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Content ArticleHealth and Social Care Select Committee This is a cross-party body that is responsible for scrutinising the work of the Department of Health and Social Care and its associated public bodies in the UK. It is composed of MPs and examines government policy, spending and administration on behalf of the electorate and the House of Commons.[1] Safety of maternity services in England The Committee opened an inquiry into the Safety of maternity services in England on the 24 July 2020. The intention of this inquiry is to examine evidence relating to ongoing concerns around recurring failings in maternity services, with MPs considering whether clinical negligence and litigation processes need to be changed to improve the safety of maternity services, as well as the extent to which a “blame culture” affects medical advice and decision-making.[2] Formal meeting (oral evidence session) - Tuesday 29 September 2020 In this video of the first oral evidence session of this inquiry, the Committee heard from: Michelle Hemmington, Co-founder at Campaign for Safer Births Dr Bill Kirkup, Chairman at Morecambe Bay maternity investigation and East Kent maternity investigation Professor Ted Baker, Chief Inspector of Hospitals at Care Quality Commission Professor Jacqueline Dunkley Bent, Chief Midwifery Office at NHS England and NHS Improvement Dr Matthew Jolly, National Clinical Director for Maternity and Women's Health at NHS England and NHS Improvement References UK Parliament, Health and Social Care Committee, Last Accessed 1 October 2020. UK Parliament, Safety of Maternity Services in England, Last Accessed 1 October 2020.
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Community PostWe should all strive to keep antibiotics working for our NHS surgeons and future generations, by decreasing antibiotic use in medicine. It is mums themselves who could dramatically decrease antibiotic use, in the only medical specialty where this is possible - in obstetrics - by keeping skin intact; by being informed of the 10cm diameter that 'Aniball' and 'Epi-no Delphine Plus' birth facilitating devices, the mechanical version of Antenatal Perineal Massage, achieve by skin expansion (much like by 'earlobe skin expanders') prior to birth, for back of baby's head. This enables a normal birth for many more babies by shortening birth, with no cutting (episiotomies) or tearing, and much fewer Caesarean sections, as each Caesarean section requires antibiotics to be injected into mum, to kill any bacteria, which might have invaded a skin cell, from being implanted with that skin cell, deep into the wall of the uterus, by the surgeon's knife. There are around 750,000 births in the UK alone and three-quarters of mums are damaged during birth and at risk of developing infection; so a dramatic decrease in antibiotic use is possible. Empowering mums with knowledge; that both the skin and the coats of the pelvic floor muscles, which form the floor of the lower tummy, can be stretched painlessly, in preparation of birth, from the 26th week of pregnancy, so a gentler, kinder birth for both baby and mum becomes possible by decreasing risky obstetric interventions. Muscle can be stretched to 3 times its original length, if stretched painlessly over 6 or more occasions, and still retains its ability to recoil back, contracting to its original length. So there is no damage to mum. Baby's delicate head is not used to achieve this 'birth canal widening', because Antenatal Perineal Massage or Aniball or Epi-no Delphine Plus have already achieved this prior to the start of birth. In birth this stretching is rushed within the last 2 hours of birth, with risk of avulsion of pelvic floor muscle fibres from the pubic bone and risk of skin tearing or the need for episiotomy. The overlying skin will likewise stretch without tearing if done over 6 or more occasions. The maximal opening in the outlet or lower part of the pelvis is 10cm diameter, so 10cm diameter is the goal of the birth aiding devices and 'Antenatal Perineal Massage' or 'Birth Canal Widening' - opening doors for baby maximally. The mother reviews on 'Aniball' and 'Epi-no Delphine Plus' are impressive: Wanda Klaman, a first time mum, gives birth at nearly 42 weeks to a 4.4kg baby, with no need for episiotomy or forceps; Sophie of London, avoids episiotomy, when forceps are used to aid delivery for her baby who lays across her tummy - transverse lay, because the skin at this opening is so stretchy thanks to the birth facilitating devices. https://www.dailymail.co.uk/news/article-7450045/Fears-infections-pandemic-grow-NINETEEN-new-superbugs-discovered-UK.html https://www.mirror.co.uk/news/uk-news/mistakes-maternity-wards-setting-nhs-22702909
