Officials point to human error in 6-year-old boy's death after ambulance sent to wrong address

It came down to the push of a button.

Authorities in New York blamed human error - not the city's Unified Call Taking system - for a 12-minute delay that may have contributed to the death of ailing 6-year-old, Ian Uro.

"It looks like an accident," said Paul Browne, the NYPD's chief spokesman.

Mariela Lazaro was too distraught to provide the correct cross streets when she called 911 on Thursday. A 911 dispatcher hit the wrong computer key, searching a Brooklyn database for the information even though Ian's mother was calling from Manhattan. The stroke of the wrong button mistakenly sent an ambulance crew to Avenue C in Brooklyn - instead of Avenue C in Stuyvesant Town.

The Brooklyn crew arrived at 9:10 a.m., six minutes after Lazaro first called 911 and said her son's nose was bleeding. When paramedics suspected there was a problem with the address, they called the mother and learned of the error.

A second crew was sent to the correct address in Manhattan. That ambulance arrived at 9:22 a.m., but the boy was already dead. It wasn't immediately clear if the boy could have been saved.

The call system, has been blamed in several 911 delays - including two fires that claimed six lives - during which firefighters were sent to the wrong addresses.

Ian had been sick, his maternal grandmother told the Daily News Friday. Relatives took him to Beth Israel Medical Center on Monday for treatment of a fever and other flu-like symptoms. On Wednesday, sources said, the boy was taken to a clinic.

"It's so sad," said his grandmother, who had was visiting from Argentina. She declined to give her name.

Autopsy results were inconclusive pending further tests, officials said.

This article is courtesy of Daily News.

NHS negligence claims rise by 20 per cent in just one year

Official figures show the number of cases registered has increased by almost 20 per cent in just one year - and by 80 per cent since 2008.

Latest forecasts suggest the bill for negligence will soon reach £19 million - almost one fifth of the total NHS budget.

In total 16,006 patients or bereaved relatives lodged claims against the health service during 2012/13, compared with 13,517 the previous year, a rise of 18.4 per cent.

Experts said the figures reflect a lack of tolerance for poor care, and patients feeling forced to take legal action because hospitals refused to apologise or explain their failings.

Last night Margaret Hodge, chairman of the Commons public accounts committee said the new figures were “deeply worrying”.

She said: “The trend is really concerning. Some of this is about ambulance-chasing lawyers, but more than that I think this reflects problems with the quality of healthcare, and that is a major concern.”

More than £1bn was spent on settlements last year, but around one quarter of costs are spent on legal fees, mainly to claimants’ lawyers under a “no-win, no fee” system which means legal firms can charge up to £900 an hour for their services if claims are successful.

Katherine Murphy, chief executive of the Patients Association, said: “I think the public has become far less tolerant about putting up with appalling failings in care, but most people only pursue legal action when every other avenue has failed.

"Most people who contact us say that all they wanted was an explanation of what went wrong, and changes made so that nobody else would suffer.”

Figures show that in 2011/12, five law firms received £35 million from legal action against the NHS.

They included Irwin Mitchell, paid £18.9 million from working on 522 cases, gaining a total of £43 million for clients, and Leigh Day & Co which made £5.5 million from 197 cases.

The firms said they had taken on major cases. Irwin Mitchell said it had won an £8 million payout for the family of a brain injury victim, and that the NHS needed to reduce its bill by stopping repeating the same errors, and by admitting to mistakes earlier.

In December, Worcestershire Acute NHS Hospital trust wrote to 38 families after appalling failings, including the case of a patient starved to death and dying people left to scream in pain. The hospital paid out £410,000 to families reperesented by Leigh Day & Co.

Laywers said they expected to see an “explosion” in medical negligence claims in future years, following the report of a public inquiry by Robert Francis QC in February into failings at Mid Staffordshire Hospital Foundation trust, where up to 1,200 more patients died than would have been expected.

Ian Pryer, senior partner at medical negligence solicitors Axiclaim said: “In the past, victims of medical accidents often had moral reservations about claiming against the NHS, despite having clearly suffered extreme negligence in some cases but the shocking findings of the Francis report have now made hospitals fair game in the eyes of the public.”

A Department of Health spokesman said: “Whilst we know the vast majority of patients get good, safe care, the best way to reduce compensation claims is to improve patient safety further - and this is a priority.”

He said the NHS had brought in a global expert, Dr Don Berwick, to provide advice on how to create “a zero-harm culture in the NHS.”

This article is courtesy of The Telegraph.

Bromsgrove man paralysed 'after missed checks'

Bromsgrove man paralysed 'after missed checks'
Stephen Onley after surgery Stephen Onley said he "gave in to having the epidural"

A man was left paralysed because doctors did not monitor him correctly after hip surgery, lawyers said.

Stephen Onley, 52, from Bromsgrove, Worcestershire, had an epidural in 2010 at The Royal Orthopaedic Hospital and had complications, Irwin Mitchell said.

The lawyers added the trust admitted responsibility for spinal damage, which paves the way for a settlement.

The Birmingham trust apologised and said it admitted liability over some aspects of managing his complications.

Irwin Mitchell stated Mr Onley, a social worker who cared for people with spinal injuries, said he asked not to have an epidural to control pain, as he was aware of a risk linked to this type of anaesthetic through working with disabled people.
'Dangerously low'

But he was given one during treatment in December 2010 and suffered complications resulting in a lack of blood to the spine, it added.

Irwin Mitchell said although medics would have been well aware a spinal epidural could cause someone's blood pressure to drop after an operation, routine checks were missed and his blood pressure fell "dangerously low".

Mr Onley was left paralysed from the waist down, had to give up his job and relies on a wheelchair, it added.

"In the end I gave in to having the epidural because they said they wouldn't go ahead with this procedure without having an epidural," Mr Onley said.

"I can't get up the stairs at home... I'm not able to do things like the washing up any more. The sink's too high for me to reach in to."

Irwin Mitchell said the trust admitted full responsibility for irreversible spinal damage, which occurred as a result of failing to correctly monitor him, and a perforated bowel, which he suffered due to inadequate care after becoming paralysed.

Trust acting chief executive Graham Bragg said it was "sorry for the complications Mr Onley experienced" following his surgery.

He added: "A number of allegations have been made regarding his treatment.

"We have admitted liability regarding some aspects of the management of the complications Mr Onley experienced and apologised to him unreservedly in September 2012.

"We are committed to providing an excellent service and continually recognise the need to learn from our failings to improve the service we provide to all patients."

Tim Deeming, a medical law expert at Irwin Mitchell, said it would work with the trust "to provide Stephen with the financial support he requires to pay for the special equipment, care and rehabilitation needed".

This article is courtesy of the Birmingham Mail.

Nurse switched off patient's life support by mistake

An agency nurse who was filmed turning off a patient's life support machine before making a bungled attempt to resuscitate the man has been suspended pending an investigation, it was reported today.

Jamie Merrett, a 37-year-old tetraplegic patient, suffered brain damage when his ventilator was switched off by mistake at his home in Devizes, Wiltshire last year.

Video footage of the incident, passed to the BBC, shows the moment a nurse, who was working for agency Ambition 24hours on behalf of the NHS, turned off the machine. "What have you done?" a colleague is seen to ask. "Switched this off," replies the nurse, who is named as Violetta Aylward, pointing at the ventilator.

Merrett was reported to have been aware of what was going on but was unable to alert the nurse to the mistake. He can be heard on the film clicking his tongue as a warning. The video camera, which was installed at Merrett's suggestion because of concerns about his care, then shows Aylward's attempts to revive him with a resuscitation bag, but she applies it in the wrong place.

The bag was eventually applied correctly by paramedics and Merrett's life support machine was turned back on 21 minutes after being switched off.

Merrett's sister, Karen Reynolds, told the BBC that his mental age dropped to that of a young child after the incident. "He doesn't have a life now," she said.

Before the incident Merrett, who was left paralysed by a road accident in 2002, was able to talk, use a computer and a wheelchair.

