware of the suspicion of Addison's disease, the need for the ACTH test and the instruction to immediately admit the child back to hospital if he became unwell. The GP informed the Powells that he would refer Robbie back to hospital immediately that day but did not inform them that Addison's disease had been suspected. The referral letter was not typed until after Robbie had already died and was backdated to the day following the consultation. In a statement after Robbie's death this GP stated: "An Addisonian crisis is precipitated by an intercurrent illness and the stress it induces." Dyfed-Powys Police investigated Robbie's death between 1994 and 1996 but asserted, supported by the Crown prosecution Service in Wales, that there was no evidence of crimes committed by the GPs who, incidentally, were retained by this police force as police surgeons. Following a complaint by Will Powell (Robbie's father) in 1998 against the Deputy Chief Constable of Dyfed-Powys Police, regarding the inadequacies of the criminal investigation, a second criminal investigation was agreed, which commenced in January 1999. As with the first criminal investigation, there was a gross failure to adequately investigate the criminality of the doctors. This resulted in Will Powell making a formal complaint against the Chief Constable of Dyfed-Powys Police in late 1999. This complaint against the Chief Constable resulted in Dyfed-Powys Police appointing an outside police force to review Robbie's case in 2000. Detective Chief Inspector Robert Poole [DCI Poole] from West Midlands Police was appointed. DCI Poole’s investigation report, entitled 'Operation Radiance', which was based on the documents provided to Dyfed Powys Police in March 1994, by Will Powell and his solicitor, was submitted to CPS York in March 2002. This report put forward 35 suggested criminal charges against five GPs and their medical secretary. The listed charges were: gross negligence manslaughter forgery attempting to pervert the course of justice conspiracy to pervert the course of justice. DCI Poole's investigation also resulted in a disciplinary inquiry by Avon & Somerset Constabulary into Will Powell's allegations of misconduct against Dyfed-Powys Police officers with regards to their two inept criminal investigations between 1994 and 2000. Dyfed-Powys Police was found to have been 'institutionally incompetent' but no police officer was made accountable. In April 2003, Will Powell met representatives from the CPS in London, who accepted there was sufficient evidence to prosecute two GPs and their secretary for forgery and perverting the course of justice. However, they would not prosecuted because of (1) the passage of time, which was caused by a decade of cover ups between 1990 and the appointment of DCI Poole in 2000, (2) Dyfed Powys Police had provided the GPs with a letter of immunity, and (3) the available evidence had been initially overlooked by the police and the CPS, between 1994 and 2000, for a variety of reasons. Following a 2013 adjournment debate, in the House of Commons, the Director of Public Prosecutions subsequently agreed, in October 2014, that there would be an independent review of the decisions made by Crown Prosecution Service, in 2003, not to prosecute, when there was sufficient evidence to do so. The reviewing Queen's Counsels have been provided with a report, written by myself ( a healthcare IT professional, former head of IT in an NHS trust and clinician) on major anomalies in Robbie's Morriston Hospital computerised records, which were erased during the first criminal investigation between 1994 and 1996. The review has not been concluded six years on. The letter below (and also attached) from the English and Welsh Ombudsman was sent on 10 November 2020 sets out the case for a Public Inquiry.
