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Content ArticleChildren being subjected to lethal medical experiments sounds like the plot of a dystopian horror film. Yet that is exactly what happened in the UK in the 1970s and 80s. New documents seen last week by the BBC reveal the extent to which children with haemophilia and other blood clotting disorders were enrolled in clinical trials, often without their parents’ consent. Most of them were infected with HIV or hepatitis C as a result of being treated with blood products that doctors knew could kill them. At one boarding school for boys with haemophilia used by the doctors conducting these trials, Treloar College in Hampshire, 75 out of the 122 pupils who attended between 1974 and 1987 have died as a result of their HIV or hepatitis C infections. The independent inquiry on the contaminated blood scandal estimated that 1,250 people contracted both HIV and hepatitis C as a result of these agents, and between 2,400 and 5,000 people hepatitis C alone. Others contracted these viruses after receiving blood transfusions following surgery or childbirth; it is thought that up to 100 people were infected with HIV this way, and 27,000 people with hepatitis C. Around 2,900 people have died so far. One gets a sense of the horrific trauma the state inflicted on people by reading the evidence those affected gave the inquiry.
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News Article
Block on data sharing contributed to death
Patient Safety Learning posted a news article in News
A failure to share medical information between IT systems contributed to the death of a man in prison custody, a coroner has concluded. In a newly published report on the death of Finlay Finlayson at HMP Lewes in 2019, the coroner highlighted “information sharing” problems and “permissions issues” between the prison IT system and that of the man’s GP surgery. Mr Finlayson died from blood clots in his lungs, having suffered from multiple long-term health conditions including cancer during his life. At the time of his death in 2019, health services at HMP Lewes were provided by Sussex Partnership Foundation Trust, though they are now provided by the Practice Plus Group. According to the Prevention of Future Deaths report issued last month, coroner Laura Bradford heard evidence that Mr Finlayson’s care was affected by “confusion and uncertainty about his medical conditions caused by information sharing and permissions issues with SystmOne”. It appears the GP practice had not enabled sharing of the data, which would have been required for it to be accessed in the prison. Read full story (paywalled) Source: HSJ, 22 April 2024 Further reading on the hub: NHS England warns electronic patient record could pose ‘serious risks to patient safety’: what can we learn? The digitalising of patient records — why patients MUST be involved -
Content Article
Digital storytelling: Learning opportunity or reputational risk?
Anonymous posted an article in Culture
In this anonymous blog, a member of NHS staff talks about their experience promoting digital storytelling to help staff members and the wider trust learn from patients’ perspectives on incidents of harm. They describe the conflicting pressures of leaders’ concerns about how these stories might affect the Trust's reputation and the need to be transparent with patients and staff.- Posted
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Content Article'Vinney' died of pulmonary thromboemboli due to deep vein thrombosis with a background of metastatic carcinoma of the base of the tongue following cardiac arrest on 25 January 2019 at HMP Lewes (Cell 216 on C-Wing), whilst on remand. He was pronounced dead at 9.16 am. The jury considered that Vinney’s care was affected by the following issues, the absence of which may have delayed or changed the circumstances of his death. There was confusion and uncertainty about his medical conditions caused by information sharing and permissions issues with SystmOne, leading to an over reliance on Vinney’s own statements. Some poor record keeping on SystmOne and confusion over when to reference the system. This affected both plans and reporting of interactions. Failures in communication between agencies and shifts, not helped by the numbers of different staff and agencies involved, high demand and challenging workloads and associated delays in accessing healthcare. This was particularly relevant between 21 and 24 January 19. In particular a lack of quantifiable evidence, e.g. NEWS scores or notes of proportionate follow-ups and recorded observations between 21 and 24/1/19 which may have allowed any deterioration in Vinney’s condition to be missed. On 25/1/19, there was a grave and unacceptable failure in communications with two or three emergency radios switched off in contravention of prison rules and protocols. This was then compounded by a delay in timely response, i.e. the proposal of a phone call rather than an in-person response, which may have been longer had it not been for decisive intervention from comms. This was followed by unacceptable indecision on calling an ambulance, in which perceptions of Vinney’s mental health were a factor, and should have been automatic on account of his head injury.