Patient campaigners today condemned the incident as an "appalling lapse in care" which highlighted failed attempts to improve nurses' training and a lack of accountability.

The Nursing and Midwifery Council has suspended Aylward while the incident is investigated.

The BBC said a leaked report by Wiltshire social services concluded Ambition 24hours was aware it was required to supply a nurse with training in the use of a ventilator, but the company did not have adequate systems in place to check what training their staff had received.

Ambition 24hours said it could not discuss the matter while its own investigation was being carried out. The NHS Wiltshire primary care trust said it was restricted in what it could say because of likely legal action. In a statement it said: "The PCT has investigated the incident in January 2009 when the patient's ventilator care was compromised. We have apologised to the patient and his family for this and have put in place a series of actions to ensure that such an event will not occur again either for this patient or others."

Katherine Murphy, chief executive of The Patients Association, said: "The response every time is lessons will be learned, but if lessons are being learned then why do the same mistakes get made? The NHS has been warned repeatedly about ensuring the staff it hires, agency or otherwise, are suitably trained to look after their patients and we have campaigned for many years for an NHS that listens to its patients' concerns.

"To think that this person was so worried that they installed a camera in their own home, but that their concerns were apparently ignored – it's outrageous.

"Who will be held to account for this? Or will managers walk away unscathed yet again, even though a life has been ruined?"• Merrett's story is featured in Inside Out on BBC1 at 7.30pm today.

This article is courtesy of theguardian.

First criminal probe into patient death at scandal-hit Mid-Staffs hospital

A criminal investigation has been launched into the death of a woman at scandal-hit Mid-Staffordshire NHS Foundation Trust following a public inquiry, which concluded patients had suffered “appalling” care.

The Health and Safety Executive is to investigate the death of Gillian Astbury, who was diabetic and 
died aged 66 in 2007 at Stafford Hospital after nurses forgot to give her insulin.

If charges are brought, it would represent the first time that anyone has faced criminal prosecution over the Mid-Staffs scandal.

Robert Francis, who chaired the inquiry into the trust, was so shocked by the case he cited it in a seminar before writing his report. He said that despite its gravity, the gross error that led to Mrs Astbury’s death had failed to trigger remedial action. “It never registered with the Trust board or the strategic health authority leading one to ask: what about accountability?”

Ron Street, 79, Ms Astbury’s “close friend, soulmate and carer”, said there was a “lack of responsibility” in the NHS. “I am not a vindictive person but I would like the people at Stafford held to account. I don’t necessarily want them clapped behind bars but I do want a message sent out across the NHS that you cannot do this with impunity,” he said.

Ms Astbury was admitted to Stafford Hospital with a fractured hip following a fall at home on 1 April 2007. After repeated instances in which Mr Street had found her lying in soiled bed linen, with meals left out of reach and bloody tissues discarded on the bedside table, she died 10 days later in a hypoglycaemic coma after she had been transferred to a new nursing team who had not read her notes and failed to realise she needed regular injections of insulin for her diabetes.  

A police investigation was launched but no prosecution was ever brought. The HSE was due to investigate but put its inquiries on hold until the conclusion of the Francis inquiry in February.
At the inquest into Mrs Astbury’s death in September 2010, the jury found “serious shortcomings” in the running of the hospital. “Nursing facilities were poor, staff levels were too low, training was poor, and record keeping and communications systems wre poor and inadequately managed,” its verdict said.
An HSE spokesman said: “Our focus will be on establishing whether there is evidence of the employer [the Trust] or individuals failing to comply with their responsibilities under the Health and Safety at Work Act.”

Julie Hendry, director of quality and patient experience at Mid Staffordshire NHS Foundation Trust, said in a statement: “I would like to offer our sincere condolences to the family of Gillian Astbury for their sad loss and apologise for the appalling care Ms Astbury received at our hospital in April 2007.

“Ms Astbury’s death was reported as a serious untoward incident at the time and a full investigation into her care and treatment was carried out. The recommendations from that investigation were implemented. Actions included raising staff awareness about the care of diabetic patients and improving the information and system for nurse handovers. In 2010 we reviewed Ms Astbury’s dreadful care and, as a result, disciplinary action was taken.”

The Francis inquiry highlighted “appalling and unnecessary suffering of hundreds of people” at the Trust between 2005 and 2009 and concluded it had put “corporate self-interest and cost control ahead of quality and patient safety”.

As many as 1,200 patients may have died needlessly after they were “routinely neglected” at the hospital.

Many were left lying in their own urine and excrement for days, forced to drink water from vases or given the wrong medication.

This article is courtesy of The Independent.

Patients 'gambling with their lives' with some GPs

Dr Neil Bacon, who worked in the NHS for nearly 20 years, said a recent report found “significant and unexplained” variation in the quality of services provided by family doctors.

Writing in The Daily Telegraph, he argued: “The NHS’s own “Atlas of Variation” makes it clear that for many common conditions such as diabetes, the care patients receive varies widely, with up to five-fold differences in the rates of amputation or death.

“Patients are literally gambling with their life when they choose which GP to register with.”

He said: “General practice remains one of the last bastions of monopolistic protectionism with no transparency on quality. This does a disservice to the many excellent doctors and nurses in the NHS.”

Dr Bacon’s Friends and Family Test, in which patients are asked if they would recommend the A&E or ward they have just visited, is being rolled out across hospitals in England. 

The Prime Minister is a firm advocate of the project, as is Jeremy Hunt, the Health Secretary. Both believe it will lead to earlier detection of problems - averting scandals like the one that engulfed Stafford hospital - and driving up standards.

Dr Bacon, chief executive of health ratings firm iWantGreatCare, said it was essential to extend the test to primary care, as he thought the variation in quality was even greater among GP practices than it was between hospitals.

He wrote: “Transparency will act like a disinfectant, driving out poor practice and improving standards.”

Once people had a better handle on how good - or bad - their local practice was, that would increase the pressure for them to be able to choose which surgery they attended, he added.

He concluded: “Remember, your doctor chooses very carefully to get the best care for their family. 

Shouldn’t you have the same choice?”

However, Dr Clare Gerada, chairman of the Royal College of GPs, thought was overstating his case. 

She said: “I think he’s wrong. There has been variability but it has been addressed over the last 20 years.

“To say people are risking their lives when they sign up is overly dramatic.”

There were “checks and balances” to ensure GPs were competent, she added.

Dr Gerada also called into question the usefulness of the Friends and Family Test to GP surgeries, saying people were already able to rank their local practice on the NHS Choices website.

This article is courtesy of The Telegraph.

Cancer patients condemn hospital care

Cancer patients are going hungry and receiving the wrong drugs while in hospital, with some feeling so badly looked after they even consider abandoning their treatment, a new survey has found.

The findings prompted Macmillan Cancer Support, which commissioned the survey of 2,142 adults in the UK who have cancer, to complain that some people with the disease are being neglected in a way reminiscent of the appalling care seen during the Mid Staffordshire scandal.

Of 358 patients who had been diagnosed within the last two years and had stayed in hospital at least one night to be treated, 122 (34%) said they had needed extra food; 69 said they had not got it.

About 6% of respondents said they had been given the wrong drugs. As about 170,000 cancer patients a year in England end up in hospital, that equates to about 10,000 patients whose health could suffer as a result of such errors, according to Macmillan.

Similarly, 11% of cancer patients usually received important news about their treatment or progress in an open ward or room, 10% had been woken up overnight by cleaners working, and 15% had had to wait over half an hour for their water to be refilled, with 5% waiting at least two hours.

About 7% of respondents, or 12,000 patients a year, said they had felt like dropping out of their treatment early because they felt badly treated by hospital staff.

"This survey sheds a worrying light on the subculture within some parts of the NHS where bad patient experience is acceptable", said Ciaran Devane, chief executive of Macmillan. Devane is also a board member of NHS England, which last month took over the running of the service.

