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Found 1,606 results
  1. News Article
    A surgeon has been suspended on the same day a hospital review concluded harm had been caused in hundreds of cases. A tribunal ruled that Tony Dixon, who used artificial mesh to treat prolapsed bowels at Southmead Hospital, in Bristol, and the Spire Hospital, still posed a risk. The Medical Practitioners Tribunal Service's hearing concluded on Thursday that a six-month suspension was "appropriate". Spire Healthcare has now released its review of Mr Dixon, and found 259 cases where harm had been caused. Health bosses have "apologised sincerely". The majority of harm was in three main areas: the failure to adequately investigate patients prior to offering the procedure; the failure to adequately offer alternative treatments; and poor consent with risks and benefits of the procedure not adequately discussed. The tribunal found Mr Dixon’s fitness to practise is impaired and his suspension would allow him time to "to develop further insight and remediate his misconduct". The General Medical Council brought the case against Mr Dixon, who denies all the allegations and maintains that the procedures were carried out in good faith. His suspension will start immediately. Read full story Source: BBC News, 18 July 2024
  2. Content Article
    The Parliamentary and Health Service Ombudsman's annual report and accounts 2023 to 2024 gives details of its performance over the past 12 months, including financial reports and statistical information about the complaints received.
  3. News Article
    A troubled mental health trust’s internal mortality review has concluded 418 of an estimated 12,503 patient deaths over a four-and-a-half year period were “unexpected and unnatural”. Norfolk and Suffolk Foundation Trust’s leaders said the findings showed there had been a “much, much smaller” number of avoidable deaths than had been implied by previous reviews and reported by the media in the past. But the review’s findings were swiftly dismissed by campaigners, who said they had “no confidence” in the new figures, accused the trust of “corporate gaslighting” and renewed calls for a statutory public inquiry. The review was initiated after a similar exercise by Grant Thornton last June concluded it was not possible to work out how many avoidable deaths there had been because of the trust’s poor data. A month later, BBC Newsnight reported evidence it had watered down criticism in the Grant Thorton report, with allegations of “weak” and “inadequate” governance in earlier versions of the report removed from the final version. The trust and auditor said the changes were due to “fact checking”. Read full story (paywalled) Source: HSJ, 18 July 2024
  4. News Article
    The former health secretaries Jeremy Hunt and Matt Hancock have been criticised for their failure to better prepare the UK for the pandemic, in a damning first report from the Covid inquiry that calls for an overhaul in how the government prepares for civil emergencies. Hunt, who was the health secretary from 2012-18, and Hancock, who took over until 2021, were named by the chair to the inquiry, Heather Hallett, for failing to rectify flaws in contingency planning before the pandemic, which claimed more than 230,000 lives in the UK. The government had focused largely on the threat of an influenza outbreak despite the fact that coronaviruses in Asia and the Middle East in the preceding years meant “another coronavirus outbreak at a pandemic scale was foreseeable”. Lady Hallett said that to overlook that was “a fundamental error”. “It was not a black swan event,” Hallett said in a 240-page report. It concluded: “The processes, planning and policy of the civil contingency structures within the UK government and devolved administrations and civil services failed their citizens. Ministers and officials were guilty of ‘groupthink’ that led to a false consensus that the UK was well prepared for a pandemic. Never again can a disease be allowed to lead to so many deaths and so much suffering.” In what families bereaved by Covid welcomed as a “hard-hitting, clear-sighted and damning analysis of how and why the UK found itself to be fatally underprepared”, Hallett said “preparedness and resilience for a whole-system emergency must be treated in much the same way as we treat a threat from a hostile state”. The arrival of another pandemic – “potentially one that is even more transmissible and lethal” – was a question of when, not if, she said, and “unless we are better prepared” it would bring “immense suffering and huge financial cost and the most vulnerable in society will suffer most”. Read full story Source: Guardian, 18 July 2024
  5. Content Article
    The Covid-19 Inquiry published its first report and recommendations following its investigation into the UK’s ‘Resilience and preparedness (Module 1)’. The Chair of the Inquiry, Baroness Heather Hallett, set out her recommendations from the Module 1 report in a live streamed statement. It examines the state of the UK’s central structures and procedures for pandemic emergency preparedness, resilience and response. Reports related to the Inquiry’s further Modules will be published later.