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News ArticleToo many English hospitals risk repeating maternity scandals involving avoidable baby deaths and brain injury because staff are too frightened to raise concerns, the chief inspector of hospitals has warned. Speaking at the opening session of an inquiry into the safety of maternity units by the health select committee, Prof Ted Baker, chief inspector of hospitals for the Care Quality Commission, said: “There are too many cases when tragedy strikes because services are not not doing their job well enough.” Baker admitted that 38% of such services were deemed to require improvement for patient safety and some could get even worse. “There is a significant number of services that are not achieving the level of safety they should,” he said. He said many NHS maternity units were in danger of repeating fatal mistakes made at what became the University Hospitals of Morecambe Bay NHS foundation trust (UHMBT), despite a high profile 2015 report finding that a “lethal mix” of failings at almost every level led to the unnecessary deaths of one mother and 11 babies. “Five years on from Morecombe Bay we have still not learned all the lessons,” Baker said. “[The] Morecombe Bay [report] did talk about about dysfunctional teams and midwives and obstetricians not working effectively together, and poor investigations without learning taking place. And I think those elements are what we are still finding in other services.” Baker urged hospital managers to encourage staff to whistleblow about problems without fear of recrimination. He said: “The reason why people are frightened to raise concerns is because of the culture in the units in which they work. A healthy culture would mean that people routinely raise concerns. But raising concerns is regarded as being a difficult member of the team.” Read full story Source: The Guardian, 29 September 2020
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Community PostSee Rob Hackett's video on the hub: Indistinct Chlorhexidine: Patients suffer unnecessarily – the reason is clear Rob highlights the story of Grace Wang. In 2010 Grace Wang was left paralysed after an accidental epidural injection with antiseptic solution (indistinct chlorhexidine – easily mistaken for other colourless solutions). This same error continues to play out again and again throughout the world. Do you have evidence or data from your organisation or healthcare system. Comment below or email: info@pslhub.org We will ensure confidentiality.
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Community PostHi The new Patient Safety Incident Response Framework is due for publication this month for early adopters and as 'introductory guidance' for everyone else: https://improvement.nhs.uk/resources/about-new-patient-safety-incident-response-framework/ I wondered if there is anyone who is involved in an organisation that is an early adopter who can share what has happened so far and also would be willing to share any local learning as the new framework is implemented? Also, more generally wondered if anyone has any initial comments on the proposals which were mentioned in the NHS patient safety strategy and any things in particular which they think will bring benefit or could represent significant challenges or issues?
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News ArticleDelays at the Great Ormond Street Hospital led to a boy dying an agonising death, a health watchdog has found. Arvind Jain, 13, who had Duchenne Muscular Dystrophy, died in August 2009 after waiting months for an operation. The ombudsman's report found he had "suffered considerable distress" and criticised referral procedures as "chaotic and substandard". The Great Ormond Street Hospital said there were "failings in clinical care". Arvind's sister Shushma said: "To read that he was suffering all the time, that was disgusting. He had been asking us repeatedly if he would get the operation and we would be constantly reassuring him that he would not die." The degenerative disease Arvind, who lived in Cricklewood, north London, suffered from was not immediately life threatening but in January 2009 his condition had become acute enough for him to struggle with swallowing and feeding. He had a temporary medical solution where a tube was inserted through his nose to help him get the required nutrition. He also experienced a number of other medical complications although none of these was considered life-threatening. The permanent solution recommended by his consultant paediatric neurologist was a gastrostomy insertion which would allow Arvind to feed through his stomach. The Great Ormond Street Hospital Trust (GOSH) excels in such procedures, however, a series of communication errors meant despite repeated and urgent requests from his neurological consultant, proper investigations were not carried out into Arvind's suitability for the operation. After five months of delays he and his family were reassured that as soon as he got the operation he would be much more comfortable. Another hospital also offered to carry out the operation in the event that the delays continued. But the surgical team that was due to carry out the operation never managed to assess Arvind. His condition deteriorated to the point where he was not well enough to be operated on and Arvind died on 9 August 2009. The Parliamentary and Health Service Ombudsman's report said he "suffered considerable distress and discomfort". It also describes a series of basic shortcomings in Arvind's care. The report said: "The standard of care provided for Arvind fell so far below the applicable standards as to amount to service failure." Read full story Source: BBC News, 23 September 2020
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News Article
10,000 more deaths than usual occurred in UK homes since June
Patient Safety Learning posted a news article in News
