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News ArticleNHS patients are being left unseen in pain and in some cases to die alone because shifts do not have enough registered nurses, a survey shows. The Royal College of Nursing said analysis of a survey it carried out showed that only a third of shifts had enough registered nurses on duty. The union has also gathered testimonies from nurses who talk of always “rushing” and being asked to do more; working in “completely unsafe” levels of care; and having to make “heartbreaking” decisions on who does or doesn’t get seen. Shortages mean individual nurses are often caring for dozens of patients at a time, the RCN said. It has called for limits on the maximum number of patients for whom a single nurse can be responsible. Nicola Ranger, the RCN’s acting general secretary and chief executive, said the survey showed that patients were being failed. “In every health and care setting, nursing staff are fighting a losing battle to keep patients safe,” she said. “Without safety-critical limits on the maximum number of patients they can care for, nurses are being made responsible for dozens at a time, often with complex needs. “It is dangerous to patients and demoralising for nursing staff.” Read full story Source: The Guardian, 1 July 2024
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Content ArticleOn the 22 January 2024 Assistant Coroner Sarah Bourke began an investigation into the death of Anoush Summers who died aged 77, on the 14 January 2024 at Homerton University Hospital. The deceased was a frail lady who was prone to falls. She lived at home, alone, with carers who visited her twice a day. She had a wrist alarm. The wrist alarm was reported as broken and not working on the 6 January 2024, but it was not repaired or replaced. Sometime after 4.45pm on 11 January 2024 the deceased fell at home. She was found the next day by a carer, wearing her wrist alarm and taken to hospital where she died on 14 January 2024 of hypothermia. The absence of a working wrist alarm prevented her from being found sooner that she was and probably contributed to her death.
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News Article
Council warned over broken alarm after woman dies
Patient Safety Learning posted a news article in News
An assistant coroner has warned an east London council more people may die if it does not take action, after a "frail lady who was prone to falls" died of hypothermia at her home. Anoush Summers, 77, died in hospital in January after a fall days earlier. In a prevention of future deaths report, external, assistant coroner Edwin Buckett said Ms Summers' inquest concluded "the absence of a working wrist alarm prevented her from being found sooner than she was and probably contributed to her death". Ms Summers lived alone but received help from two carers from Supreme Care Services, and she was visited twice a day. After falling at home on 11 January, she was found the next day at 09:00 GMT wearing her wrist alarm and was taken to hospital. She died of hypothermia at Homerton University Hospital on 14 January. The assistant coroner said among issues he identified in her case "giving rise to concern" were: Her wrist alarm had been reported as broken and not working on 6 January, but "this was not replaced or repaired by the company engaged by the local authority", which meant Ms Summers could not call for help as "it did not work" None of the carers who attended her home after the wrist alarm broke on 6 January "ensured that steps were taken to replace the alarm" or reported the matter to the local authority The last carer to see her, who visited on 11 January, "was not aware that the wrist alarm did not work as she had not read the care notes", and "no clear instruction was given" about the extent to which carers should read these notes "None of the carers had been given any training, instruction or guidance on the testing of wrist alarms to ensure they worked properly when attending" There was not a "clear system identified between the company providing carers and the local authority as to the duties and responsibilities of each in the reporting of faults with wrist alarms" Read full story Source: BBC News, 26 June 2024 -
News Article
NHS having to ‘pick up pieces’ of medical tourism ‘boom’, say doctors
Patient Safety Learning posted a news article in News
The NHS is having to provide emergency care to rising numbers of patients suffering serious complications following weight loss surgery and hair transplants abroad amid a “boom” in medical tourism, doctors have warned. Medics said they were being left to “pick up the pieces” as more Britons seeking cheap operations overseas return with infections and other issues. In some cases, patients are dying as a result of botched surgeries performed in other countries. Hospitals have even had to cancel elective procedures for patients because beds were being taken up by someone who needed an overseas procedure fixed. There were also concerns over patients buying weight loss drugs, including Wegovy, abroad without receiving the necessary “wraparound” care, doctors said. The British Medical Association’s annual meeting in Belfast heard there had been a “boom” in surgical tourism, which was “leading to a rise in serious post-surgery complications and deaths”. Read full story Source: The Guardian, 25 June 2024 -
