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Scans of 1,800 patients reviewed after private contract suspended

Ultrasound scans for around 1,800 patients have had to be reviewed over concerns about the “quality and safety” of work carried out by two sonographers employed by an independent provider.

The two sonographers were employed by Bestcare Diagnostics. The company held an “any qualified provider” contract for non-obstetric ultrasound scans with Coastal West Sussex Clinical Commissioning Group (CCG) from April 2017.

This contract was suspended in September 2018 over what the CCG said were “quality issues”. However, new information came to light in spring 2019 and the CCG decided to review all 1,800 patients seen by the pair, who worked for the company between April and August 2018.

The CCG said scans for these patients were reviewed and, wherever possible, the patients were contacted. A second stage of the review will look at whether any harm was caused to the patients.

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Source: HSJ, 20 February 2020

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NHS Digital and PHIN launch consultation on next phase of Acute Data Alignment Programme

NHS Digital and the Private Healthcare Information Network (PHIN) have launched a consultation as part of the next phase of a programme to align private healthcare data with NHS recorded activity.

The consultation sets out a series of changes to how data is recorded and managed across private and NHS care, along with a series of pilot projects, based upon feedback from a variety of stakeholders. It aims to seek the views of private and NHS providers, clinicians, the public and other organisations with an interest in private healthcare and will be used to help shape the future changes.

The consultation, which has been launched following the publication of the Paterson Inquiry, will be hosted on the NHS Digital Consultation Hub.

Under the changes proposed in the Acute Data Alignment Programme (ADAPt), PHIN will share the national dataset of private admitted patient care in England with NHS Digital, creating a single source of healthcare data in England.

This recommendation has been supported by recommendations in the Paterson Inquiry to create a single repository for practice of consultants in private and public healthcare across England.

Health Secretary Matt Hancock said: “Regardless of where you’re treated or how your care is funded, everybody deserves safe, compassionate care. The recent Paterson Inquiry highlighted the shocking failures that can occur when information is not shared and acted upon in both the NHS and independent sector. We are working tirelessly across the health system to deliver the highest standards of care for patients. Trusted data is absolutely critical to this mission and the ADAPt programme will help improve transparency and raise standards for all.”

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Source: NHS Digital, 19 February 2020

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NHS to benefit from digital 'Redbook' app

As part of the NHS Digital Child Health programme, Personal Child Health Records or “Redbook” will receive a digital makeover.

NHS Digital has considered the limitations of the physical Redbook and decided that digitalisation is the way forward for parents to easily access important health and development information.

Nurturey has been evolving its product to align with NHS' Digital Child Health programme. It aims to be an app that can make the digital Redbook vision a reality and currently in the process of completing all the necessary integrations and assurances.

It is hoped that by using smart digital records, parents will be more aware of their child’s health information like weight, dental records, appointments and other developmental milestones.  

Tushar Srivastava, Founder and CEO of Nurturey, said:

“Imagine receiving your child's immunisation alert/notification on the phone, clicking on it to book the immunisation appointment with the GP, and then being able to see all relevant immunisations details on the app itself. As a parent myself, I see the huge benefit of being able to manage my child’s health on my fingertips. We are working hard to deliver such powerful features to parents by this summer.”

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Source: National Health Executive, 5 February 2020

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Abusive NHS patients to be banned from receiving non-emergency care

Patients who abuse NHS staff will be banned from receiving non-emergency care as new figures show more than one in four NHS staff have experienced harassment, bullying or abuse from patients, relatives or members of the public.

The annual survey of more than 560,000 NHS workers found one in seven staff (15%) had experienced physical violence in the last 12 months while 40,000 staff (7.2%) had faced some form of discrimination during 2019 – an increase from 5.8% in 2015.

A total of 13% of staff reported being bullied, harassed or abused by their own manager in the past 12 months and almost a fifth (19%) said they had experienced abuse from colleagues.

The health secretary Matt Hancock has written to staff condemning the abuse and warning assaults on NHS workers will not be tolerated. Under new plans NHS England said that from April NHS hospitals will be able to bar patients who inflict discriminatory or harassing behaviour on staff from receiving non-emergency care. Previously, individual NHS organisations could only refuse services to patients if they were aggressive or violent.

Hospitals will be required to act reasonably and take into account the mental health of the patient or member of the public.

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Source: The Independent, 19 February 2020

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Harry Richford inquest: 'Lives at risk' over locum doctor recruitment

Lives may be at risk unless the NHS reviews how stand-in doctors are recruited, a coroner has warned.