  6. News Article
    The failures and weaknesses in the UK's pandemic preparations are expected to be laid out in the first report published by the Covid inquiry. Baroness Hallett, who is chairing the public inquiry, will set out her findings at lunchtime. Her report will cover the state of the healthcare system, stockpiles of personal protective equipment (PPE) and the planning that was in place. It is the first of at least nine reports covering everything from political decision-making to vaccines and the impact on children. Trained army medic Dr Saleyha Ahsan, who worked in hospitals during the first two waves of Covid and is now part of the Covid-19 Bereaved Families for Justice UK group, after losing her father to the virus, said it felt like there had been “zero planning”, with doctors often struggling to get hold of the right PPE “The rules were changing on a daily basis in the first few weeks - it was ridiculous,” she said. “We were in the flimsiest of PPE, just a little surgical mask with a white apron. “It felt like we were making do and the people who were being pushed to the front were healthcare workers." “It's so, so important for those of us who worked through it, who lost through it, or who have suffered ill health because of it, to really appreciate where things went wrong and who was responsible.” Read full story Source: BBC News, 18 July 2024 Related reading on the hub: The pandemic – questions around Government governance: a blog from David Osborn Respiratory protective equipment: An unequal solution for healthcare workers? A blog by David Osborn
  7. Content Article
    The impact of incident investigations in improving patient safety may be linked to the quality of risk controls recommended in investigation reports. This study in the Journal of Patient Safety aimed to identify the range and apparent strength of risk controls generated from investigations into serious incidents, map them against contributory factors identified in investigation reports, and characterise the nature of the risk controls proposed. The authors did a content analysis of 126 action plans of serious incident investigation reports from a multisite and multi-speciality UK hospital over a three-year period to identify the risk controls proposed. They found that: a substantial proportion (15%) of factors identified in investigation reports as contributing to serious incidents were not addressed by identifiable risk controls. most of the proposed risk controls in action plans were assessed as weak, typically focusing on individualised interventions, even when the problems were organisational or systemic in character. They identified six broad approaches to risk controls: improving individual or team performance defining, standardising or reinforcing expected practice improving the working environment improving communication process improvements disciplinary actions. The authors concluded that advancing the quality of risk controls after serious incident investigations requires involvement of human factors specialists in their design, a theory-of-change approach, evaluation, and curation and sharing of learning. This should be supported by a common framework.
  8. News Article
    Two babies died on a hospital’s neonatal intensive care unit during a bacterial outbreak which could have been prevented, the BBC has learned. An internal investigation by Bradford Royal Infirmary (BRI) said lapses in hygiene practices allowed the drug-resistant bugs to spread. Five other infants were found to have the same Klebsiella pneumoniae strain during the outbreak in November 2021. The mother of a two-week-old boy who died said she felt “betrayed” by the hospital and had begun legal action. Bradford Teaching Hospitals NHS Trust said it had implemented new infection control measures, brought in additional training and increased staffing levels. A nurse who previously worked at the neonatal unit told the BBC staff faced “extremely strenuous” conditions which led to “medical mistakes”. A patient safety incident investigation report, circulated internally in March 2022 and seen by the BBC, also said infection control practices which could have stopped the spread of Klebsiella “were not being implemented consistently” by staff in the unit. It revealed an investigation had found staff in the neonatal unit were not “consistently” following hand hygiene guidelines at the time of the outbreak and “seemed unclear” about where and when personal protective equipment was required. Read full story Source: BBC News, 16 July 2024
  9. Content Article
    In this webinar, Tracey Herlihey, Head of patient safety incident response policy, NHS England, looks at how the Patient Safety Incident Response Framework (PSIRF) is changing the culture amongst healthcare workers and what this means for individuals. Dr Henrietta Hughes discusses the events leading up to the creation of the Patient Safety Commissioner role, her priorities and the role of leaders. She also explores the importance of ‘what matters to you'—that is, why we must listen to patients and what happens if we don’t.
