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News ArticleCampaigners have accused the UK government of betraying them after a review of redress for victims of health scandals excluded families who may have been affected by the hormone pregnancy test Primodos. A report published on Wednesday by the patient safety commissioner, Dr Henrietta Hughes, found a “clear case for redress” for thousands of women and children who suffered “avoidable harm” from the epilepsy treatment sodium valproate and from vaginal mesh implants. But despite the commissioner wanting to include families affected by hormone pregnancy tests in her review, the Department of Health and Social Care (DHSC) told her they would not be included. Primodos was an oral hormonal drug used between the 1950s and 70s for regulating menstrual cycles, and as a pregnancy test. Hormone pregnancy tests stopped being sold in the late 1970s and manufacturers have faced claims that such tests led to birth defects and miscarriages. Last year, the high court dismissed a case brought by more than 100 families to seek legal compensation owing to insufficient new evidence. The Hughes report states: “Our terms of reference did not include the issue of hormone pregnancy tests. This was a decision taken by DHSC and should not be interpreted as representing the views of the commissioner on the avoidable harm suffered in relation to hormone pregnancy tests or the action required to address this. “The patient safety commissioner wanted them included in the scope but, nevertheless, agreed to take on the work as defined by DHSC ministers.” Marie Lyon, the chair of the Association for Children Damaged by Hormone Pregnancy Tests, said the families of those who took the tests felt “left out in the cold” and betrayed that they were not included in the commissioner’s review. “I feel betrayed by the patient safety commissioner, by the IMMDS [Independent Medicines and Medical Devices Safety] review and by the secretary of state for health – all three have betrayed our families because, basically, they have just forgotten us. It’s a case of ‘it’s too difficult so we will just focus on valproate and mesh’,” Lyon said. Prof Carl Heneghan, a professor of evidence-based medicine at the University of Oxford, who led a systematic review of Primodos in 2018, said: “It’s unclear to me how the commissioner can keep patients safe if they are blocked and don’t have the power to go to areas where patient safety matters.” Read full story Source: The Guardian, 7 February 2024
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News ArticleThe NHS Race and Health Observatory, in partnership with the Institute for Healthcare Improvement and supported by the Health Foundation, has established an innovative 15-month, peer-to-peer Learning and Action Network to address the gaps seen in severe maternal morbidity, perinatal mortality and neonatal morbidity between women of different ethnic groups. Across England, nine NHS Trusts and Integrated Care Systems will participate in this action oriented, fast-paced Learning and Action Network to improve outcomes in maternal and neonatal health. Through the Network, the nine sites will aim to address the gaps seen in severe maternal morbidity, perinatal mortality and neonatal morbidity between women of different ethnic groups. Haemorrhage, preterm birth, post-partum depression and gestational diabetes have been identified as some of the priority areas for the programme. The sites will generate tailored action plans with the aim of identifying interventions and approaches that reduce health inequalities and enhance anti-racism practices and learning from the programme. These will be evaluated and shared across and between healthcare systems. The Network, the first of its kind for the NHS, will combine Quality Improvement methods with explicit anti-racism principles to drive clinical transformation, and aims to enable system-wide change. Over a series of action, learning and coaching sessions, participants will review policies, processes and workforce metrics; share insights and case studies; and engage with mothers, parents, pregnant women and people. The programme will run until June 2025, supported by an advisory group from the NHS Race and Health Observatory, Institute for Healthcare Improvement, and experts in midwifery, maternal and neonatal medicine. Read full story Source: NHS Race and Health Observatory, 24 January 2024
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Content ArticleDrawing upon the findings of a PhD that captured the experiences of midwives who proactively supported alternative physiological births while working in the National Health Service, their practice was conceptualised as ‘skilled heartfelt practice’. Skilled heartfelt practice denotes the interrelationship between midwives’ attitudes and beliefs in support of women’s choices, their values of cultivating meaningful relationships, and their expert practical clinical skills. It is these qualities combined that give rise to what is called ‘full-scope midwifery’ as defined by the Lancet Midwifery Series. This book illuminates why and how these midwives facilitated safe, relational care. Using a combination of emotional intelligence skills and clinical expertise while centring women’s bodily autonomy, they ensured safe care was provided within a holistic framework.
