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News Article
Ambulance response warning after woman's death
Patient Safety Learning posted a news article in News
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 -
Content ArticleOn 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.
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News Article
Date set for mental health deaths inquiry evidence
Patient Safety Learning posted a news article in News
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 -
Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Magda talks to us about her role as Family Liaison Officer Team Lead, how PSIRF has changed the way her Trust involves patients and families after patient safety incidents and the importance of placing patient and family perspectives at the heart of learning responses. -
News ArticleThe owner of a group of privately-run children’s mental health hospitals is facing legal action by dozens of former patients, who claim they suffered inhuman and degrading treatement at the facilities. Hospitals formerly run by The Huntercombe Group face at least 54 individual clinical negligence claims, The Independent can reveal. Patients treated within several of the hospitals, now owned by Active Care Group, came forward to solicitors Hutchoen Law following several exposés by this publication, revealing allegations of “systemic abuse.” Documents submitted to Manchester Civil Court on Thursday before Judge Nigel Bird, who will decide if permission is be granted for claims to be brought, revealed allegations including: Assault and battery, relating to the inappropriate and unnecessary forced feedings and physical restraint. False imprisonment. Breaches of the Human Rights Act including prohibition of inhuman and degrading treatment. Read full story Source: The Independent, 13 June 2024
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News Article
‘Burdensome’ patient safety inquiries taking up too much time, says NHSE chief
Patient Safety Learning posted a news article in News
NHS England’s head of patient safety has suggested too much time and resource is being spent on “burdensome” inquiries to investigate failings in the system. Aidan Fowler said national chiefs want to see a shift away from “looking back 10 years and asking ‘what did we miss’”, and instead wants teams to be resolving problems in real time. At trusts where safety concerns have been highlighted, he said “people descend, and there are a lot of asks, and the pressure mounts, and they end up with an action list of hundreds of things, and it becomes very burdensome – we have to avoid that”. Speaking at a session at the NHS Confederation Expo event in Manchester this week, he encouraged organisations to report concerns early so NHSE can respond more quickly, supporting them and working through problems to prevent public inquiries from needing to happen in the first place. Mr Fowler added: “We have to get more proactive. We will spend less of our time in the future, is the plan, than we are now – doing what I call driving in the rear view mirror. “We don’t want to be looking back 10 years and asking, ‘what did we miss’, we want to be seeing things in real time… we don’t want to be spending our time in big inquiries into failings in the system.” Read full story (paywalled) Source: HSJ, 14 June 2024 -
News Article
Three staff disciplined over death at ‘culture of impunity’ trust
Patient Safety Learning posted a news article in News
Three staff have been put on “improvement plans” after a patient’s death which a coroner said nurses had been dishonest about, HSJ has learnt. North East London Foundation Trust was heavily criticised over the death of Winbourne Charles at an inquest last year. Coroner Graeme Irvine said staff “had not told the truth” about how Mr Charles came to take his own life in an inpatient unit at Goodmayes Hospital, in east London. Two witnesses refused to give evidence, citing a rule that they could not be compelled to incriminate themselves. Mr Irvine recorded a verdict of “suicide, contributed to by neglect, to which failures in medical intervention contributed and to which failures to respond to an obvious risk of self-harm contributed”. His prevention of future deaths report also noted “observation records appeared to have been created utilising a ‘cut and paste’ function” while there were “factually inaccurate entries” stating Mr Charles “was alive and well” up to two days after his death. In comments reported by the Barking and Dagenham Post last year, Mr Irvine said: “I think witnesses who have given evidence to me in this inquest have not told the truth. “It seems to me that this remarked upon a culture of impunity and that, unless someone sees there are consequences to their actions, nothing is going to change.” Read full story (paywalled) Source: HSJ, 14 June 2024 -
Content ArticleOn 11 April 2021 an investigation into the death of Winbourne Gregory Charles, aged 58, was carried out. Winbourne was admitted into hospital under section 2 of the Mental Health Act 1983 in November 2020 following an attempt to take his own life. In December 2020 on a diagnosis of depressive illness incorporating psychotic symptoms, Mr Charles was made subject to an order under section 3 of the Mental Health Act 1983. On 10 April 2021 Mr Charles was found unresponsive, suspended on the mental health ward. The Court returned a conclusion of: “Suicide, contributed to by neglect, to which failures in medical intervention contributed and to which failures to respond to an obvious risk of self-harm contributed.” Mr Charles’ medical cause of death was determined as 1a Suspension.