"We have seen this at its worst in the case of the Mid Staffordshire NHS Foundation Trust, exposed in the Francis inquiry."

In a separate survey, for ITV News, 34% of adults said they had experienced unacceptable levels of care on the NHS since 2011, though 58% believed the NHS still offered good care overall.

This article is courtesy of theguardian.

17 cancer patients are given false all-clear

Seventeen patients given a cancer all-clear have now been told they have the disease after a series of hospital blunders.

One consultant at Hereford County Hospital has been suspended since the flawed test results came to light.

More than 4,600 biopsies and tissue samples for a range of possible conditions had to be re-examined after colleagues raised concerns about the histopathologist, who has not been named.

A total of 40 patients who were recalled were told their conditions were worse than originally thought.

Meanwhile, 62 others were informed that their illness was less serious than initially feared.

Hereford Hospitals NHS Trust announced in February it was launching an investigation after the lab mistakes became apparent.

All tissue samples involved were taken between May 2006 and August 2007.

They were sent for independent review and, as a result, 102 patients were recalled.
 
The consultant has been removed from the lab pending the completion of disciplinary procedures.
In a statement, the hospital said: "The review followed indications of possible errors in the examination of a small proportion of tissue samples by one consultant working at the hospital during that time."
"The samples that have been reexamined include biopsies, surgical specimens and cytology (cell) samples."

The trust's chief executive Martin Woodford yesterday apologised for the errors.
 
He said: "Now that the review is complete, I would once again like to apologise personally and on behalf of the trust, to all patients affected by this regrettable situation - in particular to those who had received an inaccurate diagnosis.

"Our highest priority throughout has been the care and well-being of our patients and we have acted as quickly as possible to make sure that the review was carried out thoroughly and effectively.

"The patients involved have generally appreciated the efforts we have made to investigate this situation and to recheck, individually, their samples, diagnosis and treatment and I thank them all for their patience and understanding."

He added: "No patients that we have been able to identify have died as a result of a misdiagnosis.

"However, a number of patients are undergoing treatment and we cannot definitively say they will not be affected later on."

Alison Budd, the trust's medical director, said: "Following the careful and complex checking procedure, the total number of patients that we needed to recall to discuss changes in their diagnosis or treatment was 102.

"Where necessary, those patients have had their treatment amended. We would like to reassure patients that individual details about them will not be made public."

She went on: "We took immediate action to investigate when concerns were first raised and as a result we have increased our cross-checking and quality control procedures to protect against a similar situation arising."

Dr Lesley Walker, director of cancer information at Cancer Research UK, described the news as "extremely unfortunate and distressing".

She said: "It's vital that robust systems are put in place to stop this happening again." But she added: "It is also important to remember that incidences such as this are extremely rare."

4,600 Biopsies and samples had to be re-tested for the investigation.

102 Patients had to be recalled to change the diagnosis or treatment.

This article is courtesy of the Mirror.

10,000 cancer patients given the wrong drugs

The report by Macmillan Cancer Support found basic failings in the care of tens of thousands of cancer sufferers.

One in three patients said they were treated in dirty surroundings. In cases when patients required extra food - having missed meals because of surgery, or become weak because of their treatment - more than half were denied it.

The YouGov survey of more than 2,000 cancer patients found that six per cent of patients - the equivalent to more than 10,000 patients a year - were given the wrong drugs.

The charity said drug errors involved nurses mixing up medication and giving it to the wrong patients, while in other cases patients were left with inadequate pain relief, because staff did not understand their needs.

The poll found that seven per cent of patients - an estimated 12,000 of the 170,000 treated for cancer each year - became so fed up with the way that the way they were treated by staff that they considered abandoning their treatment early.

Ciarán Devane, Chief Executive at Macmillan Cancer Support, said: “It is alarming that so many cancer patients are given the wrong drugs, left hungry while being treated in hospital or have even felt like dropping out of treatment because of their interactions with staff.

“This survey sheds a worrying light on the sub-culture within some parts of the NHS where bad patient experience is acceptable. We have seen this at its worst in the case of the Mid Staffordshire NHS Foundation Trust exposed in the Francis Inquiry.”

The charity said lack of food, incorrect drugs and a dirty environment could compromise the health of cancer patients and put back their recovery.

This article is courtesy of The Telegraph.

Mother left infertile by NHS smear test error awarded more than £500,000

A woman who was left infertile after two cervical smear tests were misdiagnosed has received more than £500,000 in damages from the NHS.

Samantha Burn was first screened in October 2001 but called for a second test a month later after the initial results were found to be inadequate. She was later told nothing abnormal had been discovered.

However, after suffering problems during her pregnancy in 2003, Mrs Burn, now 31, from Bourne, Lincolnshire, was diagnosed with cervical cancer.

After giving birth to a healthy baby girl in December that year, she immediately began courses of radiotherapy and chemotherapy, which have left her infertile.

She also suffers from other medical conditions, including problems with her hips, bowel and bladder, and is on long-term hormone replacement therapy.

Her solicitor Mehmooda Duke said yesterday: ‘The greatest tragedy is there was not just one slide which was misread but two.

Of greatest significance is Mrs Burn’s inability to have children.

‘The delay in diagnosis has rendered her infertile. This is something that she cannot come to terms with.’

John Randall, medical director of Peterborough and Stamford Hospitals NHS Foundation Trust, said it regretted the errors and procedures were being reviewed.

This article is courtesy of The Mail Online.

£8.5m payout for boy whose brain was damaged in 'catalogue of errors'

A seven-year-old boy who suffered catastrophic brain damage after a "catalogue of errors" at his birth is to receive a compensation package worth £8.5 million.

Alfie Buck's lawyers told the High Court that staff at the Princess Royal Hospital in Haywards Heath, West Sussex, failed to monitor him sufficiently during his mother's labour in March 2006 or deliver him by emergency caesarean.

They claimed that if he had been delivered just 20 minutes earlier, it was highly likely he would have been born without any brain damage at all.

Alfie, whose intelligence was largely spared, now has cerebral palsy and suffers painful spasms. He is completely reliant on a wheelchair, communicates using technology and needs 24-hour support.

Despite his problems, Alfie has a great sense of humour and is doted on by his siblings, Jessica, 13, and Louis, 10, said mother Samantha, of Horsham, West Sussex.

"The cerebral palsy affects all his limbs making movement very difficult, but his mind is very bright and he can communicate by using specialist equipment that tracks eye movement. He continues to amaze us and his teachers at his specialist school and he truly is an inspiration.

"Having said that, caring for a child with cerebral palsy has to be the toughest job in the world as it is 24/7 and consumes your life.

"Not long after he was born the doctors told us brain scans showed severe abnormalities and it was hard not to be bitter or angry. It just felt very unfair as Alfie didn't deserve it."

Mrs Buck, and her husband Andrew, an estate manager, were at London's High Court with Alfie to hear Mr Justice Hickinbottom approve the award against Brighton and Sussex University Hospitals NHS Trust, which admitted liability.

A lump sum of £3.85 million plus lifelong periodical payments will fund a new wheelchair-accessible home for the family with space for live in carers and pay for physiotherapy, transport, education, specialist equipment and support.

The family's solicitor, Jane Weakley, of law firm Irwin Mitchell, said the case was "tragically a catalogue of errors".

The Trust's counsel, Paul Rees QC, echoed an apology sent to the Bucks in 2011 by its chief executive, who told them that lessons had been learned from the failures in Alfie's care.

Giving the family an unreserved public apology, Mr Rees said: "We all know that nothing I can say will turn back the clock but they are entitled to hear that."

He also paid tribute, not only to Alfie's spirit, but to the commitment, insight and devotion of his parents, brother and sister, and the sacrifices they had made.

The judge added: "It frankly never ceases to amaze me - the care and love parents and carers show - but this is another case in which they are very clearly and markedly illustrated."

This article is courtesy of The Independent.