  3. News Article
    When pharmacist Ifeoma Onwuka, known to her friends as Laura, went into hospital to have her daughter, she and her husband hoped the delivery would go smoothly, and that they would soon be able to take their new arrival home  to meet her siblings.  Onwuka's labor was induced at James Paget University Hospital in Great Yarmouth in late April 2018. Things progressed quickly and there were soon signs that her baby was in distress, causing staff to begin preparations for an emergency Caesarian section, but Onwuka's daughter was born in the recovery room. Shortly after the birth, Onwuka's condition began to deteriorate. According to the family's lawyer, Tim Deeming, she began to bleed heavily, and was taken into surgery where attempts were made to stem the loss of blood. Hours later, and only after a second consultant had been called in, she was given an emergency hysterectomy. The mother-of-three died three days later. The coroner, Yvonne Blake, said an expert had told Onwuka's inquest that the delay to surgery contributed to her death, since acting early could have controlled the bleeding.  Black mothers have worse outcomes during pregnancy or childbirth than any other ethnic group in England. According to the latest confidential inquiry into maternal deaths (MBRRACE-UK). Black people in England are four times more likely to die in pregnancy or within the first six weeks of childbirth than their White counterparts.  Read full story Source: CNN. 14 January 2021
  4. Content Article
    The majority of recommendations which MBRRACE-UK assessors have identified to improve care are drawn directly from existing guidance or reports and denote areas where implementation of existing guidance needs strengthening. In a small number of instances, actions are needed for which national guidelines are not available. These are included below. To access the report and the full list of recommendations, please click on the link at the bottom of this page. New recommendations to improve care: For professional organisations 1. Develop guidance to ensure SUDEP awareness, risk assessment and risk minimisation is standard care for women with epilepsy before, during and after pregnancy and ensure this is embedded in pathways of care. [ACTION: Royal Colleges of Obstetricians and Gynaecologists, Physicians]. 2. Develop guidance to indicate the need for definitive radiological diagnosis in women who have an inconclusive VQ scan [ACTION: Royal Colleges of Physicians, Radiologists, Obstetricians and Gynaecologists]. 3. Produce guidance on which bedside tests should be used for assessment of coagulation and the required training to perform and interpret those tests [ACTION: Royal Colleges of Anaesthetists, Obstetricians and Gynaecologists, Physicians] 4. Establish a mechanism to disseminate the learning from this report, not only to maternity staff, but more widely to GPs, emergency department practitioners, physicians and surgeons [ACTION: Academy of Medical Royal Colleges]. For policy makers, service planners/commissioners and service managers 5. Develop clear standards of care for joint maternity and neurology services, which allow for: early referral in pregnancy, particularly if pregnancy is unplanned, to optimise anti-epileptic drug regimens; rapid referral for neurology review if women have worsening epilepsy symptoms; pathways for immediate advice for junior staff out of hours; postnatal review to ensure anti-epileptic drug doses are appropriately adjusted [ACTION: NHSE/I and equivalents in the devolved nations and Ireland]. 6. Ensure each regional maternal medicine network has a pathway to enable women to access their designated epilepsy care team within a maximum of two weeks. [ACTION: Maternal Medicine Networks and equivalent structures in Ireland and the devolved nations]. 7. Ensure all maternity units have access to an epilepsy team [ACTION: Service Planners/Commissioners, Hospitals/Trusts/Health Boards]. 8. Establish pathways to facilitate rapid specialist stroke care for women with stroke diagnosed in inpatient maternity settings [ACTION: Service Planners/Commissioners, Hospitals/Trusts/Health Boards]. 9. Provide specialist multidisciplinary care for pregnant women who have had bariatric surgery by a team who have expertise in bariatric disorders [ACTION: Service Planners/Commissioners, Hospitals/Trusts/Health Boards]. 10. Use the scenarios identified from review of the care of women who died for ‘skills and drills’ training [ACTION: Hospitals/Trusts/Health Boards]. 11. Ensure early senior involvement in the care of women with extremely preterm prelabour rupture of membranes and a full explanation of the risks and benefits of continuing the pregnancy. This should include discussion of termination of pregnancy [ACTION: Hospitals/Trusts/Health Boards]. For health professionals 12. Regard nocturnal seizures as a ‘red flag’ indicating women with epilepsy need urgent referral to an epilepsy service or obstetric physician [ACTION: All Health Professionals]. 13. Ensure that women on prophylactic and treatment dose anticoagulation have a structured management plan to guide practitioners during the antenatal, intrapartum and postpartum period [ACTION: All HealthProfessionals]. 14. Ensure at least one senior clinician takes a ‘helicopter view’ of the management of a woman with major obstetric haemorrhage to coordinate all aspects of care [ACTION: All Health Professionals]. iv MBRRACE-UK - Saving Lives, Improving Mothers’ Care 2020 15. Ensure that the response to obstetric haemorrhage is tailored to the proportionate blood loss as a percentage of circulating blood volume based on a woman’s body weight [ACTION: All Health Professionals]. 16. Do not perform controlled cord traction if there are no signs of placental separation (blood loss and lengthening of the cord) and take steps to manage the placenta as retained [ACTION: All Health Professionals]. 17. Be aware that signs of uterine inversion include pain when attempting to deliver the placenta, a rapid deterioration of maternal condition and a loss of fundal height without delivery of the placenta [ACTION: All Health Professionals].