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Content ArticleLittle is known as to whether the effects of physician sex on patients’ clinical outcomes vary by patient sex. This study examined whether the association between physician sex and hospital outcomes varied between female and male patients hospitalised with medical conditions. The findings indicate that patients have lower mortality and readmission rates when treated by female physicians, and the benefit of receiving treatments from female physicians is larger for female patients than for male patients.
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News Article
Leaked NHS figures reveal 15,000 died in care of mental health trusts in one year
Patient Safety Learning posted a news article in News
The shocking number of patients who are dying while under the care of stretched community mental health services can be revealed for the first time after a major NHS report was leaked to The Independent. More than 15,000 people are estimated to have died in a single year while being cared for by community mental health teams – as trusts scramble for staff and funding while the demand for care is at an all-time high. The figures, which relate to deaths between March 2022 and March 2023, can be revealed after a concerned insider handed the secret report to this publication. Health officials admitted the statistics had been collated for the first time last year in a bid to reduce deaths – but have not made them public. The leaked report reveals that: At least 137 women died between 2022 and 2023 while under the care of services for pregnant women at one unnamed trust. Nearly one in 10 of the patients treated by a crisis service – designed to help those with the most severe mental health conditions – died while under that care. One unnamed mental health trust recorded more than 500 deaths in that year-long period. Read full story Source: The Independent, 22 April 2024 -
News Article
Letby to seek permission for conviction appeal
Patient Safety Learning posted a news article in News
Lucy Letby is to apply for permission to appeal against her convictions for the murder and attempted murder of babies in her care. A panel of three judges at the Court of Appeal in London is due to consider the former nurse’s case later. The 34-year-old was handed 14 whole life terms last year. She was found guilty of murdering seven babies and attempting to murder a further six at the Countess of Chester Hospital between 2015 and 2016. Second stage Shortly after her trial ended in August, Letby applied for leave to appeal against her convictions. She lost the first stage of the process, in which a single judge reviewed her arguments as a paper exercise. Letby, originally of Hereford, now has the right to a second stage, which involves renewing her application before a panel of judges at a hearing at the Court of Appeal. Separately to the appeal, Letby is due to be re-tried on one charge of attempted murder, which the jury at her trial was unable to decide on. Read full story Source: BBC News, 2 April 2024 -
Content ArticleAround 1.3 million people in England have a learning disability and may need more support to stay in good health. But are they able to get access to the services they are entitled to in order to prevent illness? This Nuffield Trust report looks at a set of five key preventive healthcare services and functions to understand whether they are working as they should for people with a learning disability.
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Content ArticleDiagnostic errors cause substantial preventable harms worldwide, but rigorous estimates for total burden are lacking. Newman-Toker and colleague previously estimated diagnostic error and serious harm rates for key dangerous diseases in major disease categories and validated plausible ranges using clinical experts. In this study they estimated the annual US burden of serious misdiagnosis-related harms (permanent morbidity, mortality) by combining prior results with rigorous estimates of disease incidence. They found that an estimated 795 000 Americans become permanently disabled or die annually across care settings because dangerous diseases are misdiagnosed. Just 15 diseases account for about half of all serious harms, so the problem may be more tractable than previously imagined.
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News Article
Seven more avoidable sepsis deaths spark coroner warnings
Patient Safety Learning posted a news article in News
Preventable deaths of seven people from sepsis – including four children – have prompted coroners to flag major concerns about NHS services’ management of the condition. Since the start of March, six English coroners have sent formal warnings to trusts, NHS England and the government warning of systemic failures to spot sepsis and delays in administering antibiotic treatments. It comes after an HSJ investigation in February uncovered more than 30 avoidable deaths from sepsis, and undertook analysis of internal figures revealing repeated failures by NHS trusts to provide prompt treatment. Coroner warnings since March include: Two notices were sent this week by Nottingham assistant coroner Elizabeth Didcock to Sherwood Forest Hospitals Foundation Trust, raising concerns over its ability to provide safe paediatric care following the deaths of 10-week-old Tommy Gillman and five-year-old Meha Carneiro from sepsis; A warning from earlier in April criticising University Hospitals Birmingham FT for its failure to treat 56-year-old Tracey Farndon’s sepsis and low blood pressure. Read full story (paywalled) Source: HSJ, 17 April 2024 -
Content ArticleThis French cohort study in JAMA Internal Medicine aimed to find out whether spending a night in the emergency department (ED) associated with increased in-hospital mortality and morbidity among older patients. The results showed that older patients who spent a night in the ED showed a higher in-hospital mortality rate and increased risk of adverse events compared with patients admitted to a ward before midnight. This finding was particularly notable among patients with limited autonomy.