Harry Richford's death after a series of failings at a hospital in Margate, Kent, was ruled "wholly avoidable". An inquest heard he was delivered by an "inexperienced" locum doctor who was new to the hospital.

A national review into the recruitment, assessment and supervision of locums should be carried out, Christopher Sutton-Mattocks said in a report. The coroner wrote that particular emphasis should be considered upon the scope of locums' activities before they are left responsible for out-of-hours labour care.

He issued 19 recommendations to prevent future deaths, including a request that NHS England and the Royal College of Obstetricians and Gynaecologists consider such a review, warning "there may be a risk to other lives both at this trust and at other trusts in the future".

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Source: BBC News, 19 February 2020

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Health Foundation to explore impact of data analytics and technology

The Health Foundation will begin exploring the impact of data analytics and technology on health and care in the UK.

The independent charity has launched its Data Analytics for Better Health strategy, which aims to tackle real-world problems that affect people’s health and develop a greater understanding of the role that technology and data plays in daily life. The strategy sets out how the Health Foundation aims to help policymakers, practitioners and the wider public get to grip with “seismic changes” taking place in the health sector.

Dr Adam Steventon, Director of Data Analytics at the Health Foundation, said: “Data is being used to drive innovation in ways that can revolutionise health care, including early disease detection, easier access to care services and encouraging health promoting behaviours. But such technological advances also carry the risk of harm to patients. As a nation we need to advance our understanding of these fast-moving changes. This new programme of work will help us to do that, enabling us to explore how analytics and data-driven technology can create better heath and care for people across the UK.”

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Source: Digital Health, 6 February 2020

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Thousands of patients potentially harmed by undelivered NHS mail

The NHS has launched a patient safety inquiry after a private contractor failed to send more than 28,000 pieces of confidential medical correspondence to GPs. 

NHS bosses are trying to find out if any patients have been harmed after 28,563 letters detailing discussions at outpatient appointments were not sent because of a mistake by Cerner, an IT company. The letters should have been sent by doctors at Barnet and Chase Farm hospitals in north London to GPs after consultations with 22,144 patients between June last year and last month. However, a “clinical harm review” is under way after it was found they had not been dispatched.

The incident has prompted concern among GPs and patient representatives. “Patients who have attended these two hospitals will now be very worried about whether their care might have been compromised by this IT bungle”, said Rachel Power, the chief executive of the Patients Association.

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Source: The Guardian, 18 February 2020

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New tech allowing district nurses to digitally monitor wounds

A new app has been piloted in North East London to help district nurses document chronic wound management more efficiently. The tech has been used in community services and stores a catalogue of photographs to accurately document chronic wounds. 

District nurses can use the app on a smartphone – making it lightweight, portable and easy to clean. Using two calibration stickers placed either side of the wound, the app can scan it and capture its size and depth to build a 3D image. Nurses can then fill out further characteristics on the software such as colour, pain level, location and smell to give a full picture of the wound’s development.

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Source: Nursing Times,  12 February 2020

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Doctors using AI to predict heart attack risk more accurately

London doctors are using artificial intelligence to predict which patients with chest pains are at greatest risk of death. 

A trial at Barts Heart Centre, in Smithfield, and the Royal Free Hospital, in Hampstead, found that poor blood flow was a “strong predictor” of heart attack, stroke and heart failure. Doctors used computer programmes to analyse images of the heart from more than 1,000 patients and cross-referenced the scans with their health over the next two years. The computers were “taught” to search for indicators of future “adverse cardiovascular outcomes” and are now used in a real-time basis to help doctors identify who is most at risk.

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Source: Evening Standard, 15 February 2020

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Skin cancer apps ‘cannot be relied upon for accurate results’, study finds

Smartphone apps designed to detect the risk of skin cancer are poorly regulated and “frequently cannot be relied upon to produce accurate results”, according to a new analysis. They found the apps may cause harm from failure to identify potentially deadly skin cancers, or from over-investigation of false positive results such as removing a harmless mole unnecessarily.

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Source: Digital Health, 14 February 2020

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NHS Doctors bullied to the brink

The Doctors’ Association UK has compiled stories from 602 frontline doctors which expose a startling culture of bullying and overwork in the NHS.