  5. News Article
    COVID-19 patients in England's busiest intensive care units (ICUs) in 2020 were 20% more likely to die, University College London research has found. The increased risk was equivalent to gaining a decade in age. By the end of 2020, one in three hospital trusts in England was running at higher than 85% capacity. Eleven trusts were completely full on 30 December, and the total number of people in intensive care with Covid has continued to rise since then. The link between full ICUs and higher death rates was already known, but this study is the first to measure its effect during the pandemic. Tighter lockdown restrictions are needed to prevent hospitals from being overwhelmed, says study author Dr Bilal Mateen. Researchers looked at more than 4,000 patients who were admitted to intensive care units in 114 hospital trusts in England between April and June last year. They found the risk of dying was almost a fifth higher in ICUs where more than 85% of beds were occupied, than in those running at between 45% and 85% capacity. That meant a 60-year-old being treated in one of these units had the same risk of dying as a 70-year-old on a quieter ward. The Royal College of Emergency Medicine sets 85% as the maximum safe level of bed occupancy. However, the team found there was no tipping point after which deaths rose - instead, survival rates fell consistently as bed-occupancy increased. This suggests "a lot of harm is occurring before you get to 85%". Read full story Source: BBC News, 14 January 2021
  6. News Article
    Hundreds of people a day across London are waiting hours for an emergency ambulance to get to them, as paramedics warn that patients are dying as a result of delays. Patients in emergency calls classified as category two, such as those involving a suspected stroke or chest pains, should be seen by paramedics within an average of 18 minutes but are being forced in some cases to wait up to 10 hours. Even life-threatening calls where patients are in cardiac arrest and should be reached within seven minutes have experienced delays, with data suggesting one such call was waiting 20 minutes on Monday. Internal data shared with The Independent shows that London Ambulance Service is holding hundreds of open 999 calls for hours at a time with the service’s boss acknowledging in an email to staff that the service is struggling to maintain standards. Experts warned that the problems in the capital were reflected in ambulance services across the country. One paramedic told The Independent: “Patients desperately requiring ambulances aren’t getting them and, anecdotally, people are deteriorating and dying whilst waiting. Our poor dispatchers have to stare at screens of held calls, working out who gets the next available resource and who waits, suffers or dies.” Read full story Source: The Independent, 5 January 2021
  7. News Article
    All NHS trusts in England have been given a deadline of Monday to enact safety improvements in maternity care amid Shropshire's baby deaths scandal. Heath chiefs have told hospitals they must have the 12 "urgent clinical priorities" in place by 17:00 GMT. The move is to address "too much variation" in outcomes for families. It comes during a probe into the maternity care of more than 1,800 families in Shropshire. The inquiry, launched amid concerns of repeated failings at Shrewsbury and Telford Hospital NHS Trust (SaTH), focuses on the experience of 1,862 in total, and includes instances of infant fatality. An interim report published last week found poor care over nearly two decades had harmed dozens of women and their babies. The report called for seven "essential actions" to be implemented at maternity units across England. But that has since been transformed into 12 clinical tasks, including giving women with complex pregnancies a named consultant, ensuring regular training of fetal heart rate monitoring, and developing a proper process to gather the views of families. The directions are revealed in a letter in which NHS England says there is "too much variation in experience and outcomes for women and their families". Read full story Source: BBC News, 15 December 2020
  8. News Article
    Pre-existing social inequalities contributed to the UK recording the highest death rates from Covid in Europe, a leading authority on public health has said, warning that many children’s lives would be permanently blighted if the problem is not tackled. Sir Michael Marmot, known for his landmark work on the social determinants of health, argued in a new report that families at the bottom of the social and economic scale were missing out before the pandemic, and were now suffering even more, losing health, jobs, lives and educational opportunities. In the report, Build Back Fairer, Marmot said these social inequalities must be addressed whatever the cost and it was not enough to revert to how things before the pandemic. “We can’t afford not to do it,” he said. Read full story Source: The Guardian, 15 December 2020
  9. News Article