'Essex boys' murderer wins dental pain compensation payout

A man serving a life sentence for the "Essex Boys" gangland murders has won £44,500 damages from the Home Office for negligent dental care.

Michael Steele was jailed for the triple murder of Patrick Tate, Anthony Tucker and Craig Rolfe in 1998.

Last year he was awarded £66,400 in damages.

Appeal Court judges on Friday rejected the Home Office's appeal against negligence findings, but reduced Steele's payout to £44,500.

Steele and Jack Whomes were both convicted after the three victims were shot dead in a Range Rover on an isolated farm track in December 1995 in a gangland dispute over drugs.
Mick Steele Steele was jailed in 1998 for the murders of three men

The Appeal Court heard his Steele's fillings fell out at Belmarsh Prison soon after he was given his three life sentences.

Since then, while being moved between high security prisons, Steele has suffered "persistent severe pain".

Judge Edward Bailey last year ruled the Home Office had been negligent in failing to give him the dental treatment he needed and awarded him £66,400 damages, including about £250 for every week of toothache he endured.

Lady Justice Smith, sitting in the appeal court, said it was "a bad case involving persistent severe pain over nearly four years, together with more moderate pain for two years and some significant deterioration in the general condition of his teeth".

She reduced his original damages to £25,000 and with interest and £16,000 for Steele's "pecuniary loss", the total payout comes to £44,500.

Steele represented himself after his legal aid was withdrawn.

This article is courtesy of BBC News.

GPs attempts to blow whistle on poor care go unheard

Nearly a third of GPs who have blown the whistle on poor hospital care say no action was taken to tackle concerns, a survey has found.

 Doctors said even the most serious problems were dismissed or ignored.

A Birmingham GP said he raised concerns about a patient turned away from Accident & Emergency department who ended up needing to be admitted to intensive care with renal failure at another hospital. He received a letter saying the incident should have not occurred but no assurances of any actions being taken to prevent future tragedy.

The poll of more than 300 GPs by Pulse magazine found that 41 per cent had contacted local hospitals about concerns in the last 12 months.

Of these, 31 per cent said no action was taken. A similar proportion said they did not know if if anything had been done in response to their concerns.

A north London GP said several attempts to complain on behalf of his patients had been ignored, including one about the care of a man with learning difficulties who had suffered long delays and drug errors.

The report of the public inquiry into appalling failings at Mid Staffordshire NHS Foundation Trust criticised GPs for not speaking up and said they needed to do moare to monitor the standards of hospital care.

Dr Chaand Nagpaul, from the British Medical Association’s GP committee said: “We need better systems for GPs to raise concerns at an early stage in a simple way, rather than having GPs writing isolated, ad hoc letters hoping it will reach the right person."

this article is courtesy of The Telegraph.

Health Secretary Jeremy Hunt goes on the wards to make a hands-on diagnosis of the NHS

Cynics will dismiss it as a stunt. But for the past few months and with little publicity Jeremy Hunt has been out on the wards. One day each week the Health Secretary has left Whitehall to spend time “working” on the front line of his sprawling NHS empire.

He has answered the phone to patients at a GP’s surgery in Kennington, made the beds on a busy A&E ward and joined the porters as they move patients around hospitals; visiting operating theatres, treatment rooms, and occasionally the mortuary. At one hospital he was even asked to do the photocopying. He couldn’t say no

The idea, says Hunt, is to “see what’s happening on the coalface”. Because unlike his predecessor, Andrew Lansley, who spent six years learning his trade as shadow Health Secretary before getting his hands on the levers of power, Hunt had no political knowledge or experience of the health service before being appointed last September.

Hunt  knows he could be undone by a failure to understand the fiendish complexities of the system for which he is accountable. He may have a better political bedside manner than Lansley – but that will count for nothing if another Mid Staffordshire scandal takes place under his watch.

We meet at the Chelsea and Westminster Hospital in London, where he has spent the morning on an A&E ward. It is the day after David Prior, chairman of hospital inspectorate the Care Quality Commission, warned that some A&Es were “out of control” and “unsustainable”.

By all accounts, the unit was under control at the time Hunt visited. But one nurse did leave a message for the Secretary of State: “He’s got to know it’s not usually like this.”

Hunt agrees. “The biggest pressure in the NHS is on A&E. The fundamental problem is that people are not finding it easy to see a doctor out of hours and are ending up in hospital. We also have an ageing population which means we have four million extra people going through A&E than we did in 2004.”

It is a political problem as much as a medical one. Only last week Hunt was accused of trying to find £300m that didn’t exist in an effort to solve the A&E conundrum. As for the coming years, however, Hunt believes that Britain’s ageing population – and in particular dementia – will become the biggest threat to the NHS. He likens the challenge to that of cancer 50 years ago.

To that end he will announce a review on Monday that will attempt to completely rethink the way the NHS offers care to it biggest clients – the elderly.

At the heart of Hunt’s diagnosis – from his visits and meetings – is that the NHS has lost track of what it should be doing. GPs have been incentivised to fulfil tick-box exercises proving they have assessed their patients for certain conditions – rather than looking at their care in the round. Hospitals have been paid “by results” for operations rather than thinking what happens when the elderly lady who has had a hip operation leaves the ward. And most importantly there is no obvious connection between the NHS, which is responsible for health, and local councils, which are responsible for social care.

As he puts it: “In too many parts of the country, social care systems off-load patients into hospital and say ‘nothing to do with us, gov’. They then put up a huge number of barriers to them leaving [hospital]. They say if you want us to take them back you’ve got to fill out this 64-page form and we’ll see if they are eligible.”

What Hunt wants to see is a system where GPs are rewarded for looking after patients when they’re ill and when they’re well, where social services are incentivised to prevent people from ending up in A&E in the first place – and most importantly where everyone who needs it has a dedicated individual to help them navigate the system.

“The really, really important question is who is responsible for people when they are not in hospital?

“Nobody disagrees that there has got to be someone there thinking that 85-year-old Mrs Jones needs this type of care and needs to be visited this often, have physiotherapy, occupational therapy – whatever it is.

“But now we have to make a reality of that – because unless we do that we won’t solve the long-term issues around A&E pressures – and more importantly we won’t give vulnerable elderly people the kind of care we can be proud of.”

So who will that named individual be? Hunt is wary to say – fearful of stoking up the doctors and nurses again, who will see it as more work.

But he does want GPs to take more responsibility for out-of-hours care.

“GPs will definitely be part of the [out-of-hours] system and I think GPs could be a major part of the solution,” he said. “But this exercise that we are going to do between now and October will identify how we can give vulnerable older people the round-the-clock care they need.” In return they will get more freedom to decide how to best look after their patients in a move away from targets to a more holistic approach towards patient care.

“This is part of the much bigger shift the NHS has to make to cope with an aging society,” he says. “The world of the NHS today – unlike 1948 – is a world where a quarter of the population has long-term incurable conditions. They need a permanent care plan, not a ‘here’s the medicine you’ll be better by next Friday’-type approach. At the moment the NHS is set up to deal with curable illness and people going home well – but that’s not the world we live in.

What is interesting about Hunt is that unlike his predecessors – both Labour and Conservative – he seems to genuinely believe that if you remove targets and hand back power to the professionals then better outcomes will follow.

“If you make a GP’s financial reward the number of aspirins they give to patients, you de-professionalise them because you’re saying you’re not going to trust their clinical judgement. You also make it impossible for the GP to treat the person rather than the condition.

“When I was with a GP this morning I was very conscious of the amount of paperwork they had to do. One GP told me she spent two days at work to update four separate computer data bases.

“There should be no hiding place for any professionals who don’t meet the highest of standards – but I do think you have to have faith in the people of the NHS as being people who want to do the right thing. And if we create the right structures, they will do that.”

Interestingly for a man who many thought would simply try and “close” the NHS down as a political issue, Mr Hunt does appear to want to grapple with some thorny problems.