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News Article
Whistleblowers accuse NHS trust of avoidable baby deaths
Patient Safety Learning posted a news article in News
Serious concerns about maternity services at an NHS trust have been revealed by BBC Panorama. Midwives say a poor culture and staff shortages at Gloucestershire Hospitals NHS Trust have led to baby deaths that could have been avoided. A newborn baby died after the trust failed to take action against two staff, the BBC has been told. The trust says it is sorry for its failings and is determined to learn when things go wrong. Concerns about two staff members, both midwives, had been raised by colleagues at the Cheltenham Birth Centre after another baby died 11 months earlier. The birth centre allowed women with low-risk pregnancies the choice of giving birth there under the care of midwives - there were no emergency facilities in the centre. In the event of complications, women should have been transferred to the Gloucestershire Royal Hospital, which is part of the same trust and about a 30-minute drive away. But on both occasions, the two midwives did not get their patients transferred quickly enough. The two midwives on duty for both deaths are now being investigated by their regulator, the Nursing and Midwifery Council. Read full story Source: BBC News, 29 January 2024 -
News Article
Scotland: Mother wrongly downgraded to low risk
Patient Safety Learning posted a news article in News
Doctors "failed to realise" that a first-time mother's pregnancy had become "much higher risk" because crucial warning signs were not properly highlighted in her medical records, an inquiry has heard. Nicola McCormick was obese and had experienced repeated episodes of bleeding and reduced foetal movement, but was wrongly downgraded from a high to low risk patient weeks before she went into labour. Her daughter, Ellie McCormick, had to be resuscitated after being born "floppy" with "no signs of life" at Wishaw General hospital on March 4 2019 following an emergency caesarean. She had suffered severe brain damage and multi-organ failure due to oxygen deprivation, and was just five hours old when her life support was switched off. A fatal accident inquiry (FAI) at Glasgow Sheriff Court was told that Ms McCormick, who was 20 and lived with her parents in Uddingston, should have been booked for an induction of labour "no later" than her due date of 26 February. Had this occurred, she would have been in hospital for the duration of the birth with Ellie's foetal heartbeat "continuously" monitored. In the event, Ms McCormick had been in labour for more than nine hours by the time she was admitted to hospital at 8.29pm on 4 March. A midwife raised the alarm after detecting a dangerously low foetal heartbeat, and Ms McCormick was rushed into theatre for an emergency C-section. Dr Rhona Hughes, a retired consultant obstetrician who gave evidence as an expert witness, told the FAI that Ellie might have survived had there been different guidelines in place in relation to the dangers of bleeding late in pregnancy, or had her medical history been more obvious in computer records. Read full story Source: The Herald, 24 January 2024 -
Content Article
Knitted items – potential for harm to babies? (2018)
Patient Safety Learning posted an article in Paediatrics
This safety article aims to outline the actions taken by the patient safety team at NHS Improvement in response to a reported incident and to highlight potential for harm to babies from knitted items. Related reading on the hub: Finger injuries from infant mittens; a continuing but preventable hazard (April 1996) Notes from a Patient Safety Education Network discussion on a similar incident. (This is a group for UK hub members involved in patient safety education/training in their organisations and members of the hub can join by emailing support@PSLhub.org.) -
Content ArticleDuring the last 4 years, three infants have presented with finger-tip injuries secondary to entrapment in woollen/synthetic mittens. The accident happened at home in one case but the other two occurred in different neonatal units. Spontaneous amputation of the terminal phalanx of the index finger occurred in two patients but in the other there was complete healing. This problem may be avoided by restricting the use of mittens, by changing their design, and by a greater awareness of this hazard. Related reading on the hub: Knitted items – potential for harm to babies? (2018) Notes from a Patient Safety Education Network discussion on a similar incident. (This is a group for UK hub members involved in patient safety education/training in their organisations and members of the hub can join by emailing support@PSLhub.org.)