    Strong leadership, challenging poor workplace culture, and ringfencing maternity funding are key to improving safety. That’s the message from two leading Royal Colleges as they respond to the independent review of maternity services at Shrewsbury and Telford NHS Trust led by Donna Ockenden. The RCOG and the Royal College of Midwives (RCM) have today welcomed the Ockenden Review and its recognition of the need to challenge poor working relationships, improve funding and access to multidisciplinary training and crucially to listen to women and their families to improve learning and to ensure tragedies such as those that have happened at Shrewsbury and Telford NHS Trust never occur again. The Colleges have said that the local actions for learning and the immediate and essential actions laid out in this report must be read and acted upon immediately in all Trusts and Health Boards delivering maternity services across the UK. Commenting, Dr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, said: “This report makes difficult reading for all of us working in maternity services and should be a watershed moment for the system. Reducing risk needs a holistic approach that targets the specific challenges of fetal monitoring interpretation and strengthens organisational functioning, culture and behaviour." Read press release Source: RCOG, 10 December 2020
  10. News Article
    Patient Safety Learning Press Release 10th December 2020 Today the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust published its first report on its findings.[1] The report made recommendations for actions to be implemented by the Trust and “immediate and essential actions” for both the Trust and the wider NHS. The Review was formally commissioned in 2017 to assess “the quality of investigations relating to new-born, infant and maternal harm at The Shrewsbury and Telford Hospital NHS Trust”.[2] Initially it was focused on 23 cases but has been significantly expanded as families have subsequently contacted the review team with their concerns about maternity care and treatment at the Trust. The total number of families to be included in the final report is 1,862. These initial findings are drawn from 250 cases reviewed to date. This is another shocking report into avoidable harm. We welcome the publication of these interim findings and the sharing of early actions that have been identified to make improvements to patient safety in NHS maternity services. We commend the ambition for immediate responses and action. Reflecting on the report, there are a number of broad patient safety themes, many of which have been made time and time again in other reports and inquiries. A failure to listen to patients The report outlines serious concerns about how the Trust engaged and involved women both in their care and after harm had occurred. This was particularly notable in the example of the option of having a caesarean section, where there was an impression that the Trust had a culture of wanting to keep the numbers of these low, regardless of patients’ wishes. They commented: “The Review Team observed that women who accessed the Trust’s maternity service appeared to have little or no freedom to express a preference for caesarean section or exercise any choice on their mode of deliver.” It also noted a theme in common with both Paterson Inquiry and Cumberlege Review relating to the Trusts’ poor response to patients raising concerns.[3] The report noted that “there have also been cases where women and their families raised concerns about their care and were dismissed or not listened to at all”. The need for better investigations Concerns about the quality of investigations into patient safety incidents at the Trust is another theme that emerges. The review reflected that in some cases no investigation happened at all, while in others these did take place but “no learning appears to have been identified and the cases were subsequently closed with it deemed that no further action was required”. One of the most valuable sources for learning is the investigation of serious incidents and near misses. If these processes are absent or inadequate, then organisations will be unable to learn lessons and prevent future harm reoccurring. Patient Safety Learning believes it is vital that Trusts have the commitment, resources, and frameworks in place to support investigations and that the investigators themselves have the right skills and training so that these are done well and to a consistently high standard. This has not formed part of the Report’s recommendations and we hope that this is included in their final report. Lack of leadership for patient safety Another key issue highlighted by the report is the failure at a leadership level to identify and tackle the patient safety issues. Related to this one issue it notes is high levels of turnover in the roles of Chief Executive, executive directors and non-executive directors. As part of its wider recommendations, the Report suggests trust boards should identify a non-executive director who has oversight of maternity services. Good leadership plays a key role in shaping an organisations culture. Patient Safety Leadership believes that leaders need to drive patient safety performance, support learning from unsafe care and put in place clear governance processes to enable this. Leaders need to be accountable for patient safety. There are questions we hope will be answered in the final report that relate to whether leaders knew about patients’ safety concerns and the avoidable harm to women and their babies. If they did not know, why not? If they did know but did not act, why not? Informed Consent and shared decision-making The NHS defines informed consent as “the person must be given all of the information about what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment does not go ahead”.[4] The report highlights concerns around the absence of this, particularly on the issue of where women choose as a place of birth, noting: “In many cases reviewed there appears to have been little or no discussion and limited evidence of joint decision making and informed consent concerning place of birth. There is evidence from interviews with women and their families, that it was not explained to them in case of a complication during childbirth, what the anticipated transfer time to the obstetric-led unit might be.” Again this is another area of common ground with other recent patient safety reports such as the Cumberlege Review.