The stories include:

  • a pregnant doctor who fainted after being forced to stand up for 15 hours straight and being denied water. The junior doctor was subsequently shouted at in front of colleagues and patients on regaining consciousness and told it was her choice to be pregnant and that ‘no allowances would be made’.
  • a doctor who told us that a junior doctor hung themselves in a cupboard whilst on shift and was not found for 3 days as no-one had looked for them. His junior doctor colleagues were not allowed to talk about his suicide and it was all ‘hushed up’.
  • a doctor who was denied a change of clothes into scrubs after having a miscarriage at work despite her trousers being soaked in blood.

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‘Shameful’ data reveals NHS treatment of minority ethnic staff

Five years after launching a plan to improve treatment of black and minority ethnic staff, NHS England data shows their experiences have got worse.

Almost a third of black and minority ethnic staff in the health service have been bullied, harassed or abused by their own colleagues in the past year, according to “shameful” new data.

Minority ethnic staff in the NHS have reported a worsening experience as employees across four key areas, in a blow to bosses at NHS England, five years after they launched a drive to improve race equality.

Critics warned the experiences reported by BME staff raised questions over whether the health service was “institutionally racist” as experts criticised the NHS “tick box” approach and “showy but pointless interventions”.

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Source: The Independent, 18 February 2020

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EFORT takes on the demanding implant and patient safety initiative

When orthopaedic surgeons plan a surgical procedure, they demand that safe implants be used. When a patient accepts to undergo surgery, he or she expects the implants used to be safe. When the manufacturer produces and delivers implantsto be used in patients, they take the implants through a meticulous investigation followed by an evaluation of the products by regulators and notified bodies, before the implant is released for free use on the European market by physicians. In this way, all “stakeholders” expect and desire to do their best to bring about safe implants that are used in surgery for patients, which fulfills patients’ expectations of receiving safe treatment.

However, history has shown that, although all participants in this process do their job to treat the patient safely, some implants may still unexpectedly fail. We need to know why this occurs and the trends associated with such failures, such as whether the implant or patient’s characteristics led to the problem or if there is some unforeseen reason that caused the implant to fail.

Incoming EFORT president Prof. Klaus-Peter Günther, of Dresden, Germany, has set up regular meetings to bring all 'stakeholders' in the safety of orthopaedic implants together to regularly discuss relevant issues related to safe implants used to safely treat patients. 

EFORT held the first such meeting, “EFORT Implant & Patient Safety Initiative. Inauguration Workshop,” on 21 January 21 in Brussels. Fifty participants from the EU Commission, notified bodies, regulators, patient organizations, European orthopaedic specialty societies, manufacturers and EFORT board participated in this first initiative. 

The next meeting on this initiative will be held on 10 June during the EFORT Congress in Vienna, Austria.

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Source: Orthopedics Today, 13 February 2020

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NHS Staff Survey 2019

Today the results of the National NHS Staff Survey 2019 are out. This is of the largest workforce surveys in the world with 300 NHS organisations taking part, including 229 trusts. It asks NHS staff in England about their experiences of working for their respective NHS organisations.

The results found that 59.7% of staff think their organisation treats staff who are involved in an error, near miss or incident fairly. While an improvement on recent years (52.2% in 2015) work is needed to move from a blame culture to one that encourages and supports incident reporting.

It also found that 73.8% of staff think their organisation acts on concerns raised by patients/service users. It is vital that patients are engaged for patient safety during their care and there is clear research evidence that active patient engagement helps to reduce unsafe care.

Patient Safety Learning has recently launched a new blog series on the hub to develop our understanding of the needs of patients, families and staff when things go wrong and looking at how these needs may be best met.

 

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Baby boy died from sepsis after doctors’ delay giving antibiotics

A three-month-old boy died from sepsis after ‘gross failures’ by medics to give him antibiotics until it was too late, an inquest ruled. Lewys Crawford died a day after he was admitted to the University Hospital of Wales in Cardiff with a high temperature last March. Jurors at Pontypridd Coroner’s Court said the failure of doctors to treat his illness with antibiotics until seven hours after his arrival had ‘significantly contributed’ to his death. They found the little boy died from natural causes contributed to by neglect in his care.

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Source: The Metro, 15 February 2020

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The NHS In England: Patient safety news roundup from Harvard Law

There is always a lot happening with patient safety in the NHS (National Health Service) in England. Sadly, all too often patient safety crises events occur. The NHS is also no sloth when it comes to the production of patient safety policies, reports, and publications. These generally provide excellent information and are very well researched and produced. Unfortunately, some of these can be seen to falter at the NHS local hospital implementation stage and some reports get parked or forgotten. This is evident from the failure of the NHS to develop an ingrained patient safety culture over the years. Some patient safety progress has been made, but not enough when the history of NHS policy making in the area is analysed.