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News ArticleIn 2016, Kettering General Hospital (KGH) became the focus of a major criminal inquiry. Documents seen by the BBC reveal detectives looked for evidence of gross negligence manslaughter over the treatment of Jorgie Stanton-Watts, a vulnerable toddler. Seven years of investigations followed, by the hospital, regulators and a coroner. The family has struggled to hold people to account. Since Jorgie's death, a BBC investigation has heard from more than 50 parents with serious concerns about the treatment of their children, many of whom died or suffered injury. The Northamptonshire hospital has also been inspected regularly. In April the Care Quality Commission (CQC) downgraded the hospital's children's services to inadequate, the lowest possible rating. Read full story Source: BBC News, 10 January 2024
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Content ArticleReckitt has taken the precautionary step of recalling Nutramigen LGG stage 1 and stage 2 Hypoallergenic Formula powders because of the possible presence of Cronobacter sakazakii. Both products are foods used for special medical purposes for infants. The products are mainly prescribed but are also available without a prescription. Symptoms caused by Cronobacter sakazakii usually include fever and diarrhoea, and in severe cases may lead to sepsis or meningitis which include symptoms in infants including poor feeding, irritability, temperature changes, jaundice (yellow skin and whites of the eyes) and abnormal breaths and movements. Read Reckitt's recall notice
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Content ArticleChildhood immunisation is a critically important public health initiative. However, since most vaccines are administered by injection, it is associated with considerable pain and distress. Despite evidence demonstrating the efficacy of various pain management strategies, the frequency with which these are used during routine infant vaccinations in UK practice is unknown. This study aimed to explore primary care practice nurses’ use of evidence-based pain management strategies during infant immunisation, as well as barriers to evidence-based practice.
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News ArticleAt least 38 babies died in the space of nine years after serious incidents in the country’s maternity units, it has emerged. The total is based on research of both media reports of inquests and settled claims. Before Christmas, a review by the Irish Examiner revealed 21 hospital baby deaths followed one or more serious incidents, between 2013 and 2021. However, further study in the same nine-year period shows the toll to be higher. The worst year was 2018, when not only did at least 10 babies die, but three of them died at the same Dublin hospital over a five-month period. In at least 18 of the 38 deaths, issues around foetal heartbeat monitoring (CTG) were raised either at inquest or in the High Court. At least 18 of the inquests resulted in a verdict of medical misadventure. As well as issues around heart monitoring, the Irish Examiner review shows that in at least seven of the 38 cases, maternity staff missed signs that a woman was in labour, leading to repeated recommendations around training. In at least seven cases, mothers’ concerns were ignored. Read full story Source: Irish Examiner, 29 December 2023
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News Article
Jab for winter virus could cut baby hospitalisations by 80%, study says
Patient Safety Learning posted a news article in News
Hospital admissions from a winter virus could be reduced by more than 80% if babies are given a single dose of a new antibody treatment, a study says. Respiratory syncytial virus (RSV) usually causes mild, cold-like symptoms, but can lead to bronchiolitis and pneumonia. More than 30,000 under fives are hospitalised with RSV in the UK annually, resulting in 20 to 30 deaths. One British parent said her son getting RSV was "very scary" as a first-time mother. Lorna and Russell Smith's eldest son, Caolan, got the virus when he was eight months old and was admitted to hospital twice - each time requiring oxygen. Now aged two, he has made a full recovery. "I hadn't heard of RSV and wasn't sure what to do. He had laboured breathing due to high temperature and was quite lethargic. It brought a lot of anxiety and stress," Lorna said. The Harmonie study involved 8,000 children up to the age of 12 months, with half receiving a single dose of the monoclonal antibody treatment nirsevimab. The results, published in the New England Journal of Medicine, showed that RSV-related hospitalisation was reduced by 83% in those receiving the jab and admissions for all chest infections were cut by 58%. Side effects were similar in both groups and mostly mild. Read full story Source: BBC News, 27 December 2023 -
News Article
Baby died of neglect after staff turned off emergency alarm, coroner rules
Patient Safety Learning posted a news article in News
Hospital neglect contributed to the death of a two month old baby after staff turned off emergency alarms, a coroner has ruled. Louella Sheridan died at Royal Bolton Hospital in on 24 April 2022 after she was admitted with bronchiolitis to the hospital’s intensive care unit before later dying from Covid and a related heart condition. Four alarms on a monitoring machine were silenced and then switched off before the baby collapsed in a high dependency unit, it has been found. On Wednesday coroner John Pollard ruled neglect by staff had contributed to Louella’s death after staff switched off the alarms on the monitors attached to her during the night. Summing up his conclusion Coroner Pollard reportedly said there was a “gross failure “ to provide basic medical care to Louell and that had care been given, had the alarms been switched on to alert staff her life may have been extended at least for a short period of time. He said turning off the alarms was a gross type of conduct. Read full story Source: The Independent, 22 December 2023 -
Content ArticleThis study compared two quality improvement (QI) interventions to improve antenatal magnesium sulphate (MgSO4) uptake in preterm births for the prevention of cerebral palsy. It found that PReCePT improved MgSO4 uptake in all maternity units. Enhanced support did not further improve uptake but may improve teamwork, and more accurately represented the time needed for implementation. Targeted enhanced support, sustainability of improvements and the possible indirect benefits of stronger teamwork associated with enhanced support should be explored further.