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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Neonatal herpes is a rare, and potentially fatal, disease which usually occurs in the first four weeks of a baby's life. It is caused by the same virus that causes cold sores and genital infections – the herpes simplex virus (HSV). In this blog, Sarah de Malplaquet, Chief Executive and Founder of the Kit Tarka Foundation, draws on her own devastating experience of her son dying to illustrate why healthcare staff with cold sores must stay away from new babies. Sarah highlights the lack of awareness of the dangers and calls for a widespread review of policy in order to prevent future deaths. -
News ArticleThe family of a student who died after hospital staff missed that she had developed sepsis despite a string of warning signs have claimed she was the victim of a “lack of care”, as a coroner ruled there were “gross” failures in her treatment. Staff at Southmead hospital in Bristol failed to carry out the sepsis screening and observations needed to keep 20-year-old Maddy Lawrence safe after she was taken to hospital with a dislocated hip sustained in a rugby tackle. Outside court, the student’s mother, Karen Lawrence, said: “It has been a constant struggle to understand how a healthy, strong and fit 20-year-old could lose her life to sepsis which was allowed to develop under the care of professionals. “Her screams of pain and our pleas for help were merely managed, temporarily quietened with painkillers while the infection progressed unnoticed by hospital staff. “Our daughter was failed by a number of nurses and medical staff; symptoms were ignored, observations were not taken, on one occasion for 16 hours. There was no curiosity, basic tests were not completed even when hospital policy required them. “Maddy herself expressed concern on multiple occasions but her pain was not being taken seriously. As well as failing to fulfil their duty, those nurses and medical staff offered no sympathy, no compassion and little attention. “This failure meant Maddy was not given the chance to beat sepsis. Significant delays in its discovery meant the crucial window for treatment was missed. Maddy did not die due to under-staffing or a lack of money. Her death was the result of a lack of care.” Read full story Source: The Independent, 8 September 2023
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News ArticleDr Shivani Tanna has been working in the NHS for 18 years. "Everything [she] always had concerns about played out" in the care of her husband, who died after NHS hospital failures. A passionate doctor from a circle of acclaimed medics, Dr Tanna was thrust into life ‘on the other side’ as a ‘patient and a relative’ when her husband, Professor Amit Patel, was struck by a life-threatening illness. That experience, the devastated mum-of-two claims, "corroborates what [her] own patients have told [her] about the fact that, currently, the NHS is not fit for purpose". In the wake of her husband's death, Dr Tanna says his case reveals fundamental issues in the health service. “We have been indoctrinated as doctors, service users, and as a society in general to believe that this is a wonderful entity and we are so lucky to have a national health service," she says. “However, nobody wants to address the elephant in the room - that it is operating on less than full staff constantly... there is so much poor practice that it’s become normalised." Three years on and a long-running inquest to find answers later, Prof Patel’s wife is fighting to make changes to the NHS. “It has not been fit for purpose for decades,” Dr Tanna told the Manchester Evening News. "It is operating on less than full staff constantly, relying on bank staff and locums, and we’ve got doctors leaving in droves because they’ve not been nurtured or given the opportunity to work, I think, in a safe and appropriate environment.” The Area Coroner for the Manchester City concluded that the death of a 43-year old Consultant Haematologist and father of two, Prof Amit Patel, would have been avoided were it not for ‘inexplicable’ failures by clinicians to provide a national-level Multi-Disciplinary Team (MDT) with relevant and readily available information about the patient. Prof Patel was suffering from Hemophagocytic lymphohistiocytosis (‘HLH’), a rare disorder in which he himself was an expert. The Coroner found that the local clinicians at Wythenshawe Hospital had failed to provide a National HLH MDT with relevant and readily available information that would have influenced the decision making about Prof Patel’s care. As a result the National MDT, operating on incomplete information, recommended that Prof Patel undergo an Endobronchial Ultrasound guided biopsy (EBUS) procedure, a complication of which ultimately led to his death. The Coroner also found that there were failures in the process by which Prof Patel’s consent was obtained to undergo the procedure and as a result he was not given the opportunity to provide his informed consent to the EBUS that ultimately led to his death. Read full story Source: Manchester Evening News, 17 June 2024