His proposals on elderly care may be sensible but given the huge vested interests across the NHS they are unlikely to pass without controversy. And that’s a big risk for any Conservative Health Secretary.

So how does he want to be remembered? He pauses. “I hope people would say that I was someone who faced up to the big issues. I would like to say that I’m someone who stands up for the values of the NHS when it was founded.”

He won’t win round the cynics. But he does sound sincere.

This article is courtesy of The Independent.

Toddler 'could have been saved at another hospital'

A toddler who bled to death could have been saved if he had been treated at "any other children's hospital in the UK", an inquest heard.

The damning verdict of independent expert Dr David Crabbe against Sheffield Children's Hospital came at the conclusion of a hearing into the death of two-year-old Tharun Umashankar.

Coroner Christopher Dorries ordered a report of the findings to be issued under Rule 43 of his court, urging action to prevent further deaths.

Medical experts said Tharun could have been saved if doctors at the hospital had acted more quickly and worked together to detect the bleed and operate.

The criticism comes just a day after it was revealed that police were investigating the death of two-month-old Hanna Fareem at the hospital. Three staff have been suspended over that incident.

Tharun was admitted to Barnsley Hospital and transferred to Sheffield Children's Hospital on July 10, 2010, suffering from a severe bleed and died in the early hours of the following morning.

An eight-day inquest held at Sheffield's Medico Legal Centre in March heard the youngster had been admitted to hospital vomiting blood twice in the fortnight leading up to his death, thought to be caused by an intolerance to milk.

When he was admitted to Sheffield Children's Hospital a third time, consultant paediatric gastro-enterologist Dr David Campbell ordered an endoscopy to be carried out the next day.

Tharun's mother Sentamil, aged 38, broke down as Mr Dorries said his life might have been saved if the procedure was carried out straight away.

Dr Crabbe told the inquest: "What was a complete failure was the lack of collaboration between surgeons and gastro-enterologists. Closer teamwork would have resulted in a different outcome."

Mr Dorries said: "The independent expert Dr Crabbe is critical that once Tharun's admission was known there wasn't a clear plan formed between seniors of gastroenterology and surgery, with a fall-back plan if there was a re-bleed.

"He feels that it was an error of judgement not to have proceeded to endoscopy that afternoon by the surgeons with, he says, the likely result of an overall bleed being recognised.

"Dr Crabbe is confident Tharun would have survived if this would have been undertaken, indeed to quote 'I'd go as far as to say that had he been admitted to any other children's hospital in the country, he'd have gone in under the surgeons, had endoscopy that afternoon and survived'."

At the previous hearing Dr Campbell said he had instructed staff to contact him if Tharun had another bleed before he went off duty that weekend.

But when his condition deteriorated colleagues did not make the call.

Paediatric registrar Dr Tafadzwa Makaya told the inquest she had not been told to alert Dr Campbell.

Despite a blood transfusion, Tharun failed to respond and he died at 9am the next day. The family are now taking civil action for damages.

Both Mrs Umashankar and her petrol station cashier husband Sivananthan, 42, who ran a grocery store in Barnsley, South Yorks., at the time, heard it was a factor which led their son's death.

Recording a narrative verdict, Mr Dorries said: "On the basis of expert opinion there was a failure to plan and a failure to communicate about a child known to be at serious risk. Endoscopy and surgery on the previous day would likely have saved Tharun's life but such was a matter of judgement rather than specific failure."

A spokeswoman for Sheffield Children's Hospital said the referral pathway has since been changed.

This article is courtesy of The Telegraph.

Three confirmed cases of HIV amongst patients after dodgy dentist used rusty instruments and reused needle

fter months of testing hundreds of patients of a Tulsa dentist who is accused of unclean medical practices, results have been revealed that will send a chill through anyone who had sat in the dentists' chair.

The Tulsa Health Department says three patients have tested positive for the HIV virus which causes AIDS, 70 patients have tested positive for hepatitis C and a further four patients have tested positive for hepatitis B.

At one time, it was believed up to 7,000 patients may have been exposed to blood-borne viruses at the clinics of Dr. Scott Harrington in Tulsa and Owasso because he used filthy instruments in their mouths.

So far, 3,796 patients have been tested at Oklahoma health departments across the state.

The department says they will personally contact those who have tested positive for any of the diseases and will offer them and their family counseling.

The department notes the possibility that some that test positive may not be related to the dental procedures at the Harrington practice.

'This is a complex investigation,' emphasized State Epidemiologist Dr. Kristy Bradley.

Health officials opened their investigation into Harrington's surgeries after a patient with no known risk factors tested positive for both hepatitis C and HIV, the virus that causes AIDS. It turned out the person was a patient of Harrington's and had recently had a dental procedure at one of his clinics.

On one occasion authorities launched a surprise inspection at his practice on March 18 that turned up old needles, rusty instruments and a practice of pouring bleach on patients' wounds, until they 'turned white,' according to a complaint filed by the Oklahoma Board of Dentistry.

While testing for HIV and hepatitis continues among former patients of Harrington, the criminal investigation continues with the involvement of both state and federal authorities.

Tulsa County District Attorney Tim Harris has released a statement regarding the allegations against Harrington by the Oklahoma Board of Dentistry.

The state dental board filed a 17-count complaint calling Harrington "a menace to the public health.'

Among the allegations, Harrington allowed dental assistants to administer IV sedation and reused equipment on multiple patients.

It is improper sterilization procedures such as this that could have infected many of his patients with any number of blood-borne viruses.

Among the claims was one detailing the use of rusty instruments in patients known to have infectious diseases that were dipped twice in bleach in hope of cleaning them.

‘The CDC has determined that rusted instruments are porous and cannot be properly sterilized,’ the board said of that practice.

Harrington told officials he left questions about sterilization and drug procedures to his employees.

‘They take care of that, I don't,’ the dentistry board quoted him as saying.

'The goal is to do a thorough investigation and then make some common sense decisions on potential criminal charges and which agency is in the best position to prosecute any case,' Harris said.

Based on the number of individuals to be interviewed and the involvement of both federal and state investigators, Harris says the investigation is likely to be a long one.

'Once an investigation is complete, the case will be reviewed for potential criminal charges.'

Health inspectors found expired morphine and dirty, rusty instruments that were used on patients with infectious diseases inside an Oklahoma dental clinic, putting thousands of people at risk for hepatitis and the virus that causes AIDS.

Health officials opened their investigation after a patient with no known risk factors tested positive for both hepatitis C and HIV, the virus that causes AIDS. After determining the 'index patient' had a dental procedure about the likely time of exposure, investigators visited Harrington's office and found a number of unsafe practices, state epidemiologist Kristy Bradley said.

Inspectors allege workers at his two clinics risked cross-contamination to the point that the state Dentistry Board branded Harrington a 'menace to the public health.'

According to the insepctors' complaint, needles were re-inserted in drug vials after their initial use and the office had no written infection-protection procedure.

Harrington told officials he left questions about sterilization and drug procedures to his employees.

'They take care of that, I don't,' the dentistry board quoted him as saying.

The doctor also is accused of letting his assistants perform tasks only a licensed dentist should have done, including administering IV sedation. The complaint says the doctor's staff could not produce permits for the assistants when asked.

Susan Rogers, executive director of the state Dentistry Board, said that as an oral surgeon Harrington regularly did invasive procedures involving 'pulling teeth, open wounds, open blood vessels.' The board's complaint also noted Harrington and his staff told investigators a 'high population of known infectious disease carrier patients' received dental care from him.

Despite the high-risk clientele, a device used to sterilize instruments wasn't being properly used and hadn't been tested in six years, the board complaint said. Tests are required monthly.

Also, a drug vial found at a clinic this year had an expiration date of 1993 and one assistant's drug log said morphine had been used in the clinic last year despite its not receiving any morphine shipments since 2009.

'The office looked clean,' said Joyce Baylor, who had a tooth pulled at Harrington's Tulsa office 1½ years ago. In an interview, Baylor, 69, said she'll be tested next week to determine whether she contracted any infection.