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Content ArticleSince the launch of the national Perinatal Mortality Tool (PMRT) in early 2018, over 23,000 reviews have been started. This fifth annual report presents the findings for reviews completed from March 2022 to February 2023 coinciding with the third year of the global health emergency due to the COVID-19 virus.
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News Article
Huge delays to access maternal mental health care in England called a scandal
Patient_Safety_Learning posted a news article in News
NHS figures obtained by Labour reveal 11,507 women sought care but did not get any last year. Almost 20,000 women a year living with mental health problems triggered by being pregnant or giving birth are being denied support by the NHS, the Guardian can reveal. Furthermore, those who do receive mental health help for their trauma are having to wait up to 19 months to start treatment in some parts of England because specialist services are so overstretched. The situation has been described as “an absolute scandal” and sparked warnings that “rationing” of such vital care could leave women who do not get it in a very vulnerable state and risk their children facing lifelong health problems and stop mothers bonding with their baby. Read full story Source: Guardian, 5 December 2023 -
News ArticleNewborn babies could be at a higher risk of a deadly bacterial infection carried by their mothers than previously thought. Group B Strep or GBS is a common bacteria found in the vagina and rectum which is usually harmless. However, it can be passed on from mothers to their newborn babies leading to complications such as meningitis and sepsis. NHS England says that GBS rarely causes problems and 1 in 1,750 babies fall ill after contracting the infection. However, researchers at the University of Cambridge have found that the likelihood of newborn babies falling ill could be far greater. They claim one in 200 newborns are admitted to neonatal units with sepsis caused by GBS. Pregnant women are not routinely screened for GBS in the UK and only usually discover they are carriers if they have other complications or risk factors. Jane Plumb, co-founded charity Group B Strep Support with her husband Robert after losing their middle child to the infection in 1996. She said: “This important study highlights the extent of the devastating impact group B Strep has on newborn babies, and how important it is to measure accurately the number of these infections. “Inadequate data collected on group B Strep is why we recently urged the Government to make group B Strep a notifiable disease, ensuring cases would have to be reported. “Without understanding the true number of infections, we may not implement appropriate prevention strategies and are unable to measure their true effectiveness.” Read full story Source: The Independent, 29 November 2023 Further reading on the hub: Leading for safety: A conversation with Jane Plumb, Founder of Group B Strep Support
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Content ArticleThe MHRA is asking organisations to put a plan in place to implement new regulatory measures for sodium valproate, valproic acid and valproate semisodium (valproate). This follows a comprehensive review of safety data, advice from the Commission on Human Medicines and an expert group, and liaison with clinicians and organisations. This alert is for action by: Integrated Care Boards (in England), Health Boards (in Scotland), Health Boards (in Wales), and Health and Social Care Trusts (in Northern Ireland).