[5] Patient Safety Learning believes it is important that patients are not simply treated as passive participants in the process of their care. Informed consent and shared decision making are vital to respecting the rights of patients, maintaining trust in the patient-clinician relationship, and ensuring safe care. Implementation for action and improved patient safety In its introduction, the report states: “Having listened to families we state that there must be an end to investigations, reviews and reports that do not lead to lasting meaningful change. This is our call to action.” Responding with an official statement in the House of Commons today, Nadine Dorries MP, Minister for Mental Health, Suicide Prevention and Patient Safety, did not outline a timetable for the implementation of this report’s recommendations. In 2020 we have seen significant patient safety reports whose findings have been welcomed by the Department of Health and Social Care but where there has subsequently been no formal response nor clear timetable for the implementation of recommendations, most notably the Paterson Inquiry and Cumberlege Review. Patient Safety Learning believes there is an urgent need to set out a plan for implementing the recommendations of the Ockenden Report and these other patient safety reports. Patients must be listened to and action taken to ensure patient safety. [1] Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Emerging findings and recommendations form the independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, 10 December 2020. https://www.ockendenmaternityreview.org.uk/wp-content/uploads/2020/12/ockenden-report.pdf [2] Ibid. [3] The Right Reverend Graham Jones, Report of the Independent Inquiry into the Issues raised by Paterson, 2020. https://assets.publishing.serv...; The Independent Medicines and Medical Devices Safety Review, First Do No Harm, 8 July 2020. https://www.immdsreview.org.uk/downloads/IMMDSReview_Web.pdf [4] NHS England, Consent to treatment, Last Accessed 16 July 2020. https://www.nhs.uk/conditions/consent-to-treatment/ [5] Patient Safety Learning, Findings of the Cumberlege Review: informed consent, Patient Safety Learning’s the hub, 24 July 2020. https://www.pslhub.org/learn/patient-engagement/consent-and-privacy/consent-issues/findings-of-the-cumberlege-review-informed-consent-july-2020-r2683/
  11. News Article
    Health chiefs are designing an “early warning” system to detect and prevent future maternity care scandals before they happen, a health minister has said. Patient safety minister Nadine Dorries said she hoped the system would highlight hospitals and maternity units where mistakes were being made earlier. The former nurse also revealed the Department of Health and Social Care was drawing up a plan for a joint national curriculum for both midwives and obstetricians to make sure they had the skills to look after women safely. During a Parliamentary debate following the publication of a report into the Shrewsbury and Telford Hospital care scandal, the minister was challenged by MPs to take action to prevent future scandals. The former health secretary, Jeremy Hunt, warned the failings at the Shropshire trust, where dozens of babies died or were left with permanent brain damage, could be repeated elsewhere. He said: “The biggest mistake in interpreting this report would be to think that what happened at Shrewsbury and Telford is a one-off — it may well not be, and we mustn't assume that it is.” Ms Dorries said: “Every woman should own her birth plan, be in control of what is happening to her during her delivery and I really hope ... this report is fundamental in how it's going to reform the maternity services across the UK going forward. Read full story Source: The Independent, 11 December 2020
  12. Content Article
    Immediate and essential actions 1) Enhanced safety Essential action - Safety in maternity units across England must be strengthened by increasing partnerships between Trusts and within local networks. Neighbouring Trusts must work collaboratively to ensure that local investigations into Serious Incidents (SIs) have regional and Local Maternity System (LMS) oversight. 2) Listening to women and families Essential action - Maternity services must ensure that women and their families are listened to with their voices heard. 3) Staff training and working together Essential action - Staff who work together must train together. 4) Managing complex pregnancy Essential action - There must be robust pathways in place for managing women with complex pregnancies Through the development of links with the tertiary level Maternal Medicine Centre there must be agreement reached on the criteria for those cases to be discussed and /or referred to a maternal medicine specialist centre. 5) Risk assessment throughout pregnancy Essential action - Staff must ensure that women undergo a risk assessment at each contact throughout the pregnancy pathway, 6) Monitoring fetal wellbeing Essential action - All maternity services must appoint a dedicated Lead Midwife and Lead Obstetrician both with demonstrated expertise to focus on and champion best practice in fetal monitoring. 7) Informed consent Essential action - All Trusts must ensure women have ready access to accurate information to enable their informed choice of intended place of birth and mode of birth, including maternal choice for caesarean delivery.