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News Article
New support for families critical of pregnancy care
Patient Safety Learning posted a news article in News
A new service in Somerset is being set up to support women who have had adverse outcomes during pregnancy. Maternity and neonatal independent senior advocates (MNISA) say they will act on behalf of women if they feel their experience when being cared for during pregnancy led to something going wrong. This can include death, babies being diagnosed with brain injuries or mothers needing critical care. MNISAs can attend meetings or support users through investigations and complaints. The service will be piloted until next year and while the role is independent from the maternity and neonatal trust provider (Somerset NHS Foundation Trust), it sits within NHS Somerset. Jane Innes, a qualified lawyer who has worked across the NHS for 30 years, will take up the new role in Somerset. She said: "There is an acknowledgement that people's voices need to be heard and listened to so systems can act and respond appropriately." Read full story Source: BBC News, 11 June 2024 -
Content ArticleThis template standardises the reporting of After Action Reviews (AARs). It is not intended to be an AAR facilitation guide. The template has been co-designed with staff leading AARs in a range of healthcare organisations. The structure is purposefully simple so that AARs can focus on reflective conversation and do not become a bureaucratic documentation exercise. This structure will continue to be evaluated and developed by the National Patient Safety Team. It can be downloaded from the attachment below or it's available on FutureNHS within the AAR tool space here: https://future.nhs.uk/NHSps/view?objectId=42826256
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News Article
Hospitals harm hundreds of patients a year by misidentification
Patient Safety Learning posted a news article in News
Hundreds of patients are being harmed each year because NHS organisations have incorrectly identified who they are, an HSJ investigation has found. Responses to Freedom of Information requests from 166 trusts revealed 58,537 cases of patient misidentification logged in Datix or other patient safety systems between 2019 and 2023, including 4,713 causing some sort of harm. This is equivalent to 11,707 incidents a year, with 943 leading to harm. It includes a wide range of errors, but harm typically happens when patients are given the wrong treatment or medicine, or miss out on the right treatment, as a result of errors in recording and/or miscommunication. A typical example is patients being given a wristband with the wrong name – or ID information resulting in patients not being treated, or the wrong treatment being given. Some of the worst examples are where the wrong patient, or the wrong part of the body, is operated on. Patient Safety Learning's CEO Helen Hughes called on NHS England to review cases nationally to identify root causes. She added: “Where avoidable harm has occurred, it is vital these incidents are investigated, that causes and contributory factors are identified, and steps put in place to prevent their reoccurrence. In some cases, this may require standardisation of approaches to patient identification, while others may highlight contributory factors that are more difficult to address, such as staff fatigue.” Read full story (paywalled) Source: HSJ, 11 June 2024 -
News Article
Parents hope documentary will help maternity inquiry bid
Patient Safety Learning posted a news article in News
A couple whose child died before birth due to failings in her care hope a new documentary can support their calls for a public inquiry into England's maternity services. Jack and Sarah Hawkins' daughter Harriet was stillborn at Nottingham City Hospital in April 2016. They hope an ITV programme - Maternity: Broken Trust - shown on Sunday evening can help their bid for a wider probe. An independent review into failings in maternity services in Nottingham is now the biggest maternity investigation in NHS history, but a report is not expected to be returned until 2025. Dr and Ms Hawkins - who received a £2.8m settlement over failings in their daughter's care - said a wider investigation was needed to highlight national issues. "I think maternity services across England are absolutely terrible," Ms Hawkins said. "We're in contact with people with dead babies from Leeds to Plymouth, and I think what really needs to happen is for there to be a public inquiry into England's maternity services. "It's not just Nottingham, it's everywhere, and hopefully this platform will give people the strength to come forward and speak up." Read full story Source: BBC News, 10 June 2024 -
Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Making Families Count is an organisation that offers practical training based on lived experience to healthcare professionals. Rosi talks to us about how MFC training benefits patient safety and improves the way in which patients and families are involved in incident investigations. She explains how she came to be involved in MFC after the death of her son Nico and outlines the vital importance of seeing patient and family voices as equal to those of people working for healthcare organisations. -
Content Article
Urology Services Inquiry
Patient Safety Learning posted an article in Other reports and inquiries
A decision was taken by the Minister for Health, Robin Swann MLA, to establish a statutory public inquiry following the lookback review of urology patients (January 2019 until May 2020) initiated by the Southern Health and Social Care Trust. These concerns were related to Mr Aidan O’Brien, Consultant Urologist employed within the Southern Trust. Terms of Reference Key documents, the hearings and latest news on the Inquiry can be found on the Urology Services Inquiry website. -
News ArticleThe NHS and government have failed to implement a single recommendation from a key Jimmy Savile inquiry – almost 10 years after plans to prevent future sex abuse of patients in hospitals were put forward, The Independent can reveal. The shocking discovery was uncovered by the panel tasked to chair the public inquiry into Lucy Letby, the nurse who killed several newborn babies in her care. Analysing the progress made by the NHS and government after some of the most high-profile health scandals in the UK, it found across 30 inquiries, dating back to 1967, just 302 out of more than 1,400 key recommendations had been adopted. Alan Collins, a lawyer who represented dozens of victims in claims against Savile’s estate, slammed politicians and public bodies over the failure. He says: “The thread that runs through the numerous reports, the investigations behind them, and the ongoing failures with lack of implementation is the lack of accountability. “We have seen time after time the lack of professional curiosity in the face of glaring wrongdoing yet this cultural vacuum rarely sees those charged with responsibility for safeguarding subject to any consequences.” Read full story Source: The Independent, 3 June 2024