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News Article
Concerns at Nottinghamshire hospital after baby's sepsis death
Patient Safety Learning posted a news article in News
The parents of a baby who died from sepsis said their son deserved a "fighting chance" after concerns were raised over his care in hospital. Ten-week-old Tommy Gillman was admitted to King's Mill hospital on 7 December 2022 but died the next day. Tommy Gillman, from Coddington, Nottinghamshire, was "extremely unwell" with what proved to be Salmonella Brandenburg meningitis when admitted to the Sutton-in-Ashfield hospital at 12:35 GMT. His assessment was delayed, and then the severity of his condition missed, meaning correct treatment with antibiotics and fluids did not start until 17:00. A coroner's report identified a lack of experienced paediatric nurses and confusion in handovers between staff. "I am not reassured that necessary actions to address these serious issues identified are in place," the coroner said. Sherwood Forest Hospitals NHS Foundation Trust said it welcomed the review and a "rapid" programme of improvements was being worked on. Tamzin Myers and Charlie Gillman said their son deserved "a fighting chance" by getting prompt treatment Read full story Source: BBC News, 17 April 2024 -
Content ArticleTommy Gillman died on 8 December 2022 from sepsis and multi organ failure secondary to Salmonella Brandenburg meningitis. There were missed opportunities to provide him with earlier antibiotics, fluid resuscitation and intensive monitoring from 12.35pm on the 7 December 2022 at Kings Mill Hospital. Once the severity of his illness had been recognised at approximately 17:00 hours on that day, he was provided with prompt treatment for septic shock and meningitis. Sadly however he did not respond to this treatment and died the following day following transfer to Leicester Royal Infirmary. Whilst there were serious missed opportunities to provide earlier treatment of sepsis and meningitis.
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News Article
Causes of death to be scrutinised in revamp of death certificates
Patient Safety Learning posted a news article in News
Public protection and support for bereaved families are at the heart of a government overhaul of how deaths are certified. From September, medical examiners will look at the cause of death in all cases that haven’t been referred to the coroner in a move designed to help strengthen safeguards and prevent criminal activity. They will also consult with families or representatives of the deceased, providing an opportunity for them to raise questions or concerns with a senior doctor not involved in the care of the person who died. The changes demonstrate the government’s commitment to providing greater transparency after a death and will ensure the right deaths are referred to coroners for further investigation. Health Minister, Maria Caulfield said: Reforming death certification is a highly complex and sensitive process, so it was important for us to make sure we got these changes right. At such a difficult time, it’s vital that bereaved families have full faith in how the death of their loved one is certified and have their voices heard if they are concerned in any way. The measures I’m introducing today will ensure all deaths are reviewed and the bereaved are fully informed, making the system safer by improving protections against rare abuses. From 9 September 2024 it will become a requirement that all deaths in any health setting that are not referred to the coroner in the first instance are subject to medical examiner scrutiny. Welcoming the announcement today, Dr Suzy Lishman CBE, Senior Advisor on Medical Examiners for Royal College of Pathologists, said: “As the lead college for medical examiners, the Royal College of Pathologists welcomes the announcement of the statutory implementation date for these important death certification reforms. “Medical examiners are already scrutinising the majority of deaths in England and Wales, identifying concerns, improving care for patients and supporting bereaved people. The move to a statutory system in September will further strengthen those safeguards, ensuring that all deaths are reviewed and that the voices of all bereaved people are heard.” Read full story Source: Gov.UK, 15 April 2024 -
News Article
Deaths inquiry extended to last three years
Patient-Safety-Learning posted a news article in News
A statutory inquiry into deaths of mental health patients will now cover fatalities that took place as late as December 2023. The inquiry’s investigations are focused “on the trusts which provide NHS mental health inpatient care in Essex”. This includes: “Essex Partnership University Foundation Trust, and the North East London Foundation Trust and their predecessor organisations, where relevant.” NELFT was not specifically mentioned in the original terms of reference although the inquiry told HSJ it had been within the original scope. The inquiry will also now cover deaths of NHS patients from Essex who died when under the care of private sector providers. The inquiry’s previous terms of reference covered a period ending in 2020. However, the inquiry’s chair, Baroness Kate Lampard, proposed extending the inquiry’s scope last year due to “ongoing concerns” over services at EPUFT. Read full story (paywalled) Lampard Inquiry: Terms of reference Source: HSJ, 11 April 2024 -