Some 10,000 more deaths than usual have occurred in peoples’ private homes since mid June, long after the peak in Covid deaths, prompting fears that people may still be avoiding health services and delaying sending their loved ones to care homes. It brings to more than 30,000 the total number of excess deaths happening in people’s homes across the UK since the start of the pandemic. Excess deaths are a count of those deaths which are over and above a “normal” year, based on the average number of deaths that occurred in the past five years. In the past three months the number of excess deaths across all settings, has, in the main been lower than that of previous years. However, deaths in private homes buck the trend with an average of 824 excess deaths per week in people’s homes in the 13 weeks to mid-September. Experts are citing resistance from the public to enter hospitals or home care settings and “deconditioning” caused by decreased physical activity among older people shielding at home, for example not walking around a supermarket or garden centre as they might normally. Read full story Source: The Guardian, 24 September 2020 -
Content ArticleRecommendations As a result of the national investigation, HSIB has made three safety recommendations to facilitate better understanding of the role of the ward-based pharmacist, and to encourage best practice and resilience when identifying and developing models of pharmacy provision. It is recommended that NHS England and NHS Improvement carry out work to understand and further define the work of hospital clinical pharmacy teams, including the period between initial medicine reconciliation and discharge, in consultation with relevant stakeholders. It is recommended that the Royal Pharmaceutical Society, supported by NHS England and NHS Improvement, should provide guidance on models of hospital clinical pharmacy provision. The guidance should provide information on the models’ ability to enhance safety and healthcare resilience and include consideration of the appropriate skill mix and experience within the clinical pharmacy team. It is recommended that the NHS Specialist Pharmacy Service should update its resource on the prioritisation of hospital clinical pharmacy services to facilitate the dissemination of developments in good practice and policy with respect to pharmacy prioritisation and the issues highlighted in this report.
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News ArticleA third of coronavirus patients in intensive care are from black, Asian and minority ethnic backgrounds, prompting the head of the British Medical Association to warn that government inaction will be responsible for further disproportionate deaths. Chaand Nagpaul, the BMA Council chair, was the first public figure to call for an inquiry into whether and why there was a disparity between BAME and white people in Britain in terms of how they were being affected by the pandemic, in April. Subsequent studies, including a Public Health England (PHE) analysis in early June, confirmed people of certain ethnicities were at greater risk but Nagpaul said no remedial action had been taken by the government. Nagpaul told the Guardian: “We are continuing to see BAME people suffering disproportionately in terms of intensive care admissions so not acting means that we’re not protecting our vulnerable communities. Action was needed back in July and it’s certainly needed now more than ever. “As the infection rate rises, there’s no reason to believe that the BAME population will not suffer again because no action has been taken to protect them. They are still at higher risk of serious ill health and dying.” Read full story Source: The Guardian, 20 September 2020
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News ArticleA decision not to "urgently" refer an anorexic woman whose condition had significantly deteriorated contributed to her death, a coroner said. Amanda Bowles, 45, was found at her Cambridge home in September 2017. An eating disorder psychiatrist who assessed her on 24 August apologised to Ms Bowles' family for not organising an admission under the Mental Health Act. Assistant coroner Sean Horstead said the decision not to arrange an assessment "contributed to her death". Mr Horstead told an inquest at Huntingdon Racecourse that also on the balance of probabilities the "decision not to significantly increase the level of in-person monitoring" following 24 August "contributed to the death". In his narrative conclusion, Mr Horstead said it was "possible... that had a robust system for monitoring Ms Bowles in the months preceding her death been in place, then the deterioration in her physical and mental health may have been detected earlier" and led to an earlier referral to the Adult Eating Disorder Service. He said this absence "was the direct consequence of the lack of formally commissioned monitoring in either primary or secondary care for eating disorder patients". Read full story Source: BBC News, 17 September 2020
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News ArticleYesterday marked the second World Patient Safety Day, and this year’s theme shined a light on health worker safety – those on the frontline of the pandemic have been selfless in their sacrifices to care for an ailing global population. What has become ever clearer is that a health system is nothing without those who work within it and that we must prioritise the safety and wellbeing of health workers, because without safe health workers we cannot have safe patients. Improving maternity safety has been a priority for some time – although rare, when things go wrong the consequences are unthinkable for families and the professionals caring for them. Maternity negligence makes up 50% of the total value of negligence claims across all NHS sectors, according to the latest NHS Resolution annual report and accounts. It states there were claims of around £2.4 billion in 2019/20, which is in the region of £6.5 million a day. This cost says nothing of the suffering families and professionals associated. However, without investing in the maternity frontline we cannot hope to make integral systemic changes to improve maternity safety and save mothers’ and babies’ lives, writes Sara Ledger, head of research and development at Baby Lifeline in the Independent. "We owe it to every mother and baby to rigorously and transparently scrutinise the safety of maternity services, which will be in no small way linked to the support staff receive." Read full story Source: The Independent, 17 September 2020