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News Article
Parents 'destroyed' after baby's death at Royal Sussex County Hospital
Patient Safety Learning posted a news article in News
Parents of a two-day-old girl who died in hospital after an emergency C-section are calling for a national inquiry into maternity services. Abigail Fowler Miller died at Brighton's Royal Sussex County Hospital (RSCH), in January last year. On 21 January 2022, Mr Miller and Katie Fowler contacted the hospital's maternity assessment unit four times during the day. Their first phone call was to inform the maternity assessment unit Ms Fowler was in labour, then to report bleeding, and finally to tell them she had become faint and short of breath. According to the Health Safety Investigation Branch's (HSIB) report, staff recorded that Ms Fowler sounded "distressed" in the fourth phone call to the unit, and she thought she was having a panic attack. Staff said she could not answer questions in the fourth phone call because of her "distressed state" and she was asked to come into the hospital. Ms Fowler went into cardiac arrest on the journey in a taxi due to a uterine rupture. An inquest last week found her life would have been prolonged if her mother had been admitted to hospital sooner. In October, families whose babies have died or been harmed in the care of the NHS called for a statutory public inquiry into England's maternity services. Robert Miller, Abigail's father, told BBC Newsnight: "A national inquiry is the only way forward - we cannot continue to treat every incident as a separate tragedy." Read full story Source: BBC News, 28 November 2023 -
News Article“Gut-wrenching,” says Lisa McManus. She is looking for words to describe how she and other thalidomide survivors feel ahead of a historic apology by Anthony Albanese for government failings in the tragedy. She is grateful for recognition of the medical disaster and relieved that a decade of advocacy has come to fruition. Around 80 of the 146 recognised survivors will witness the apology in Canberra on Wednesday in what McManus hopes will be “a step in the healing process”. But she is also frustrated that too many others have not lived to see the day. Thalidomide caused birth defects including “shortened or absent limbs, blindness, deafness or malformed internal organs”, according to the Department of Health. The drug was not tested on pregnant women before approval, and the birth defect crisis led to greater medical oversight worldwide, including the creation of Australia’s Therapeutic Goods Administration. Survivors and independent reports have criticised the government of the day for not acting sooner to remove thalidomide from shelves when problems became apparent. McManus leads Thalidomide Group Australia, having lobbied governments for a decade for an apology and better support. She’s “extremely grateful” for the apology, and says many survivors are anxious, excited and nervous – but that the apology itself can’t be the end. “I’m relieved it’s happening, I just can’t say ‘thank you’,” McManus says. “I’m very happy to think it’s here, but it won’t fix things, and I don’t want the government thinking they will deliver this and it’ll all be fine.” Read full story Source: The Guardian, 28 November 2023
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News Article
Woman stored baby’s remains in fridge after London hospital refused them
Patient Safety Learning posted a news article in News
A London hospital has launched an investigation after a woman whose baby died in the womb had to deliver her son at home due to lack of beds and keep his remains in her fridge when A&E staff said they could not store them safely. Laura Brody and her partner, Lawrence, said they were “tipped into hell” after being sent home by university hospital Lewisham to await a bed when told their baby no longer had a heartbeat but no beds were immediately available to give birth, the BBC reported. Two days later, after waking up in severe pain, Brody, who was four months into her pregnancy, gave birth in agony on the toilet in their bathroom. “And it was then,” she told the broadcaster, “I saw it was a boy”. The couple, who wanted investigative tests to be carried out at a later time, dialled 999 but were told it was not an emergency. They wrapped their baby’s remains in a wet cloth, placed him in a Tupperware box, and went to A&E where they were told to wait in the general waiting room, they said. She was eventually taken into a bay and told she would require surgery to remove the placenta. But, with the waiting room hot and stuffy and staff refusing to store the remains or even look inside the Tupperware box, they decided as it got to midnight they had no option but for her partner to take their baby’s remains home. Brody said the whole experience “felt so grotesque”. “When things go wrong with pregnancy there are not the systems in place to help you, even with all the staff and their experts – and they are working really hard – the process is so flawed that it just felt like we had been tipped into hell,” she told Radio 4’s Today programme. The case is said to have raised wider concerns among campaigners who argue that miscarriage care needs to be properly prioritised within hospitals including A&E. Read full story Source: The Guardian, 30 May 2022 -
News ArticleDonna Ockenden, the midwife who investigated the Shopshire maternity scandal, has been appointed to lead a review into failings in Nottingham following a dogged campaign by families. The current review will be wound up by 10 June after concerns from NHS England and families that it is not fit for purpose. It was commissioned after revelations from The Independent and Channel Four News that dozens of babies had died or been brain-damaged following care at Nottingham University Hospitals Foundation Trust. In a letter to families on Thursday, NHS England chief operating officer David Sloman said: “I want to begin by apologising for the distress caused by the delay in our announcing a new chair and to take this opportunity to update you on how the work to replace the existing Review has been developing as we have taken on board various views that you have shared with us.” “After careful consideration and in light of the concerns from some families, our own concerns, and those of