'I'm sure he's not suffering financially that he can't afford instruments,' Baylor said of Harrington.

Harrington voluntarily gave up his license, closed his offices in Tulsa and suburban Owasso, and is cooperating with investigators, said Kaitlin Snider, a spokeswoman for the Tulsa Health Department.

'It's uncertain how long those practices have been in place,' Snider said. 'He's been practicing for 36 years.'

The Centers for Disease Control and Prevention is consulting on the case, and agency spokeswoman Abbigail Tumpey said such situations involving dental clinics are rare.

Last year a Colorado oral surgeon was accused of reusing needles and syringes, prompting letters to 8,000 patients, Tumpey said. It wasn't clear whether anyone was actually infected.

'We've only had a handful of dental facilities where we've had notifications in the last decade,' Tumpey said.

The Oklahoma Dentistry Board lodged a 17-count complaint against Harrington, saying he was a 'menace to the public health by reasons of practicing dentistry in an unsafe or unsanitary manner.' Among the claims was one detailing the use of rusty instruments in patients known to have infectious diseases.

'The CDC has determined that rusted instruments are porous and cannot be properly sterilized,' the board said.

Health officials sent letters to 7,000 known patients but cautioned that they don't know who visited his clinics before 2007. The letters urged the patients to be tested for hepatitis B, hepatitis C and HIV — viruses typically spread through intravenous drug use or unprotected sex, not occupational settings.

This article is courtesy of the Mail Online.

'Medical error’ makes 4-yr-old girl paralytic

An alleged medical error has resulted in a 4-year-old Saudi girl getting paralyzed in both arms and legs.

A female doctor in a private hospital has been accused of the medical error causing young Mayan to suffer from the disease called quadriplegia in the medical jargon.

The Health Affairs in Madinah has forwarded the complaint from Mayan's Saudi father to an expert committee to further investigate the case.

The case will then be referred to the Shariah Committee.

Mayan's father told Okaz/Saudi Gazette that his wife went to a private hospital in the city when she had labor pains.

“The female doctor dealing with her case left her during delivery to treat other patients and did not return for two hours. This led to deficiency of oxygen during delivery and the death of cells in Mayan's brain causing her to suffer from quadriplegia with inability to speak.”

A Madinah Health Affairs committee acknowledged the error pointing out that abandoning the woman at the time of delivery was wrong. Besides, it also conceded that the device for monitoring the infant’s pulse was not functioning.

“I visited the Shariah Medical Committee for implementation of the decision, but I was told that the committee was busy with the circumcision case.”

He said he visited many rehabilitation centers in Jeddah and Riyadh that confirmed that his daughter’s treatment was available abroad.

The father is demanding action against the hospital and Mayan's treatment abroad.

Dr. Abdullah Al-Taifi, Director of Health Affairs in Madinah, said the father's complaint has been sent to the Follow-up Department. It will then be referred to the Shariah Medical Committee.

This article is courtesy of the Saudi Gazette.

Heart surgeon leaves 16cm of metal in patient

A patient recovering from heart surgery has launched legal action after finding his doctor left him more than a prescription for painkillers. Mysterious pains led to the discovery of several pieces of a metal probe in his arteries.

A 50-year-old patient from the Rhône-Alpes region of south-east France might have been forgiven for thinking that surgery was the best thing for him, after suffering a heart attack in 2010.

It turns out, however, that the cure may have been worse than the disease, after six separate pieces of a metal probe, measuring up to 7 cm in length, were found in his arteries, seven months after his operation.

The unlucky patient, Nourredine Lamache, underwent an invasive probe at the CHU hospital in Annecy, in July 2012, but all did not go smoothly thereafter.

“I had pins and needles in my right arm, and a prickling pain in my head. I couldn’t sleep, and I had a pain in my shoulder,” Lamache told French daily Le Parisien on Tuesday.

Devoid of explanations, he consulted an angiologist (blood vessel and vein specialist) in February this year. A scan of his arteries revealed something out of the ordinary – several metal fragments, between 3 and 7 cm long.

The pieces of a broken probe had, unbelievably, been left inside Lamache’s body after his 2012 operation and were moving slowly towards his brain, causing serious risk of a stroke.

“I could have died. I’m waiting for the surgeon’s apology,” Lamache told Le Parisien.

Surgeons opened him once again and removed the metal earlier this month.

But his troubles didn’t end there, however. Further scans and consultations with doctors suggest that Lamache’s arteries are still home to three other fragments of the broken metal probe - in his arm, shoulder and the base of his neck.

According to Le Parisien, he is still deciding whether or not to go under the knife once more to have them removed. In the meantime, Lamache is taking action of another kind.

His lawyer, Caroline Colomb, told Le Parisien, “The error here is obvious. And we will be demanding compensation.”

For its part, the hospital has offered Lamache their services, and is seeking an amiable, out-of-court settlement.

 This article is courtesy of The Local.

The safest cities in the UK to have surgery

Never events as coined by the BBC are medical accidents so serious yet avoidable that they should never occur if the correct procedures in place. Hence ‘never events’ are likely caused by malpractice and negligence.

The NHS Trusts below each had one ‘never event’ over the last 4 years; hence these cities appear to be the safest in the UK to be operated on in.

Avon & Wiltshire Mental Health Partnership NHS Trust
Barnsley Hospitals NHS Foundation Trust
Berkshire West PCT
Birmingham Women's NHS Foundation Trust
Bolton
Brighton & Hove City PCT
Calderdale and Huddersfield NHS Foundation Trust
Retained foreign object post-operation
Calderdale Independent/Non NHS Providers
Cornwall Independent Treatment Centre
Coventry and Warwickshire Partnership NHS Trust
Cumbria Partnership NHS Foundation Trust
Dorset County Hospital NHS Foundation Trust
East Lancashire Hospitals NHS Trust
East London NHS Foundation Trust
Emerson's Green Treatment Centre
Gateshead Health NHS Foundation Trust
Harbour Hospital
Hertfordshire PCT
Hillingdon PCT
Ipswich Hospital NHS Trust
Lister Surgicentre (Clinicentre Ltd)
Mid Cheshire Hospitals NHS Foundation Trust
Mid Yorkshire Hospitals NHS Trust
Middlesbrough PCT
NHS South East Essex
NHS West Essex
Norfolk PCT
North East Essex PCT
North Essex Partnership NHS Foundation Trust
North West London sector
Northamptonshire Healthcare NHS Foundation Trust
Nottinghamshire County PCT - Provider   
Nottinghamshire Healthcare NHS Trust   
Nuffield Health - Exeter Hospital   
Nuffield Hospital Leeds   
Outer London North East sector   
Oxford Health NHS Foundation Trust   
Partnerships in Care
Pennine Care
Plymouth Independent Treatment Centre
Poole Hospital NHS Foundation Trust
Princess Alexandra Hospital NHS Trust
Shepton Mallet Treatment Centre
Somerset Primary Care Trust
South London and Maudsley NHS Foundation Trust
South Tyneside Healthcare NHS Trust
South West Yorkshire partnership NHS Foundation Trust
Southampton City PCT (Moorgreen)
Southern Health NHS Foundation Trust
St Helen's & Knowsley Hospitals NHS Trust   
tockport NHS Foundation Trust    1
Stoke on Trent Community Health Services (NHS Stoke on Trent provider arm)   
Tameside Hospital NHS Foundation Trust
The Manor Hospital, Oxford
The Rotherham NHS Foundation Trust
The Rotherham NHS Foundation Trust
The Royal Marsden Hospital NHS Foundation Trust
The Winfield Hospital   
Trafford Healthcare NHS Trust*   
University Hospitals Morcambe Bay NHS Foundation Trust
University Hospital of South Manchester NHS Foundation Trust
Warrington & Halton Hospitals NHS Foundation Trust
West Kent PCT
Wiltshire Primary Care Trust
Wirral University Teaching Hospital NHS Foundation Trust

The worst NHS hospitals in Britain to have surgery at

A recent BBC report has revealed that across NHS hospitals there have been more than 750 ‘never events’. These are medical accidents which have serious implications but which are also quite preventable and therefore should never happen.