  10. Content Article
    Serious failings in support for deaf children have been laid bare in the final report of the Independent Review of Audiology Services in Scotland. Mark Ballard, National Deaf Children's Society, Head of Policy for Scotland, outlines the history of the Review, and suggests that it is time for the Scottish Government to act on the recommendations of the report.
  11. Content Article
    Review report and recommendations from the Independent Review of Audiology Services in NHS Scotland. The Review was announced by the Scottish Government in January 2022 in the context of failings in the standards of care provided in the NHS Lothian Paediatrics Services.
  12. News Article
    A small number of biomedical scientists are being investigated following fitness to practise concerns relating to cervical screening in the Southern Trust, BBC News NI understands. In October 2023, it emerged smear tests of more than 17,000 women in the trust would be re-checked as part of a review dating back to 2008. It is understood that some of the women affected have since referred the matter to the Health and Care Professions Council (HCPC) which investigates concerns about the practice of a professional on its register. Stella McLoughlin from Newry, who is one of the 17,500 women affected by the re-check, said the review process has left her feeling “very afraid, fragile, and angry”. Following news that other women in her position have referred the matter to the HCPC, she said there needs to be an investigation. "I don't know why they're calling it a review because to me this is a scandal. This has affected so many women," she said. Read full story Source: BBC News, 11 July 2024
  13. News Article
    An independent investigation will be held into the performance of the NHS, the health secretary has announced. Writing in the Sun, Wes Streeting said the investigation would be aimed at “diagnosing the problem” so the government could “write the prescription”. Streeting said: “It’s clear to anyone who works in or uses the NHS that it is broken. Unlike the last government, we are not looking for excuses. I am certainly not going to blame NHS staff, who bust a gut for their patients. “This government is going to be honest about the challenges facing us, and serious about solving them.” Streeting said the investigation would be led by the former health minister Lord Ara Darzi, who he has asked to “tell hard truths”. Streeting said: “Honesty is the best policy, and this report will provide patients, staff and myself with a full and frank assessment of the state of the NHS, warts and all. “The NHS has been wrecked. This investigation will be the survey, before we draw up plans to rebuild it anew, so it can be there for all of us when we need it, once again.” Read full story Source: The Guardian, 11 July 2024
  14. Content Article
    This film demonstrates how using SEIPS can help illuminate contributory factors within a work system, such as unconscious bias, stereotyping, workload, incivility, societal pressures and environmental factors under the six entity headings. Staff watch an animated explanation of SEIPS and then a short fictional maternity scenario looking out for relevant contributory factors. After viewing the film staff take part in a facilitated discussion to reflect. It is hoped that those using this film will be able to build on this experience, and then reflect on their own clinical service through the SEIPS lens, as taking a systems-based approach will strengthen a Just Culture, reduce blame and supports the PSIRF process.
  15. News Article
    Fourteen never events recorded at University Hospitals Birmingham Foundation Trust’s transfusion service were the “tip of an iceberg”, an external review has concluded. The Royal College of Physicians (RCP) investigation, obtained by HSJ, reveals the service saw more than 150 additional “adverse events” recorded in just three months. The review of the service’s activities between 2019 and early 2023 also concluded there had been “inaction” at senior management level on addressing the problems and that there was a lack of understanding among senior leaders about the significance of the risks posed by the service. The RCP report said it was unlikely the reviewed never events “comprised the totality” of transfusion errors by the service and concluded that they were in fact just the “tip of an iceberg” of the errors made by the service. These included seven incidents of the wrong blood being stored in tubes and a patient “with childbearing potential” incorrectly transfused in accident and emergency with group O RhD positive blood. This risks the patient’s antibodies attacking a future unborn baby if the foetus is RhD positive. ABO-incompatible blood transfusions have a potential for significant morbidity and mortality and are “wholly preventable”, according to NHS Blood and Transplant. Read full story (paywalled) Source: HSJ, 10 July 2024
  16. Content Article
    How is it possible to ensure that NHS Trusts learn from their mistakes? In this blog, Trevor Stevens, member of Making Families Count, explains how he intends to go about it. 