  13. News Article
    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
  14. News Article
    More than 60,000 people in the UK have now died within 28 days of a positive COVID-19 test, official figures show. A further 414 were recorded on Thursday, taking the total to 60,113. Two other ways of measuring deaths - where Covid is mentioned on the death certificate, and the number of "excess deaths" for this time of year - give higher total figures. Only the US, Brazil, India and Mexico have recorded more deaths than the UK, according to Johns Hopkins University. However, the UK has had more deaths per 100,000 people than any of those nations. In terms of deaths per 100,000 people, the UK is the seventh-highest country globally, behind Belgium, San Marino, Peru, Andorra, Spain and Italy. Read full story Source: BBC News,
  15. News Article
    Staff at a mental health unit missed "multiple opportunities" to realise a woman had become unwell before she died, a coroner has said. Sian Hewitt, 25, died at Milton Keynes Hospital last year after collapsing at the nearby Campbell Centre. Coroner Tom Osborne said there was "a failure to start effective CPR". A spokesman for the centre said changes have been made to how care is delivered. Ms Hewitt, who had Asperger's syndrome and bipolar disorder, was admitted to the inpatient unit on 13 March 2019. She died less than a month later on 6 April 2019 at Milton Keynes Hospital, where she was taken after collapsing on Willow Ward at the centre. An inquest concluded she died of a pulmonary embolism, caused when a blood clot travels to the lungs. In a Prevention of Future Deaths Report, Mr Osborne said the centre failed to carry out a risk assessment and there was a delay in administering a drug resulting in "her mania not being brought under control". His report said the "failure to recognise how seriously ill she had become" had "resulted in lost opportunities to treat her appropriately that may have prevented her death". He said her death suggested the NHS was "unable to provide a place of safety for those who are suffering from Asperger's syndrome" or other forms of autism "when they are also suffering additional mental health problems such as bipolar". Read full story Source: BBC News, 4 December 2020
  16. News Article
    The safety of maternity services at a major north London hospital has been criticised by the care watchdog after an inspection prompted by the death of a woman. The Care Quality Commission (CQC) has issued the Royal Free Hospital, in Hampstead with a warning notice after inspectors identified serious safety failings in its maternity unit. An unannounced inspection of the hospital’s maternity service took place in October, following the death of Malyun Karama, in February this year. The 34-year-old died while giving birth to her stillborn baby. She suffered a ruptured uterus after being given an overdose of misoprostol to induce her labour. In a report following an inquest into her death Coroner Mary Hassell said: “Abnormal observations were relayed by a midwife to a senior registrar, but the doctor failed to attend Ms Karama and instead ordered fluids. The uterine rupture would have been life threatening whatever the care rendered to Ms Karama, but if the doctor had attended immediately and had reviewed and treated appropriately, the likelihood is that Ms Karama’s life would have been saved.” The CQC has yet to publish a full report on its inspection of the hospital but confirmed it had taken enforcement action and issued the trust with a warning notice. The concerns relate to the trust being too slow to investigate and make changes after incidents of harm. It’s understood a panel to investigate Ms Karama’s death did not meet until June this year. Read full story Source: The Independent, 1 December 2020
  17. News Article
    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
  18. News Article
    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
  19. Content Article
    Elizabeth Dixon was a child with special health needs. She had been born prematurely at Frimley Park Hospital on 14 December 2000. Following treatment and care at Great Ormond Street Hospital and a children’s hospice she was nursed at home under a care package. As a result of a failure to clear a tracheostomy tube she asphyxiated and was pronounced dead at Frimley Park hospital on 4 December 2001. The investigation chaired by Dr Bill Kirkup looked at the events surrounding the care of Elizabeth and makes a series of recommendations in respect of the failures in the care she received from the NHS. Recommendations Hypertension (high blood pressure) in infants is a problem that is under-recognised and inconsistently managed, leading to significant complications. Its profile should be raised with clinicians; there should be a single standard set of charts showing the acceptable range at different ages and gestations; and a single protocol to reduce blood pressure safely. Blood pressure should be incorporated into a single early warning score to alert clinicians to deterioration in children in hospital. Community care for patients with complex conditions or conditions requiring complex care must be properly planned, taking into account and specifying safety, effectiveness and patient experience. The presence of mental or physical disability must not be used to justify or excuse different standards of care. Commissioning of NHS services from private providers should not take for granted the existence of the same systems of clinical governance as are mandated for NHS providers. These must be specified explicitly. Communication between clinicians, particularly when care is handed over from one team or unit to another, must be clear, include all relevant facts and use unambiguous terms. Terms such as palliative care and terminal care may be misleading and should be avoided or clarified. Training in clinical error, reactions to error and responding with honesty, investigation and learning should become part of the core curriculum for clinicians. Although it is true that curricula are already crowded with essential technical and scientific knowledge, it cannot be the case that no room can be found for training in the