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News Article
Parents call for inquiry into maternity services
Patient Safety Learning posted a news article in News
The families of nine babies who died at a scandal-hit NHS trust over a three-year period have called for a public inquiry into the standard of its maternity care. A collective letter has been sent to each of the families' MPs after they lost babies at hospitals run by the University Hospitals Sussex NHS Foundation Trust. Of the nine bereaved mothers, four said they too almost died as a result of "poor standards of care" from maternity teams between 2021 and 2023 The trust said it had recruited more midwives and "changed" how it supported families, with outcomes now better "than most other trusts in the country". But the Sussex-based families said they had called for a public inquiry into its maternity services to ensure accountability for "systemic failures", and so the trust learns from past mistakes. In the letter to the MPs, the parents said: "With the volume and repetition of errors in maternity care by the trust, we believe that babies and potentially mothers will continue to unnecessarily die under the trust’s care unless there is additional intervention." Read full story Source: BBC News, 4 June 2024 -
Content ArticleIn 2017, a change (serendipity) in the philosophy of occurrence investigations took place at NS (Dutch Railways). It seems the investigations conducted and published before and after 2017 are different, both in the way the investigations are executed and in their effects on the organisation. This research has been carried out to find out if, in what way, and to what degree the two specific types of investigations are different with a special interest in the effects of the investigations on the organisation. This research, published by Lund Universities Libraries, comprises two parts. In part 1 a comparative analysis is conducted on investigation reports — scrutinising five reports pre-2017 and four reports post-2017. The analytical framework is derived from Hollnagel's categorisation regarding incident investigation models, which delineates three models: sequential, epidemiological, and systemic. The findings show that there are distinctions in both the nature and effects of the investigation reports. Investigations conducted pre-2017 exhibit characteristics of the sequential model due to a focus on what went wrong, (broken) components and measures that mostly aim at the sharp end operator (train drivers, conductors, train dispatcher) such as training and discussing specific findings of the investigations with those involved only.
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Content Article
In 1990, 10-year-old Robbie Powell died due to undiagnosed Addison’s disease. Tragically, his death was preventable. Concerns that Robbie may have had Addison’s disease had been raised following a previous hospital admission and a diagnostic test requested, but this was not followed up or shared with his parents, Will and Diane. In the two weeks before Robbie died, Robbie was seen by five GPs on seven occasions, but his parents were consistently told that there was nothing seriously wrong with their son. Robbie’s father Will has worked for decades to uncover why his son died and how the doctors and organisations involved responded following Robbie’s death. In this long-read interview, Will describes the events that led to Robbie’s death and his subsequent fight for justice, including his role in the successful campaign which resulted in organisational legal duty of candour. He talks about the devastating impact that having the truth withheld continues to have on his family and other families. Will then outlines what needs to be done to better protect families and ensure they get the full truth when a child dies due to avoidable harm. Please note: readers may find the following content distressing. -
Content ArticleThe Thirlwall Inquiry is examining events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital. As part of this Inquiry, its Terms of Reference asks: “Whether recommendations to address culture and governance issues made by previous inquiries into the NHS have been implemented into wider NHS practice? To what effect?”. To help inform its work in this area, the Inquiry Legal Team has produced this Table of Inquiries and reviews which have been conducted in England and Wales over the last thirty years. Recommendations from each Inquiry have been set out in a comprehensive table, alongside details of whether or not those recommendations have been implemented.
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News Article
Trust scraps suicides review
Patient-Safety-Learning posted a news article in News
A trust has announced it is scrapping a major suicides review, prompting concerns about the “devastating” impact the surprise move could have on some grieving families. The concerns from a whistleblower—and a family member who has reportedly expressed their “upset and shock”—come despite the provider’s insistence they had taken relatives’ views into account when reaching their decision. Cambridgeshire and Peterborough Foundation Trust originally announced plans for the review of over 60 cases in July last year—a move which followed allegations that a patient’s record was tampered with after they had died by suicide in the trust’s care. A chair was appointed to lead the review just last month. But in a short statement on its website, the trust said it had now taken the decision “not to proceed with [the review] as originally intended [after] speaking with several families and loved ones with lived experience” of the suicide cases, which date back to 2017. The review had been “planned with the best of intentions [but] it has become clear… that the review would not answer the individual and highly personal questions some families might have,” the trust said. Read full story (paywalled) Source: HSJ, 13 May 2024 -
Content ArticleThis insightful session was inspired by Louise Roe's blog "Why it made sense at the time: Local rationality questions for healthcare investigations". In this webinar from Maternity and Newborn Safety Investigations (MNSI), participants explored the importance of how questions are asked, the local rationality principle, how the local rationality question tool was developed, putting the tool into practice, and had a Q&A session.