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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 ArticleA 33-year-old New Zealand woman who was accused of faking debilitating symptoms has died of Ehlers-Danlos Syndrome (EDS). Stephanie Aston became an advocate for patients' rights after doctors refused to take her EDS symptoms seriously and blamed them on mental illness. She was just 25 when those symptoms began in October 2015. At the time, she did not know she had inherited the health condition. EDS refers to a group of inherited disorders caused by gene mutations that weaken the connective tissues. There are at least 13 different types of EDS, and the conditions range from mild to life-threatening. EDS is extremely rare. Aston sought medical help after her symptoms—which included severe migraines, abdominal pain, joint dislocations, easy bruising, iron deficiency, fainting, tachycardia, and multiple injuries—began in 2015, per the New Zealand Herald. She was referred to Auckland Hospital, where a doctor accused her of causing her own illness. Because of his accusations, Aston was placed on psychiatric watch. She had to undergo rectal examinations and was accused of practising self-harming behaviours. She was suspected of faking fainting spells, fevers, and coughing fits, and there were also suggestions that her mother was physically harming her. There was no basis for the doctor’s accusations that her illness was caused by psychiatric issues, Aston told the New Zealand Herald. “There was no evaluation prior to this, no psych consultation, nothing,” she said. She eventually complained to the Auckland District Health Board and the Health and Disability Commissioner of New Zealand. “I feel like I have had my dignity stripped and my rights seriously breached,” she said. Read full story Source: The Independent, 6 September 2023
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Content Article
The Voicing Loss project is a collaboration between the Institute for Crime & Justice Policy Research at Birkbeck, University of London, and the Centre for Death & Society at the University of Bath. The research was conducted from May 2021 to May 2024, with funding from the Economic and Social Research Council. The research examined the role of bereaved people in coroners’ investigations and inquests, as defined in law and policy and as experienced in practice. It also explored ways in which the inclusion and participation of bereaved people in the process can be better supported. A range of project outputs are available via the dedicated Voicing Loss project website. They include a short research summary, along with thematic research reports and policy and practice briefings. The website also has an information and resources section for the general public, and an Expert Insights blog to which many stakeholders have contributed. Many of the study’s key findings, and the research context and methodology, are presented in the papers listed on the website. Implications of these findings for policy and practice are considered in a series of briefings also available through the website which you can access via the link below. -
News Article
Sussex NHS trust apologises for cancer treatment delays before man’s death
Patient Safety Learning posted a news article in News
A troubled NHS trust has apologised to the family of a man who died after a series of delays led to him waiting four times longer for an operation than a national cancer target. Before he died in November 2022, Ken Valder, 66, complained of “delays after delay” to his treatment for oesophageal cancer. University Hospitals Sussex – the focus of a separate police investigation into allegations of surgical negligence and cover-ups over dozens of deaths between 2015 and 2021 – admitted that errors, failures and disagreements between surgeons contributed to delays to Valder’s treatment. They also accepted that the case highlighted patient safety concerns that prompted the hospital regulator in 2022 to suspend upper gastrointestinal cancer services at the trust, which includes the Royal Sussex County hospital in Brighton. An independent review of the case also found that Valder’s care was “suboptimal” and that if he had received surgery earlier it “might have led to a better oncological outcome”. Read full story Source: The Guardian, 17 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 ArticleThe United States continues to have the highest rate of maternal deaths of any high-income nation, despite a decline since the Covid-19 pandemic. And within the U.S., the rate is by far the highest for Black women. Most of these deaths — over 80% — are likely preventable. With policies and systems in place to support women during the perinatal period, several high-income countries report virtually no maternal deaths. As policymakers and health care delivery system leaders in the U.S. seek ways to end the nation’s maternal mortality crisis, these countries may offer viable solutions. This brief updates an earlier Commonwealth Fund study of differences in maternal mortality, maternal care workforce composition, and access to postpartum care and social protections between the U.S. and other high-income countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom. In this edition, we have also included data on Chile, Japan, and Korea — all high-income countries with universal healthcare systems.