third leading cause of death in western health systems. Clinical error, openly disclosed, investigated and learned from, must not be subject to blame. Conversely, there should be zero tolerance of cover up, deception and fabrication in any health care setting, not least in the aftermath of error. There should be a clear mechanism to hold individuals to account for giving false information or concealing information relating to public services, and for failing to assist investigations. The Public Authority (Accountability) Bill drawn up in the aftermath of the Hillsborough Independent Panel and Inquests sets out a commendable framework to put this in legislation. It should be re-examined. The existing haphazard system of generating clinical expert witnesses is not fit for purpose. It should be reviewed, taking onto account the clear need for transparent, formalised systems and clinical governance. Professional regulatory and criminal justice systems should contain an inbuilt ‘stop’ mechanism to be activated when an investigation reveals evidence of systematic or organisational failures and which will trigger an appropriate investigation into those wider systemic failures. Scrutiny of deaths should be robust enough to pick up instances of untoward death being passed off as expected. Despite changes to systems for child and adult deaths, concern remains that without independent review such cases may continue to occur. The introduction of medical examiners should be reviewed with a view to making them properly independent. Local health service complaints systems are currently subject to change as part of wider reform of public sector complaints. Implementation of a better system of responding to complaints must be done in such a way as to ensure the integration of complaints into NHS clinical governance as a valuable source of information on safety, effectiveness and patient experience. The approaches available to patients and families who have not been treated with openness and transparency are multiple and complex, and it is easy to embark inadvertently on a path that is ill-suited to deliver the answers that are being sought. There should be clear signposting to help families and the many organisations concerned. Ministerial Statement Anne and Graeme Dixon reaction to Dr Bill Kirkup’s report Patient Safety Learning's statement on the Dixon Inquiry report
  20. News Article
    Former health secretary and chair of the Commons health committee Jeremy Hunt has criticised Great Ormond Street Hospital after it was accused of covering up errors that may have led to the death of a toddler. Writing for The Independent, Mr Hunt, who has set up a patient safety charity since leaving government, said it was “depressing” to see how the hospital had responded to the case of Jasmine Hughes, which has now been taken to the Parliamentary Health Service Ombudsman for a new investigation. Mr Hunt said the hospital had chosen to issue a “classic non-apology apology of which any politician would be proud” and added he was left angry over the hospital’s “ridiculous decision” to stop talking to Jasmine’s family and the refusal to apologise for what went wrong. The MP for South West Surrey said the case was symbolic of a wider problem in the health service of a blame culture that prevents openness and transparency around mistakes. Read full story Source: The Independent, 24 November 2020
  21. News Article
    A world-leading children’s hospital has been accused of a “concerted effort” to cover up the mistakes that led to the death of a toddler. Jasmine Hughes died at London’s Great Ormond Street Hospital aged 20 months after suffering acute disseminated encephalomyelitis (ADEM), a condition in which the brain and spinal cord are inflamed following a viral infection. Doctors said that her death in February 2011 had been caused by complications of ADEM. But an analysis of detailed hospital computer records shows the toddler died after her blood pressure was mismanaged – spiking when she was treated with steroids then allowed to fall too fast. Experts say this led to catastrophic brain damage. Although the detailed computer records were supplied to the coroner who carried out Jasmine’s inquest, crucial information concerning her blood pressure was not included in official medical records that should hold the patient’s entire clinical history. Dr Malcolm Coulthard, who specialises in child blood pressure and medical records examination, carried out the analysis of the files, comprising more than 350 pages of spreadsheets. Dr Stephen Playfor, a paediatric intensive care consultant, examined the computer records and came to the same conclusion as Dr Coulthard, that mismanagement of Jasmine’s blood pressure by Great Ormond Street and Lister Hospital, in Stevenage, was responsible for her death. Dr Coulthard told The Independent: “As a specialist paediatrician, it is with great regret and disappointment that I have concluded that the doctors' records in Jasmine Hughes’ medical notes fail to reflect the truth about her diagnosis and treatment.” Read full story Source: The Independent, 20 November 2020
  22. News Article
    Death rates for a major emergency abdominal surgery are almost eight times higher at some outlier hospitals compared with top performers, a national report has found. A review of emergency laparotomies in England and Wales has identified six hospitals as having much higher-than-average 30-day mortality rates for the surgery between December 2018 and November 2019. Hospitals identified by the annual National Emergency Laparotomy Audit as having the best outcomes, such as Stepping Hill Hospital and Salford Royal Hospital, had mortality rates of around 2.5%. But the review, published this month, found some hospitals, such as George Eliot Hospital, had 30-day mortality rates for emergency laparotomies as high as 19.6% The national 30-day mortality rate for emergency laparotomies in England and Wales was 9.3% last year and has fallen consistently since the review started in 2013. Some trusts told HSJ that data collection issues were partly to blame for the high mortality rates recorded in the review. Read full story (paywalled) Source: HSJ, 20 November 2020 .