Lessons going unlearnt from previous patient safety event crises is also an acute problem. Patient safety events seem to repeat themselves with the same attendant issues.

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Source: Harvard Law, 17 February 2020

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Not enough pharmacists are aware of the yellow card scheme

Every pharmacist must report adverse drug reactions using the yellow card scheme, says chair of the Community Pharmacy Patient Safety Group, Janice Perkins

Polypharmacy, when different medications are used by an individual at the same time, is becoming increasingly common because people are living for longer and with multiple different illnesses. One study, published in 2018 by the Oxford University Press, found that over half (54%) of those aged 65 years and above who took part in the study had two or more long-term conditions, for which they could have been taking a range of medicines.

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Source: Community Pharmacy News, 17 February 2020

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Whistleblowing district nurse 'different person' after unfair dismissal

A senior district nurse who was unfairly dismissed after blowing the whistle over valid safety concerns has told how the ordeal has left her life in "chaos" and she feels forced to quit the profession for good. 

Linda Fairhall, who had worked at North Tees and Hartlepool NHS Foundation Trust for 38 years, has spoken to Nursing Times about her experiences after she successfully challenged her employer's decision to sack her. Between December 2015 to October 2016, Ms Fairhall raised 13 concerns to the trust regarding staff and patient safety. At the time, she was managing a team of around 50 district nurses in her role of clinical care co-ordinator.

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Source: Nursing Times, 17 February 2020

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The NHS should act now to avoid a worse crisis next winter

Action must be taken now if the NHS is to avoid an even worse winter crisis next year, the chief inspector of hospitals has warned.

The Care Quality Commission (CQC) said the use of corridors to treat sick patients in A&E was “becoming normalised”, with departments struggling with a lack of staff, poor leadership and long delays leading to crowding and safety risks. Professor Ted Baker said: “Our inspections are showing that this winter is proving as difficult for emergency departments as was predicted. Managing this remains a challenge but if we do not act now, we can predict that next winter will be a greater challenge still. “We cannot continue this trajectory. A scenario where each winter is worse than the one before has real consequences for both patients and staff.”

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Source: The Independent, 18 February 2020

 

 

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NHS staffing crisis: A critical exception to the immigration rules

Staffing shortages remain a pervasive challenge for the NHS, risking patient safety, care standards and the pursuit of innovation. 

There are now 106,000 vacancies across the NHS in England, with over 44,000 vacancies in nursing. Overseas staff are a crucial way of filling those vacancies, but the message to potential workers is confused to say the least.

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Source: Health Europa, 14 February 2020

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Infected Blood Enquiry: Timetable and factsheet for expert hearings

This is the independent public statutory inquiry into the use of infected blood. 

The timetable and factsheet to provide information for those attending the hearings in London on 24-28 February have just been published.

Go to this link for more information >> https://www.infectedbloodinquiry.org.uk/news 

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Senior nurse who tried to whistleblow unfairly dismissed, tribunal rules

A trust unfairly dismissed a senior nurse after she tried to invoke its formal whistleblowing policy, an employment tribunal has ruled.

North Tees and Hartlepool Foundation Trust had suspended Linda Fairhall for 18 months without a “meaningful or adequate” explanation prior to her dismissal, the judgment said. 

Ms Fairhall, who led a team of 50 district nurses in Hartlepool, reported on the trust’s risk register that a “change in policy” by the local authority had directly led to increased workloads for her staff. The change meant staff had to monitor patients who had been prescribed medication “so as to ensure the correct medicines were being taken at the correct time”, the judgment said.

She reported numerous concerns to senior management between December 2015 and October 2016, amounting to 13 protected disclosures according to the tribunal, ranging from work-related stress, sickness, absenteeism and a need to retrain healthcare assistants.

A patient’s death triggered a meeting involving her and senior managers, which she said could have been prevented had her earlier concerns “been properly addressed”.

Ms Fairhall told care group director Julie Parks she wanted to initiate the formal whistleblowing policy on 21 October 2016, before going on annual leave a few days later. When she returned, she was told she had been suspended for 10 days.

The judgment, handed down at Teesside Justice Hearing Centre and published last week, added: “No reasonable employer, in all the circumstances of this case, would have conducted the investigation in this manner.”

The judgment said the tribunal believed the principal reason for her dismissal was because she had made protected disclosures. It upheld her claim that her dismissal was automatically unfair.