  17. News Article
    The daughter of an elderly care home resident who suffered 32 falls in only 11 months said she had sent social services "a begging email" to warn her mother "was going to die" unless urgent improvements were made. "She suffered neglect in every way - it was devastating to see," said Kylie Gobin, whose mother Winifred Tubb lived at St Luke's in Runcorn, Cheshire. Mrs Gobin spoke to the BBC as part of an in-depth investigation which found nearly one in five care homes across England were rated as either "requiring improvement" or "inadequate". A spokesman for Halton Borough Council, which operates St Luke's, said it had "fully investigated" the complaints and "some lessons have been learnt". BBC England's data journalism team analysed Care Quality Commission (CQC) statistics and found the regulator now regards more than 2,500 care homes across England as "requiring improvement". The number of "inadequate" homes stands at 194 across England, but this figure is down on both 2022 and 2023. Read full story Source: BBC News, 9 July 2024
  18. Content Article
    This webpage outlines the role and purpose of the Norwegian Healthcare Investigation Board (NHIB)—or 'Ukom' in Norwegian—an independent government agency set up in 2019. NHIB investigates serious adverse events and other serious concerns involving Norwegian healthcare services, aiming to improve patient and user safety by learning for improvement. Its investigations focus on systems and processes in healthcare, identifying factors that could have led, or could potentially lead, to harm for patients. On this page, you can also access NHIB reports and summary reports that have been translated into English, including: Death at a psychiatric intensive care ward: Risk factors in conjunction with seclusion Early diagnosis and treatment of serious illness in the febrile child Adolescents with mental health issues Investigation following the tragic drowning in Tromsø: What can we learn about integration and refugee health? Maintaining patient safety with new surgical and invasive methods
  19. News Article
    The health minister has announced that a further review of clinical records of 18 patients who died under the care of neurologist Michael Watt is to be carried out. Mr Watt was at the centre of Northern Ireland's largest patient recall in 2018. In 2022 a review of 44 patients' records found significant failures in their care and treatment under Mr Watt and poor communication with the families. In a written statement to the assembly, Mike Nesbitt acknowledged "the exceptionally difficult circumstances which the families of deceased patients have experienced". It is anticipated that this phase of the Neurology Deceased Patients Review (DPR) will be completed before the end of March 2025. These reviews followed the 2018 recall of 2,500 outpatients who were in Dr Watt's care at the Belfast Health Trust. About one in five patients had to have their diagnoses changed. Mike Nesbitt said the work done to date as part of the Deceased Patients Review (DPR) has been "challenging and extensive". Read full story Source: BBC News, 3 July 2024
  20. News Article
    A hospital trust has ordered a review of potential death and harm caused by an outbreak of a serious healthcare-acquired infection, which is resistant to many antibiotics. Frimley Health Foundation Trust has seen outbreaks of carbapenemase-producing enterobacterales (CPE) at both its Frimley Park and Wexham Park sites, starting in the middle of last year, it has emerged. In total, it identified 94 new CPE cases in 2023–24 compared with just 20 in total in 2022–23. It is not clear what the outcomes were for patients infected with CPE, which is associated with a high mortality rate but often infects patients who are already seriously ill. The trust has commissioned a mortality and morbidity review but refused to answer any questions about it before publication. CPE bacteria are resistant to many antibiotics, including carbapenems, which are broad-spectrum drugs used to treat serious infections. CPE infections pose a particular risk to vulnerable patients and can spread rapidly in hospitals. There has been increasing concern about them in the UK, with reporting requirements increasing and screening and testing of patients stepping up. Read full story (paywalled) Source: HSJ, 4 July 2024
  21. Content Article
    This video was produced as a training resource for NHS organisations, to demonstrate the impact the initial response to a patient safety incident and subsequent investigation have on the patient. In this video, Kathryn talks about her experience following an incident where she was harmed when her cannula was not flushed following surgery, leaving her close to death and temporarily paralysed. She describes the clear, compassionate communication displayed by the healthcare professionals involved in her care, both immediately after the incident and throughout the subsequent investigation.