  23. News Article
    A coroner has urged ministers to revisit plans to make it possible to hold inquests into babies that are stillborn after a baby died due to “excessive force” during an attempted forceps delivery. Senior coroner Caroline Beasley-Murray has written to the Ministry of Justice after she was forced to stop hearing evidence into the death of baby Frederick Terry, known as Freddie, who died under the care of the Mid and South Essex Hospitals Trust on 16 November, last year. An inquest into his death was started in September where Freddie was found to have died after suffering hypovolaemic shock as a result of losing a fifth of his blood when his skull was fractured during a traumatic birth attempt. In a report on the case the coroner said: “Baby Frederick Joseph Terry was delivered by caesarean section, after a failed forceps attempted delivery on 16 November 2019 and death was confirmed after 40 minutes of resuscitation attempts." "The evidence showed that baby Freddie's very serious scalp and brain injuries were sustained during the failed forceps attempted delivery and, but for these, baby Freddie would have survived as a perfectly formed, healthy baby." The coroner said the injuries he sustained implied “an excessive degree of force” in the application of the forceps, which are curved metal instruments that fit around a baby’s head and are designed to help deliver the baby. The inquest had to be stopped from hearing any more evidence because coroners are not able to investigate stillborn babies. As part of her report, the coroner said: “It would have been helpful for there to have been, during the course of the inquest, an exploration, in the course of evidence, of the treatment and care provided to baby Freddie and his parents at the time of delivery. "Currently there is no legislation to cover the holding of a coroner’s inquest into a stillbirth. In March 2019, the Government issued a consultation on coronial investigations of stillbirths It would be helpful for this important topic to be progressed, whatever the ultimate jurisdictional decisions.” Read full story Source: The Independent, 17 November 2020
  24. News Article
    Expectant mothers are being warned about potentially confusing guidance on consuming caffeine while pregnant, as research suggests energy drinks could have potentially deadly consequences for their babies. A new report by Tommy’s Maternal and Fetal Health Research Centre claims to have established a 27 per cent rise in the risk of stillbirth for each 100mg of caffeine consumed. Researchers compared stillbirths to ongoing pregnancies among 1,000 women across 41 hospitals from 2014 to 2016 as well as interviewing women about their consumption of caffeinated drinks. They adjusted for demographic and behavioural factors, such as age and alcohol consumption, to determine whether stillbirth was linked to caffeine. One in 20 women were found to have increased their caffeine intake while pregnant in spite of evidence some caffeinated drinks put babies lives at risk. However, experts say that calculating precise intake can be difficult, and guidance on limiting caffeine is not consistent The NHS recommends pregnant women keep their daily caffeine intake below 200mg whereas the World Health Organization stipulates 300mg as the safe amount to consume. Tommy’s, a leading baby charity, called for both the NHS and the World Health Organisation to rethink such guidelines, but refused to outline a specific limit - saying it was the NHS and World Health Organisation’s responsibility to decide the recommendations in light of their new study. Professor Alexander Heazell, an author of the study, said: “Caffeine has been in our diets for a long time, and, as with many things we like to eat and drink, large amounts can be harmful – especially during pregnancy. It’s a relatively small risk, so people shouldn’t be worried about the occasional cup of coffee, but it’s a risk this research suggests many aren’t aware of." Read full story Source: The Independent, 18 November 2020
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