stakeholders including in the wider NHS that the current Review is not fit for purpose, we have taken the decision to ask the current Review team to conclude all of their work by Friday 10 June.” “We will be asking the new national Review team to begin afresh, drawing a line under the work undertaken to date by the current local Review team, and we are using this opportunity to communicate that to you clearly.” Ms Ockenden said: “Having a baby is one of the most important times for a family and when women and their babies come into contact with NHS maternity services they should receive the very best and safest care." “I am delighted to have been asked by Sir David Sloman to take up the role of Chair of this Review and will be engaging with families shortly as my first priority. I look forward to working with and listening to families and staff, and working with NHS England and NHS Improvement to deliver a Review and recommendations that lead to real change and safer care for women, babies and families in Nottingham as soon as possible.” Read full story Source: BBC News, 26 May 2022
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News ArticleThe former health secretary Jeremy Hunt has claimed the government snubbed bereaved families’ requests for Donna Ockenden to chair a review into maternity services in Nottingham as she is “too independent”. Hundreds of families involved in the Nottingham maternity scandal review have called for Ms Ockenden, chair of the Shrewsbury maternity scandal inquiry, to take over the investigation. NHS England had attempted to appoint a former healthcare leader, Julie Dent to chair the review. However, following pressure from families not to accept, Ms Dent announced shortly after she would be declining the role. Following the families’ calls for Ms Ockenden, Mr Hunt, chair of the government’s health committee, said on Wednesday: “I can’t see any other barriers to appointing her but sounds like she still won’t be. For some reason the Department of Health appears to think she is too independent – which is of course precisely why Nottingham families do have confidence in her. It feels like another own goal.” Families involved in the Nottingham maternity review, which will now cover almost 600 cases, have said they’ve been left in limbo by NHS England after if informed them of an interim report which has been completed by the review team. This follows several letters from families to health secretary Sajid Javid raising concerns over the review and calls for it to be overhauled. Speaking with The Independent, a couple whose son died under the care of Nottingham University Hospitals Foundation Trist said: “The key to successful long term change is developing a relationship with harmed families, built on trust, sensitivity and understanding. The current review does not command this. The relationship is untenable.” Read full story Source: The Independent, 26 May 2022
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News Article
Respiratory syncytial virus kills 100,000 under-fives every year
Patient Safety Learning posted a news article in News
Respiratory syncytial virus is killing 100,000 children under the age of five every year worldwide, new figures reveal as experts say the global easing of coronavirus restrictions is causing a surge in cases. RSV is the most common cause of acute lower respiratory infection in young children. It spreads easily via coughing and sneezing. There is no vaccine or specific treatment. RSV-attributable acute lower respiratory infections led to more than 100,000 deaths of children under five in 2019, according to figures published in the Lancet. Of those, more than 45,000 were under six months old, the first-of-its-kind study found. More children are likely to be affected by RSV in the future, experts believe, because masks and lockdowns have robbed children of natural immunity against a range of common viruses, including RSV. “RSV is the predominant cause of acute lower respiratory infection in young children and our updated estimates reveal that children six months and younger are particularly vulnerable, especially with cases surging as Covid-19 restrictions are easing around the world,” said the study’s co-author, Harish Nair of the University of Edinburgh. “The majority of the young children born in the last two years have never been exposed to RSV (and therefore have no immunity against this virus).” Read full story Source: The Guardian, 19 May 2022 -
News Article
Families dismay at interim report plans despite review ‘chaos’
Patient Safety Learning posted a news article in News
Families involved in a major review into maternity failings at Nottingham University Hospitals Trust (NUH) have criticised the decision of the review team to press ahead with the publication of an interim report, despite serious concerns about its terms of reference and methodology. A “thematic review” into NUH was first announced last year after reports that dozens of babies died or were brain damaged after errors were made at the trust over the last decade. More than 460 families have since contacted the review team. The review has been overseen by NHS England and local commissioners, but, in April, the families called for an independent inquiry and asked for it to be carried out by Donna Ockenden, the senior midwife who chaired the high-profile review of Shropshire maternity services, which reported in March. Last month, NHSE chief operating officer Sir David Sloman wrote to families and said former strategic health authority chair Julie Dent would be brought in to chair the review. However, Ms Dent stepped down from the role weeks later, citing “personal reasons”. A new chair is yet to be appointed. Despite these uncertainties, families have been told by the review team that an interim report will be issued shortly. Gary Andrews, whose daughter Wynter died after being delivered by caesarean section at NUH’s Queens Medical Centre in 2019, said to issue an interim report “seems at odds with the current situation” and risked causing “significant distress” to families. He added: “We need government to get to grips with this review. Put the brakes on, ensure its structure and design and objectives are fully supported by families, before any interim report can be issued.” Read full story (paywalled) Source: HSJ, 19 May 2022