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News ArticleAccidents on maternity wards cost the NHS nearly £1 billion last year, Jeremy Hunt, the chairman of the Commons health committee, has revealed. The former health secretary said the bill for maternity legal action was nearly twice the amount spent on maternity doctors in England. It was part of the NHS’s £2.4 billion total legal fees and compensation bill, up £137 million on the previous year. Mr Hunt has also told the Daily Mail there is evidence that hospitals are failing to provide details of avoidable deaths despite being ordered to do so three years ago as he highlighted “appalling high” figures which showed that up to 150 lives are being lost needlessly every week in public hospitals. Responding to the figures, Mr Hunt said: "Something has gone badly wrong." In 2017, he told trusts to publish data on the number of avoidable deaths among patients in their care. But freedom of information responses from 59 hospital trusts, about half the total, found less than a quarter gave meaningful data on avoidable deaths. Mr Hunt cited “major cultural challenges” which he blamed for preventing doctors and nurses from accepting any blame. He blamed lawyers who get involved “almost immediately” once something goes wrong with a patient’s care. “Doctors, nurses and midwives worry they could lose their licence if they are found to have made a mistake. Hospital managers worry about the reputation of their organisation,” he added. Mr Hunt said: “We have appallingly high levels of avoidable harm and death in our healthcare system. We seem to just accept it as inevitable.” An NHS spokesman said: “Delivering the safest possible health service for patients is a priority, and the national policy on learning from deaths is clear that hospitals must publish this information every three months, as well as an annual summary, so that they are clear about any problems that have been identified and how they are being addressed. Read full story Source: The Telegraph, 18 September 2020
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News ArticleAn investigation into the outbreak of a bacterial infection that killed 15 people has found there were several “missed opportunities” in their care. Mid Essex Clinical Commissioning Group has released the outcome of a 10-month investigation into a Strep A outbreak in 2019, which killed 15 people and affected a further 24. The final report was critical of Provide, a community interest company based in Colchester, as well as the former Mid Essex Hospital Services Trust (now part of Mid and South Essex Foundation Trust). It said: “This investigation has identified that in some cases there were missed opportunities where treatment should have been more proactive, holistic and timely. These do not definitively indicate that their outcomes would have been different.” Investigators found that 13 of the 15 people that died had received poor wound care from Provide CIC. They reported that inappropriate wound dressings were used and record keeping was so poor that deterioration of wounds was not recognised. Even wounds that had not improved over 22 days were not escalated to senior team members for help or referred to the tissue viability service for specialist advice, with investigators told this was often due to concerns over team capacity. The report, commissioned by the CCG and conducted by consultancy firm Facere Melius, said: “[Some] individuals became increasingly unwell over a period of time in the community, yet their deterioration either went unnoticed or was not acted upon promptly. Sometimes their condition had become so serious that they were very ill before acute medical intervention was sought”. Other findings included delays in the community in the taking of wound swabs to determine if the wound was infected and by which bacteria. It said in one case nine days elapsed before the requested swab took place. Even after Public Health England asked for all wounds to be swabbed following the initial outbreak, this was only conducted on a single patient. In other cases there were delays in patients being given antibiotics and this “could have had an adverse impact on the treatment for infection”. It also found that sepsis guidelines were not accurately followed, wounds were not uncovered for inspection in A&E, and some patients were given penicillin-based antibiotics despite penicillin allergies being listed in their health records. Read full story (paywalled) Source: HSJ, 17 September 2020
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Event
The Killing of Alison - Lessons in honesty and integrity in public service
Sam posted a calendar event in Community Calendar