  22. News Article
    The NHS will face scrutiny over alleged failures to listen to whistleblowers’ warnings about baby killer Lucy Letby after the nurse was convicted of another attempted murder. Letby was convicted of trying to murder a “very premature” infant by dislodging her breathing tube in the early hours of 17 February 2016, following a retrial at Manchester Crown Court. The 34 year-old’s latest conviction comes after she was found guilty of the murders of seven babies and the attempted murders of six others at the Countess of Chester Hospital’s neo-natal unit between June 2015 and June 2016, following her original trial last August. The former nurse was given a rare whole-life order, making her one of Britain’s most prolific child serial killers. She is due to be sentenced for the further offence on Friday. Detective superintendent Simon Blackwell, who is strategic lead for Operation Hummingbird, said: “The investigation, which is ongoing, focuses on the indictment period of the charges for Lucy Letby, from June 2015 to June 2016, and is considering areas including senior leadership and decision making to determine whether any criminality has taken place. The investigation is complex and sensitive and specific updates regarding progress will be issued at the appropriate time. At this stage we are not investigating any individuals in relation to gross negligence manslaughter. “We recognise that this investigation has a significant impact on a number of different stakeholders including the families in this case and we want to reassure that we are committed to carrying out a thorough investigation. Since Letby’s original convictions in August 2023 it has been a very busy period for the investigation team. This has included a subsequent appeal, the re-trial for one count of attempted murder and the launch of the statutory public inquiry that Cheshire Constabulary is assisting with.” Read full story Source: The Independent, 2 July 2024
  23. News Article
    Long waiting times at hospitals in the north-west of England are putting patient's lives at risk by holding up ambulance crews, a coroner has warned. It comes after the death of Bobilya Mulonge, who called 999 with breathing problems on 24 November 2022. She waited 72 minutes for an ambulance - four times longer than North West Ambulance Service's (NWAS) 18-minute target for her category of emergency call - which "probably contributed to her death", coroner Lauren Costello said. A NWAS spokesman said the service was "very sorry" an ambulance was unable to attend sooner and the service had made "significant" improvements since. A report by Ms Costello has been sent to the health secretary and NWAS and urges the region's health authorities to take action to prevent further deaths. She said evidence about ambulance delays revealed during the inquest had given rise to her concerns. "In my opinion there is a risk that future deaths could occur unless action is taken," she wrote. Dale Ollier, north-west regional organiser for Unison, which represents some ambulance staff, said backlogs in moving patients out of hospitals was having a "knock-on effect" at A&E, leading to a "bottleneck crisis". “We have patients that could be safely discharged but there isn’t anywhere to discharge them to because of the lack of capacity in social care." Ambulances were working "flat out", he added, but delays had lead to an "unbearable demand" on crews who were sometimes "tied up for several hours" waiting at hospitals. Read full story Source: BBC News, 20 June 2024
  24. Content Article
    On 24 May 2023 an investigation was commenced into the death of Bobilya Mulonge then aged 62 years. The investigation concluded at the end of the inquest on 19 April 2024. The conclusion of the inquest was a narrative conclusion that Mrs Mulonge died as a result of congestive cardiac failure against a background of hypertensive heart disease. Ambulance response times probably contributed to her death.     The medical cause of death being:   1 (a) Congestive Cardiac Failure (b) Hypertensive Heart Disease   II) Chronic Kidney disease and Type II diabetes mellitus.
  25. News Article
    An inquiry looking into mental health deaths in Essex will begin hearing evidence on 9 September. The Lampard Inquiry will investigate the deaths of more than 2,000 patients in the care of NHS trusts in Essex between 1 January 2000 and 31 December 2023. Evidence will be heard in public in Essex and live-streamed online over a three-week period. The first hearings are expected to include opening statements as well as evidence from those impacted by mental health deaths. The inquiry was announced in November 2020 after warnings from health watchdog the Care Quality Commission (CQC) and a damning Parliamentary and Health Service Ombudsman report in 2019, external into the deaths of two men in Essex. Read full story Source: BBC News, 20 June 2024
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