These ‘never events’ include:

•    Retained foreign object post operation – where surgical sponges, swabs or utensils are left behind in a patient.
•    Wrong site surgery – when the wrong body part is operated on.
•    Misplaced naso-or oro-gastric tubes – where a tube going from the nose or mouth to the stomach is inserted in such a way that it is misplaced.
•    Wrong implant/ prosthesis – the wrong implant of prosthesis being used.
•    Air embolism – when an air bubble gets into the circulatory system causing obstructions.
 
The worst offending hospitals listed by the BBC are below:
 
Barts Health NHS Trust - 11 errors, four cases of retained foreign object post-operation, three wrong site surgery errors, two misplaced naso-or oro-gastric tubes, one wrong implant/prosthesis and one air embolism.
 
Guy's and St Thomas' NHS Foundation Trust had 15 errors, eight of these were wrong site surgery and there were an additional four cases of retained foreign objects and two cases where the wrong implant/prosthesis were used, additionally there was also a misplaced naso-or oro-gastric tube error.
 
Imperial College Healthcare NHS Trust had 11 errors, including eight retained foreign object post-operation, two were wrong site surgery and one cases of a misplaced naso-or oro-gastric tube.

Mid Essex Hospital Services NHS Trust had 11 incidents, being being retained foreign object post-operation, two were misplaced naso-or oro-gastric tubes, and they had one case of maladministration of Insulin, and also one wrong site surgery.
 
Nottingham university hospitals NHS Trust had 13 errors, eight retained surgical objects post-operation, four wrong site surgeries and one wrong route administration of chemotherapy. 

Plymouth Hospitals NHS Trust had 14 errors, six being retained foreign bodies, four cases of the wrong body part being operated on, two patients had misplaced naso-or oro-gastric tubes, maladministration of insulin to one patient and maladministration of potassium fluids to another.
 
West Hertfordshire Hospitals had 11 errors in total, five were wrong site surgery, five were retained foreign objects and they had one case of a misplaced naso/oro-gastric tube.

The United Lincolnshire Hospitals NHS Trust had 12 errors, four of which were objects left in after surgery, three were wrong site surgery, two were wrong implants, two were transfusions of incompatible blood types and the maladministration of potassium fluids to one patient.

322 retained foreign objects left inside NHS patients after operations

A recent BBC report has revealed that over the last 4 years there have been hundreds of NHS patients nationwide who have retained foreign objects after operation.

In total 322 cases of Retained Foreign Body surgical errors were uncovered. Retained Foreign Bodies (RFBs) are objects which are left behind by the surgical team after closure. Common RFBs include: surgical implements, surgical mesh or cotton padding that can all be accidentally left inside the patient after surgical closure.
 
Objects left inside the body after operation are dangerous because of the inflammatory response from the body which can result in an abscess which causing obstructions of the bowl, perforations or fistulisation. All of these symptoms cause considerable pain and discomfort for the patient. On top of this 69% of RFBs require re-operation or the management of the complication, such as pain medication.

There are also cases where these surgical objects, such as surgical sponge, have migrated to another part of the body and caused considerable harm. There was a case in the USA where a piece of surgical sponge migrated to a patient’s lung and caused a pulmonary embolism.
 
Sponges and cotton left in a patient can also cause misdiagnosis since they can bear resemblance to small primary tumors with certain imaging techniques such as x-ray.

With all of these consequences in mind it is no wonder that the BBC grouped Retained Foreign Bodies in their list of ‘never' events. These are mistakes that should never, ever happen, not accidents or slips but cases of malpractice.

More than 750 patients have suffered after preventable mistakes in England's hospitals

More than 750 patients have suffered after preventable mistakes in England's hospitals over the past four years, a BBC investigation has found.

The incidents, such as operating on the wrong body part or leaving instruments inside patients, are categorised by the Department of Health as "never events".
This means they are incidents that are so serious they should never happen.

NHS England admitted the figures were too high and said it had introduced new measures to ensure patient safety.

Find out how many "never events" occurred between 2009 and 2012 within NHS trusts in your area in England by clicking here.

This article is courtesy of BBC News.

Hospitals reveal 750 'should never happen' blunders

More than 750 patients have suffered after preventable mistakes in England's hospitals over the past four years, a BBC investigation has found.

This video is courtesy of BBC News.

Left-behind items in surgery a common problem

With healthcare costs the way they are, when you are having surgery, you would expect the surgeon to perform the operation in a nearly perfect manner. Although nobody is perfect, you certainly expect that the surgeon would not make an obvious error. However, the reality is that this is often the case. A recent article in USA Today points out that surgeons leave behind surgical items in their patients more than 12 times per day.

In addition, an investigation conducted by USA Today found that although items such as clamps, forceps and other surgical items are sometimes left behind, the most common left-behind object was the humble cotton surgical sponge. This object is used to soak up blood and other fluids during surgical procedures.

Shockingly, there is not a federal mandate to report these types of surgical errors. According to what little government data exists on the subject, objects are left behind in about 3,000 surgeries per year. However, since the data is incomplete, this number is likely too low. The USA Today investigation of studies, statistics and medical malpractice lawsuits found that the actual number is closer to 4,500 to 6,000 per year.

Effective solutions are rarely used

According to the investigation, hospitals are hesitant to implement solutions, despite the seriousness and prevalence of these errors. In most hospitals, surgical staffs count the number of sponges. However, it is easy to lose count or miscount, so this method has limited effectiveness.
A better solution is to equip sponges and other surgical tools with electronic tracking devices, which allow a computer to quickly and accurately do the counting. However, despite the low cost of $8 to $12 per procedure, fewer than 15 percent of hospitals have implemented this system, according to the investigation.

Left-behind objects can cost the patient and the hospital dearly. According to Medicare data, to correct the damage done by left-behind objects, patients can expect to pay an average of $60,000. Additionally, hospitals can expect to shell out an average of between $100,000 and $200,000 in medical malpractice lawsuits.

Consult a medical malpractice attorney

In addition to the financial costs, there is the suffering that victims of left-behind objects can experience. This mistake can cause pain for months or years following the operation. Often the error is not discovered until infections or other complications develop. This delay can result in the loss of a body part or even death.

If you or a loved one have been the victim of medical malpractice, you may be entitled to recover medical expenses, lost wages and damages for pain and suffering. Contact an experienced medical malpractice attorney who can evaluate your case and work to recover the maximum amount of compensation due to you under the law.

This article is courtesy of The Digital Journal and was provided by DeVore Acton & Stafford, PA Visit us at www.devact.com

NHS patients want summit with health secretary as they reveal agony after prolapse operations

Health Secretary Alex Neil was yesterday urged to meet more than 100 Scots women whose lives have been ruined by plastic mesh used to treat prolapse problems.

The growing scale of the scandal has become clear after scores more NHS patients contacted the Sunday Mail when we revealed last week the horrendous pain being endured by many surgery victims.

We told of the escalating concerns surrounding polypropylene mesh implants used to correct bladder and pelvic floor problems after ops left patients in agony.

Some were left unable to walk, others had their sex lives ruined and many have endured a series of gruelling operations as surgeons struggle to remove the mesh.

In America, one victim has been awarded £10million compensation after the vaginal mesh sliced through her organ walls.

In Scotland, it is believed around 6000 women have had the procedures.

Experts believe hundreds may now be suffering from complications, including organ damage, caused by the mesh.

Yesterday, Shadow Health Minister Jackie Baillie said: “I’m shocked at the numbers, especially as this may still only be the tip of the iceberg. I’ll be asking Health Secretary Alex Neil to meet some of these women so he can hear their
experiences.

“We need clear and decisive action from the Scottish Government.

“From evidence we’re hearing, many of these women have not even been given one-to-one consultations.