Content Article
Lampard Inquiry: terms of reference (10 April 2024)
Mark Hughes posted an article in Other reports and inquiries
The Lampard Inquiry will seek to understand the events that led to the tragic deaths of mental health inpatients under the care of NHS trusts in Essex between 2000 and 2023. This document outlines the terms of reference set following consultation with the chair of the inquiry, Baroness Lampard. -
Content ArticleNHS England’s response to claims of excess deaths due to long A&E waits leaves a lot to be desired, writes Steve Black for the HSJ. The Royal College of Emergency Medicine (RCEM) claim that more than 250 A&E patients are dying each week because they waited more than 12 hours to be admitted. If long waits in A&E are killing an extra 250-400 people every week, it is the biggest performance problem in the NHS. NHSE should urgently ask their analysts to rework this analysis with current data to test (or refute) the validity of the claim. The first step to solving a huge problem is admitting the scale of the problem, not denying it exists. This analysis features a refinement of the RCEM estimate that includes estimated mortality from waits between four and 12 hours. This increases the estimate to 400 extra deaths per week compared to the RCEM number of 250.
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Content ArticleIn November 2023, the Parliament’s Justice Select Committee launched a follow-up inquiry to The Coroner Service, to examine changes and progress since the first inquiry in 2020-2021.
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News Article
Catherine died on the operating table. Now police are investigating
Patient Safety Learning posted a news article in News
Catherine O’Connor was 17 when she died, having lost 14 litres of blood during high-risk surgery on her back. At her inquest, the surgeon who operated on her, John Bradley Williamson, told the coroner the procedure at Salford Royal Hospital in Greater Manchester had “progressed uneventfully” and “the blood loss was perhaps a little higher than one would usually anticipate but was certainly not extreme”. The coroner recorded a verdict of death by misadventure. Now Greater Manchester police are examining O’Connor’s death, in February 2007, and whether Williamson misled the coroner during the inquest in September that year. Catherine's family are now demanding a new inquest into her death in 2007. This is because in the days after O’Connor’s death, Williamson sent an internal letter to the head of the hospital’s haematology department, Simon Jowitt, describing the surgery as “difficult” and having involved “a catastrophic haemorrhage”. Williamson had also ignored advice to have a second surgeon present during the operation. Officers led by Detective Inspector Michael Sharples have commissioned two expert reports and sought advice from the Crown Prosecution Service ahead of a meeting with the coroner, who has been asked to consider reopening O’Connor’s inquest. Read full story (paywalled) Source: The Times, 31 March 2024 -
News ArticleFamilies have been told they will have to prove liability for the harm caused to mothers and children at East Kent Hospitals University Foundation Trust before getting compensation. This is despite the inquiry having examined each case in detail and concluding 45 babies could have survived, while 12 who sustained brain damage could have had a different outcome. It also determined 23 women who either died or suffered injuries might have had better outcomes had care been given to “nationally recognised” standards. However, NHS Resolution – which handles claims for clinical negligence – now says families must prove causation and a breach of duty of care before any compensation can be made. This stipulation has been made even in cases where the inquiry found different treatment would have been reasonably expected to make a difference to the outcome. The investigation into the trust’s maternity care led by Bill Kirkup reported 18 months ago. Speaking to HSJ, its author said: “I am disappointed that East Kent families are facing these problems after everything that has happened to them. Of course, it is true that the independent investigation panel was not in a position to rule on negligence, but we did provide a robust clinical assessment of each case. “I would have hoped that this could be taken into account in deciding to offer early settlement instead of a protracted dispute. It seems sad that a more compassionate approach has not been adopted.” Read full story (paywalled) Source: HSJ, 2 April 2024
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News Article
Vulnerable Britons dying as not being given antibiotics at dentist, doctors say
Patient Safety Learning posted a news article in News