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Content ArticleOn the 8 March 2023, an investigation commenced into the death of Christine Rita Booker, born on the 6th October 1943. The investigation concluded at the end of the Inquest on the 17 May 2024. The medical cause of death was: la Haemorrhagic shock lb Iatrogenic injury of right pelvic blood vessels 2 The conclusion of the Inquest recorded that Christine Rita Booker died as a consequence of a complication of elective hip replacement surgery.
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News Article
Woman bled to death after hip replacement operation
Patient Safety Learning posted a news article in News
A 79-year-old woman bled to death following a hip operation after being rushed to a hospital which lacked a service to save her, a coroner has said. Christine Booker from Wareham died on 24 February 2023, the day after her hip replacement. Coroner Brendan Allen said she was initially transferred to Dorset County Hospital in Dorchester, which had no out-of-hours interventional radiology (an imaging procedure), before being sent to Royal Bournemouth Hospital. In a Prevention of Future Deaths report, he said patients in west Dorset faced a "potentially considerable and significant delay in the provision of urgent and life-saving treatment". Writing to Dorset County Hospital, external, the coroner said the lack of an out-of-hours service in Dorchester exposed patients to an "increased risk of death". Read full story Source: BBC News, 10 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 -
News Article
Trust suspends treatment for premature babies after several deaths
Patient-Safety-Learning posted a news article in News
A national study is examining whether a treatment for premature babies could cause harm, amid concerns about the deaths of four infants last year, it has emerged. HSJ has learned a national study into the use of prophylactic low-dose hydrocortisone steroids, also known as “premiloc”, is being carried out at the Neonatal Data Analysis Unit, part of the Imperial College London Medical School. Meanwhile, University College London Hospitals Foundation Trust confirmed that four children died in January and February 2023 last year, having been transferred from UCLH to nearby Great Ormond Street Hospital, after receiving the treatment. They had been given hydrocortisone steroids at UCLH to reduce the risk of developing a lung condition called bronchopulmonary dysplasia. UCLH said its own internal investigations “did not confirm a direct link” between the deaths and the drug, “but concern remained” so they were reported to the regional neonatal network. UCLH noted that the national study at Imperial was now under way, although the Imperial team told HSJ it was not specifically aware of the UCLH/GOSH deaths last year. A report from GOSH’s safety team last year, seen by HSJ, said: “In all four deaths the mortality review group identified modifiable/potential modifiable factors around the administration of premiloc prior to admission to GOSH. Administration of premiloc (hydrocortisone steroids) to these babies may have been associated with the subsequent perforations. A series of incidents of perforations was flagged to the UCLH neonatal unit who reviewed data and have stopped the administration of premiloc.” Read full story (paywalled) Source: HSJ, 5 June 2024 -
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 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 ArticleThis is the transcript of a statement in the House of Commons by the Minister for the Cabinet Office and Paymaster General, John Glen MP, in response to the publication of the final report of the Infected Blood Inquiry. He sets out plans for a proposed scheme to provide compensation to those infected and affected by this scandal. This was followed by comments from other members of the House of Commons.
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Content ArticleThis is the transcript of a statement in the House of Commons by the Prime Minister, Rishi Sunak MP, in response to the publication of the final report of the Infected Blood Inquiry. He apologises for the failure in blood policy and blood products, the repeated failure of the state and medical professionals to recognise the harm caused by this and for the institutional refusal to face up to these failings. He also says that the Government will pay comprehensive compensation to those infected and affected by this scandal. This statement is followed by a response from the Leader of the Opposition, Sir Keir Starmer MP, and comments from other members of the House of Commons.
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Hugh Pym and Chloe Hayward speak about the Infected Blood Inquiry in this 30 minute piece from the BBC, one of the worst treatment disasters in NHS history. -
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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