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Content ArticleThis report by the Maternity & Newborn Safety Investigations (MNSI) programme examines findings from 92 of their investigations where safety recommendations were made to midwife-led units in NHS hospital trusts in England. It highlights key learnings and prompts to help trusts to consider how safety risks can be mitigated and drive improvements in care.
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News Article
Contaminated blood scandal victims were ‘being used for research without knowing’
Patient-Safety-Learning posted a news article in News
Bereaved families who lost loved ones in the contaminated blood scandal have claimed their relatives were being “used for research” after discovering historic notes in medical records. It is claimed that some patients being treated for the blood clotting disorder haemophilia in the 1970s and 1980s were given blood plasma treatment which doctors knew might be contaminated and infect them with hepatitis. They wanted to study the links between the haemophilia treatment Factor VIII and the risk of infection, but a number of families have claimed their loved ones were enrolled in these studies without their knowledge or consent. The Factor 8 campaign group alleges that instead of stopping treatment, clinicians lobbied to continue trials, even after identifying the association between hepatitis and the treatment. Jason Evans, director of the campaign group, found notes alluding to the research in his father’s medical records. He has since found other families who have discovered the same notes in the records of their loved ones. Mr Evans, whose father died in 1993 after being infected with both HIV and hepatitis C during the course of his treatment for haemophilia, said: “It is appalling that hundreds of people with haemophilia across the country were knowingly infected with lethal viruses under the guise of scientific research. These secret experiments, conducted without consent, show individuals were treated as mere test subjects, not human beings." Read full story Source: Independent, 9 May 2024 -
News Article
'Unprecedented': Coroner prohibits naming of surgeon in herpes deaths inquest
Patient Safety Learning posted a news article in News
A surgeon who may have infected two new mothers with herpes has been granted anonymity during the inquests into their deaths in an "unprecedented" ruling. Coroner Catherine Wood said she made the decision because the surgeon's "apprehension" about being named when he stands as a witness would "likely impede his evidence in court" and affect his health. Mid Kent and Medway Coroners is investigating the cases of Kimberly Sampson, 29, and Samantha Mulcahy, 32, who both died in 2018 after the same obstetrician conducted their caesareans. They were treated 6 weeks apart in hospitals run by East Kent Hospitals University NHS Trust (EKHUT). On February 26 – the day before the inquest was due to begin and 16 months after it was first announced – EKHUT made a last-minute bid for anonymity covering the surgeon and a midwife also involved in both cases. The trust said they should not be named unless the inquest concluded they had passed on the infection, because of the "reputational damage" they would suffer, and because the surgeon's health was already being impacted by reports. Read full story Source: Medscape, 9 March 2023 -
News ArticleA study cited at the infected blood inquiry as evidence that the devastating consequences of blood products contaminated with hepatitis could not have been foreseen, misrepresented the results of a trial in making its case, according to the Guardian. Up to 6,520 people are believed to have been infected with hepatitis C through imported factor VIII blood products in the 1970s and 80s, while a further 26,800 are estimated to have been infected with the virus though blood transfusions. About 2,000 people are estimated to have died as a result. The inquiry, which publishes its final report on 20 May, heard that the medical profession considered non-A and non-B hepatitis (later known as hepatitis C) as “relatively benign” at the time, with Pier Mannuccio Mannucci’s 2003 paper, 'Aids, hepatitis and haemophilia in the 1980s: memoirs from an insider', quoted in support of this proposition. Mannucci’s 2003 paper argued that the view held by “the great majority of haemophilia treaters was that the problem of hepatitis was a tolerable one, because the benefits of concentrates seemed to outweigh risks”. In making his argument, Mannucci cited his own work, writing: “A prospective biopsy study was undertaken by me … in 10 haemophiliacs with non-A, non-B chronic hepatitis followed up for more than six years. The study, published in 1982, demonstrated no case of progression towards cirrhosis or haepatocellular carcinoma.” However, the original 1982 report says that there were actually 11–not 10–people included in the study and “one patient with active cirrhosis died of liver failure during the follow-up period”. Who knew what about the risks and when is a key plank of the inquiry. Read full story Source: Guardian, 2 May 2024