untilThe story of Alison Bell, and her family's uncovering of the truth about what happened to her in the care of an NHS Trust will be told by her brother Tom. He will describe the nature of the various investigations that were held into Alison's death and the role of the prevailing cultures within the public sector organisations they have dealt with; the NHS, Police, CPS and Regulatory Bodies. This true and ongoing story shines a light on the personal, emotional and financially costly impact that public sector service cultures can have on the lives of their service-users and their own bottom-line. Tom’s lived and current experience will help us to explore the implications for our own practice and the organisations we might seek to influence, manage and lead. Registration -
News ArticleToday, the nonpartisan nonprofit Patient Safety Movement Foundation will lead a demonstration in the nation’s capital to raise awareness for the patient safety crisis that claims more than 200,000 lives annually in the U.S. due to preventable medical harm. The demonstration begins from Freedom Plaza and participants will walk down Pennsylvania Avenue to the Capitol Lawn, where they will hold a remembrance of loved ones lost needlessly to preventable medical errors. The demonstrators will also demand the creation of a National Patient Safety Board to implement data-driven standards, transparency, accountability, and aligned incentives. “COVID-19 has exposed the safety gaps in our healthcare system that already cause 200,000 deaths a year,” said Dr. David B. Mayer, CEO of the Patient Safety Movement Foundation. “Many of us also have very personal stories of loss and tragedy related to preventable medical harm. Now is the time for change and improvement as we work toward zero preventable patient deaths by 2030.” Read full story Source: Patient Safety Movement
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News ArticleA damning report into Devon’s NHS 111 and out of hours GP service has revealed shocking stories of patients who have either had their health put at risk or tragically died due to the service being in need of urgent improvement. Devon Doctors Limited, which provides an Urgent Integrated Care Service (UICS) across Devon and Somerset, was inspected by independent health and social care regulator the Care Quality Commission (CQC) in July, after concerns were raised about the service. They included the care and treatment of patients, deaths and serious incidents, call waits, staff shortages, and low morale. Inspectors found 'deep rooted issues'. The CQC concluded it was not assured that patients were being treated promptly enough and, in some cases, they had not received safe care or treatment. It is calling for the service to make urgent improvements which will be closely monitored. Since August 2019, the report stated Devon Doctors had received 179 complaints. Nine had been identified by the service as incidents of high risk of harm and six had been identified by the service as incidents of moderate risk of harm. These had been recorded on the service’s significant event log. However, on review, the CQC identified an additional 30 events from the complaints log which could also have been classed as either moderate or high risk of harm. Read full story Source: Devon Live, 15 September 2020
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News ArticleA trust which accounted for one in eight of covid deaths in hospital during part of the summer has been criticised by the Care Quality Commission for its infection control. Staff did not follow social distancing rules in a staff room at East Kent Hospitals University Foundation Trust, did not always practise hand hygiene, and the trust had used incorrect PPE, the CQC said. In addition, two hourly cleans were not always carried out, soap and hand sanitiser were missing, and the emergency department at the William Harvey Hospital in Ashford did not have enough sinks for staff and visitors to wash their hands in. There was also a lack of hand hygiene guidance on display. Inspectors added that not all staff understood what needed to be done when a walk-in patient presented with covid symptoms, and the emergency department did not have an escalation plan if areas were crowded and patients could not socially distance. The CQC inspected the William Harvey Hospital on 11 August and took enforcement action after the visit. It has yet to publish the report but the initial feedback was summarised in the trust’s latest board papers, together with the trust’s response. Read full story (paywalled) Source: HSJ, 14 September 2020
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News ArticleA third of those who died with diagnosed or suspected COVID-19 in English hospitals did so at Tameside and Glossop Integrated Care Foundation Trust in the seven days to 10 September. The Greater Manchester Trust has seen a significant rise in COVID-19 deaths, from a weekly total of five on 4 September to 18 six days later. The total number of COVID-19 hospital deaths in the seven days to 10 September across England was 54. COVID-19 deaths at Tameside and Glossop had fallen to a weekly total of zero on 23 July, before beginning to climb steadily from 20 August. The last time the trust recorded 18 deaths in a seven-day period was in late April when the pandemic was still close to its first peak. The highest seven day figure recorded by the trust was 28, meaning the 10 September figure is equivalent to 64% of its peak covid-19 mortality. Nationally, hospital deaths with the virus are running at less than 1 per cent of the early-April peak. No other trust recorded more than three covid-19 deaths during the seven days to 10 September. Read full story (paywalled) Source: HSJ, 13 September 2020