Patients are dying needlessly every year due to vulnerable Britons with heart problems not being given antibiotics when they visit the dentist, doctors have said. Almost 400,000 people in the UK are at high risk of developing life-threatening infective endocarditis any time they have dental treatment, the medics say. The condition kills 30% of sufferers within a year. A refusal to approve antibiotic prophylaxis (AP) in such cases means that up to 261 people a year are getting the disease and up to 78 dying from it, they add. That policy may have caused up to 2,010 deaths over the last 16 years, it is claimed. That danger has arisen because the National Institute for Health and Care Excellence (NICE) does not follow international good medical practice and tell dentists to give at-risk patients antibiotics before they have a tooth extracted, root canal treatment or even have scale removed, the experts claim. The doctors – who include a professor of dentistry, two leading cardiologists and a professor of infectious diseases – have outlined their concerns in The Lancet medical journal. In it, they urge NICE to rethink its approach in order to save lives, citing pivotal evidence that has emerged since the regulator last examined the issue in 2015, which shows that antibiotics are “safe, cost-effective and efficacious”. Read full story Source: The Guardian, 2 April 2024 -
News Article
Long A&E wait times lead to more than 250 needless deaths a week
Patient Safety Learning posted a news article in News
More than 250 patients a week could be dying unnecessarily, due to long waits in A&E in England, according to analysis of NHS data. The Royal College of Emergency Medicine analysed the 1.5 million who waited 12 hours or more to be admitted in 2023. A previous data study had calculated the level of risk of people dying after long waits to start treatment and found it got worse after five hours. The government says the number seen within a four-hour target is improving. This is despite February seeing the highest number of attendances to A&E on record, it adds. The Royal College of Emergency Medicine (RCEM) carried out a similar analysis in 2022, which at that time resulted in an estimate of 300-500 excess deaths - more deaths than would be expected - each week. The analysis uses a statistical model based on a large study of more than five million NHS patients that was published in 2021. RCEM president Dr Adrian Boyle said long waits were continuing to put patients at risk of serious harm. "In 2023, more than 1.5 million patients waited 12 hours or more in major emergency departments, with 65% of those awaiting admission," he said. "Lack of hospital capacity means that patients are staying in longer than necessary and continue to be cared for by emergency department staff, often in clinically inappropriate areas such as corridors or ambulances. "The direct correlation between delays and mortality rates is clear. Patients are being subjected to avoidable harm." Read full story Source: BBC News, 1 April 2024 -
Content ArticleThe idea of Emergency care services experiencing seasonal spikes in demand – so called ‘Winter Pressures’ are fast becoming a thing of the past. Instead, long waits have become the new norm year-round, and staff are caring for patients in unsafe conditions on a daily basis. It is well established that long waits are associated with patient harm and excess deaths. Last year the UK Government published a Delivery Plan for the Recovery of Urgent and Emergency Care (UEC) services. A year on, far too many patients are still coming to avoidable harm. New analysis by the Royal College of Emergency Medicine (RCEM) reveals that there were almost 300 deaths a week associated with long A&E waits in 2023.
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Content ArticleMedical errors happen all the time. They can be overlooked or they can lead to big lawsuits and settlements. But what they rarely lead to is an apology. However, increasingly, patients, families and healthcare professionals, are calling for a new approach, one that acknowledges the lasting damage that comes from a failure to address medical mistakes. In this report for US media company NPR, a Naomi and Jeff tell their story of losing their daughter Thalia to medical error following planned surgery. They report that concerns they and Thalia raised about their breathing were ignored by healthcare professionals, and Thalia died after her brain was starved of oxygen. The hospital didn't give an explanation or apology for Thalia's death.
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News ArticlePatients at the hospital that treated killer Valdo Calocane were discharged too soon and released in a worse state into the community, the NHS safety watchdog has found. Serious failings by Nottinghamshire Hospital Foundation Trust in keeping patients and the public safe have been identified in a review from the Care Quality Commission (CQC). More than 1,200 patients are waiting to be seen by community services, the report found. Meanwhile, several hundred who are receiving treatment did not have a clinician overseeing their care,the CQC found. The review was launched by the government following the conviction of killer Valdo Calocane, who was under the care of the NHS trust’s community services. The CQC review said patients reported that crisis services are either “useless” or detrimental to their health. The three broad areas of concern, highlighted in the CQC’s report, were: High demand for services was leading to long waiting times for care and a lack of oversight of those waiting. The trust does not have enough staff to keep patients safe in the community and within some hospital services. Senior leaders at the trust do not have clear oversight of the risks and issues within the service. Read full story Source: The Independent, 27 March 2024