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Source: HSJ, 17 February 2020

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Surgeon suspended over treatment concerns

A doctor who worked at the same private healthcare firm as rogue breast surgeon Ian Paterson has been suspended, it has emerged.

Spire Healthcare said Mike Walsh – a specialist in trauma and orthopaedic surgery – was suspended in April 2018 over concerns about patient treatment. Almost 50 of his patients from its Leeds hospital had been recalled.

The details emerged following an independent inquiry into Paterson, who is serving a 20-year jail sentence.

Earlier this month, an inquiry into the breast surgeon found that a culture of "avoidance and denial" had allowed him to perform botched and unnecessary operations on hundreds of women.

Spire said in a statement that it acted after concerns were raised about Mr Walsh's work at its hospital in Leeds in 2018. The company, which contacted the Royal College of Surgeons to assist with its investigation, said it had reviewed the notes of fewer than 200 patients, of which "fewer than 50" had been invited back for a follow-up appointment.

"Where we have identified concerns about the care a patient received, we have invited the patient to an appointment with an independent surgeon to review their treatment," a spokesman for Spire Healthcare said. "This is a complex case and the review is ongoing."

It said that Mr Walsh, who was immediately suspended after the concerns were raised, was no longer working with Spire Healthcare. The company said any patients at its Spire Leeds Hospital who had concerns about their treatment under Mr Walsh should contact the hospital. It said its findings had also been shared with the Care Quality Commission and the General Medical Council (GMC).

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Source: BBC News, 17 February 2020

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‘Plug-and-play’ regtech solution enhances patient safety

With a focus on pharmaceutical supply chain regulation, Bonafi is one of the latest companies to launch within the regtech startup sector.

“Companies operating in the global pharma industry must verify that those they are buying from and selling to are authorised to handle medicinal products for human use in their own countries,” explains its founder, Katarina Antill. “At present, this verification process is manual. Companies are using screenshots as proof and relying on spreadsheets to track verification activities, which increases the risk of errors.”

“Manual processes are very labour intensive not least because companies must deal with multiple registries across multiple countries,” she says. “Most pharma manufacturers and wholesalers don’t have the resources to reverify their trading partners more than once a year, which is the current minimum legal requirement, and this too creates a potential vulnerability that can ultimately have an impact on patient safety and increase corporate risk.

 “I could see that this huge volume of manual work was a threat to patient-safety and extremely inefficient,” she adds. “Our solution gives companies much greater control over their compliance activities because they no longer have to rely on manual processes. It can also retrieve and aggregate data from multiple registers across multiple countries and has a constant monitoring and alert system, quality management dashboards, electronic signatures and workflows and will strengthen the attributes of traceability, transparency and security. It is all designed to help companies to be pro-active in their compliance activities, enabling them to go beyond compliance alone to reduce corporate risk and patient risk.”

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Source: The Irish Times, 13 February 2020

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Health Secretary faces legal challenge for failing patients with learning disabilities and autism

The Equality and Human Rights Commission have launched a legal challenge against the Secretary of State for Health and Social Care over the repeated failure to move people with learning disabilities and autism into appropriate accommodation.

Their concerns are about the rights of more than 2,000 people with learning disabilities and autism being detained in secure hospitals, often far away from home and for many years. These concerns increased significantly following the BBC’s exposure of the shocking violation of patients’ human rights at Whorlton Hall, where patients suffered horrific physical and psychological abuse.

The Equality and Human Rights Commission have sent a pre-action letter to the Secretary of State for Health and Social Care, arguing that the Department of Health and Social Care (DHSC) has breached the European Convention of Human Rights (ECHR) for failing to meet the targets set in the Transforming Care program and Building the Right Support program.

These targets included moving patients from inappropriate inpatient care to community-based settings, and reducing the reliance on inpatient care for people with learning disabilities and autism.

Rebecca Hilsenrath, Chief Executive of the Equality and Human Rights Commission, said: 'We cannot afford to miss more deadlines. We cannot afford any more Winterbourne Views or Whorlton Halls. We cannot afford to risk further abuse being inflicted on even a single more person at the distressing and horrific levels we have seen. We need the DHSC to act now."

"These are people who deserve our support and compassion, not abuse and brutality. Inhumane and degrading treatment in place of adequate healthcare cannot be the hallmark of our society. One scandal should have been one too many."

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Souce: Equality and Human Rights Commission, 12 February 2020

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