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News ArticleCOVID-19 may have contributed to the deaths of 18 people who contracted the infection while being treated at Weston general hospital in Somerset, an investigation has found. The layout of the hospital and the proximity of staff and other patients who had Covid but were asymptomatic may have been among the reasons for the 18 people acquiring the virus. The hospital temporarily stopped accepting new patients, including into its A&E department, on Monday 25 May following a Covid outbreak among patients. It fully reopened on 18 June. As part of its investigation, University Hospitals Bristol and Weston NHS foundation trust identified 31 patients who died after contracting Covid while they were in-patients from 5-24 May. A detailed review of each of the cases was undertaken and it concluded that in 18 patients, the infection may have contributed to their death. Dr William Oldfield, the trust’s medical director, said: “We are deeply sorry for this. We are already in contact with the families of these patients and have informed them of the outcome of the review. We have apologised unreservedly and have offered them support." “For each family concerned, we will undertake an investigation into the specific circumstances that led to the death of their loved one. We will invite them to help inform the investigation to ensure that any questions they have are addressed. We recognise that other patients and families may have concerns and we would like to provide reassurance to everyone that the safety of our patients and staff continues to be our main priority.” Read full story Source: The Guardian, 10 September 2020
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News ArticleA risk calculator that takes seconds to produce a score indicating a COVD-19 patient’s risk of death could help clinicians make care decisions soon after patients arrive in hospital, according to a large study conducted by a consortium of researchers across the UK. As UK COVID-19 cases rise, schools reopen and the weather gets colder, doctors at UK hospitals are expected to see an influx of coronavirus patients. Patients with COVID-19 behave very differently to patients with other conditions such as flu and bacterial pneumonia, said Dr Antonia Ho of the University of Glasgow, one of the study’s authors, and it is very challenging for doctors managing this unfamiliar disease to accurately identify those who are at high risk of deterioration or who can ride out their illness at home. “So having a tool that … can help clinicians at the front door to accurately group patients who are coming in with COVID-19 into four distinct risk categories – low, intermediate, high and very high risk – is hugely valuable,” she added. “Having an accompanying low-risk score will provide that doctor with increased confidence that the vast majority of people, patients with that low-risk score, will come to no real harm.” Read full story Source: The Guardian, 9 September 2020
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News ArticleInquest finds Susan Warby, 57, received insulin she did not need after blood test mistakes. Hospital errors contributed to her death five weeks after bowel surgery, an inquest into her death has concluded. Susan Warby, 57, who died at West Suffolk hospital in Bury St Edmunds, was incorrectly given glucose instead of saline through an arterial line that remained in place for 36 hours and resulted in inaccurate blood test readings. She was subsequently given insulin she did not need, causing bouts of extremely low blood sugar (hypoglycemia) and the development of “a brain injury of uncertain severity”, recorded Suffolk’s senior coroner, Nigel Parsley. Speaking after the inquest was adjourned in January, Susan's husband, Jon Warby, said he was “knocked sideways completely” when he received an anonymous letter two months after her death highlighting blunders in her treatment. Doctors at the hospital were reportedly asked for fingerprints as part of the hospital’s investigation into the letter, a move described by a Unison trade union official as a “witch-hunt” designed to identify the whistleblower. Following January’s adjournment, Parsley instructed an independent expert to review the care that Warby received. Warby’s medical cause of death was recorded as multi-organ failure, with contributory causes including septicaemia, pneumonia and perforated diverticular disease, affecting the bowel. Recording a narrative conclusion, Parsley wrote: “Susan Warby died as the result of the progression of a naturally occurring illness, contributed to by unnecessary insulin treatment caused by erroneous blood test results. This, in combination with her other comorbidities, reduced her physiological reserves to fight her naturally occurring illness.” Jon Warby said in a statement: “The past two years have been incredibly difficult since losing Sue, and it is still a real struggle to come to terms with her no longer being here. The inquest has been a highly distressing time for our family, having to relive how Sue died, but we are grateful that it is over and we now have some answers as to what happened." “After learning of the errors in Sue’s care, I wanted to know how these occurred and what action was being taken to prevent any similar incidents in the future. The trust has now made a number of changes which I am pleased about.” Read full story Source: The Guardian, 7 September 2020
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Content ArticleI have included this poignant video as a matter of public interest. This is an issue which goes beyond party politics. I use Robbie's story in all of my teaching on ethics and clinical governance.