“They haven’t been offered alternatives to the mesh and tape procedures.

“And they haven’t been made aware of possible side-effects or the difficulties of removing mesh.

“This highlights the long-overdue need for a national register for every single implant.”

Last month, Linda Gross was awarded almost £10million after a US jury ruled she was not told about possible complications. Medical giants Johnson & Johnson deny their product is responsible and are appealing the verdict.

It has been reported that Johnson & Johnson, their subsidiary Ethicon and other firms face claims from 4000 women who say they have been left in agony after their mesh cut into organ walls.

In Scotland, lawyer Cameron Fyfe, of Drummond Miller, said: “We’ve been inundated with calls from women
desperate for help and each story is more horrifying than the last.

“I fully expect this to end up being one of the biggest group actions the Scottish civil courts have ever seen.”

Lawyer Victoria Ulph, of Martin & Co, said: “I’ve heard from a number of women who weren’t given one-to-one consultations with their surgeons so how could they be making informed choices?”

The Scottish Government said: “There are a small number of surgeons in NHS Scotland who provide this service. They monitor patients and, where required, provide aftercare.

“Mr Neil meets with his opposition opposite numbers regularly and can discuss this matter further at the next meeting.”

Antonia McCulloch, 47, from Largs, Ayrshire, had mesh implants to correct bladder and bowel
prolapse last May at the Royal Alexandra Hospital in Paisley.

She said: “Immediately prior to
the surgery, four of us were taken into a room so there was no proper chance to discuss such an intimate procedure in front of the others.

“We weren’t told the mesh couldn’t be easily removed or how awful any complications could be – or there’s no way I would have gone ahead.

“Any concerns raised were swept aside and we were assured it wasn’t a complex procedure.

“Before I knew it, I was waking up in recovery, screaming in pain.

“Nursing staff were dismissive, telling me I couldn’t be feeling so much pain. But I was in agony.

“I was rushed back into hospital three days after being discharged and again a few days later.

“On June 19 last year, 20 days after my first surgery, the mesh was already starting to push its way through my body. I’ve had six operations but they still haven’t managed to get all the mesh out.”

Mum-of-two Antonia has spent months off her job as a shop assistant and cleaner.

Antonia McCulloch, 47, from Largs, Ayrshire, had mesh implants to correct bladder and bowel prolapse last May at the Royal Alexandra Hospital in Paisley.

She said: “Immediately prior to the surgery, four of us were taken into a room so there was no proper chance to discuss such an intimate procedure in front of the others.

“We weren’t told the mesh couldn’t be easily removed or how awful any complications could be – or there’s no way I would have gone ahead.

“Any concerns raised were swept aside and we were assured it wasn’t a complex procedure.

“Before I knew it, I was waking up in recovery, screaming in pain. “Nursing staff were dismissive, telling me I couldn’t be feeling so much pain. But I was in agony.

“I was rushed back into hospital three days after being discharged and again a few days later.

“On June 19 last year, 20 days after my first surgery, the mesh was already starting to push its way through my body. I’ve had six operations but they still haven’t managed to get all the mesh out.”

Mum-of-two Antonia has spent months off her job as a shop assistant and cleaner.

She said: “I don’t feel 47, I feel like I’m 74. Some days the pain is so bad, I’m physically sick.

“When I complained to the hospital, I was told I was unlucky.

“But after reading the Sunday Mail, there seems to be an awful lot of unlucky women out there.

“I just want my life back. I used to ride horses, cycle and loved to walk. Now I can’t even lift my baby granddaughter. I don’t know when this nightmare will end.”

NHS Greater Glasgow and Clyde said: “Any risks associated with surgery should be fully discussed with patients. We’d be happy to discuss any concerns patients may have after their procedure.”

Anne Marie Conley, 51, from Kilmaurs, Ayrshire, has been admitted to hospital six times since her op four years ago.

She had mesh surgery at Crosshouse Hospital in Kilmarnock in 2009 for bladder and bowel prolapse.

She said: “After the procedure, I had to be rushed back in and given six pints of blood during a 12-hour blood transfusion.

“Eighteen days after the first surgery, I had an operation to remove all the mesh.

“But I’ve had procedure after procedure and I still feel the mesh. It’s like there’s something dead inside me.

“I’ve spent 18 months on steroids to control the pain but nothing works. Doctors put a camera into my bladder and I could see all the debris, the purple and black patches inside me.

“There’s no way I would have consented to this if it had been properly explained to me.

“Until I read the Sunday Mail, I thought I was suffering on my own as doctors kept saying that what happened to me was rare.”

Mandy Yule, of NHS Ayrshire and Arran, said: “We’re sorry Ms Conley feels we did not meet the high standards we strive for. We would urge anyone with concerns about our services to talk to us directly.”

Josephine McLaughlan, from Barrhead, Renfrewshire, is surviving on morphine to kill the pain after seven operations.

The 60-year-old had a mesh procedure for bowel prolapse in 2011 at the RAH, Paisley.

She said: “I was asked to sign a consent form. Nobody explained about complications or if there were alternatives.

“When I awoke after that first surgery, I was haemorrhaging and could already feel the tape coming through my body.

“Within six weeks, I’d had so many infections, the surgeon agreed to start removing the mesh. I’ve had another six ops so far. I’m on massive doses of morphine to try to dull the pain and I now walk with a stick.

“I’ve just turned 60 and feel my life is over.

“I can’t go anywhere unless I’m within sight of a toilet.”

Josephine, who used to work as a catering manager at Reid Kerr College in Paisley, said: “I’ve been made to feel as if I’m a nuisance and I’m the only one with these complications.

“When I read the Sunday Mail last week, I couldn’t believe so many others are going through the same thing.”

 This article is courtesy of the Daily Record.

Hospitals slow to learn from own mistakes

Anyone who has experienced the chaotic environment of a hospital has an acute sense of the many things that can go wrong. In a typical visit, most patients encounter dozens of small oversights — from a misspelled name on a medical chart to a misscheduled diagnostic test.

For Rupinder Pannu, the error was more serious. She left the delivery room of the Trillium Health Centre in Mississauga, Ont., after giving birth to a baby boy in July 2008 with an object inside her that shouldn't have been there.

"The second week, I start smelling myself as a dead fish," she told CBC's the fifth estate. "My youngest son would come over and sit on me and say, 'Mommy, you smell funny.' "

The smell, it turns out, was coming from a gauze sponge that had been left inside her after she underwent an episiotomy, a procedure sometimes done during childbirth in which an incision is made in the perineum.

It was Pannu herself who found and removed the sponge after weeks of enduring pain so bad that she said she found it hard to walk.

"I would just sit in the bathtub with Epsom salts so my wound would heal faster, but that didn't help," Pannu said. "People would come visit me, and I would feel very stressed out [because of the smell]."

No compensation

According to Pannu, she only discovered the sponge when she decided to examine herself after the antibiotics a family doctor had prescribed, thinking the stitches used to close her incision had gotten infected, didn't get rid of the pain or the odour.

The hospital and the obstetrician who performed the delivery and episiotomy, Dr. Dalip Bhangu, met with Pannu after she went to the emergency department and reported what she had found. Pannu said hospital administrators apologized but told her she was not entitled to financial compensation.

Pannu complained about the incident to the College of Physicians and Surgeons of Ontario. In a 2009 letter responding to the complaint, Bhangu said he felt sorry Pannu had to "endure discomfort" but that when he left the delivery room, the nurse, who is responsible for verifying that all instruments, needles and sponges are accounted for, assured him the sponge count was correct.

He also said in the letter that he had been called to another delivery a mere 10 minutes after Pannu gave birth.

"I definitely hold the doctor responsible, because he is trained to do these things, and he cannot ignore me because he's got another patient," Pannu said of Bhangu's explanation. "If he doesn't want to work on me, he could just leave me rather than just leave stuff inside me and kind of walk on to another one."

According to a claims management company representing the hospital's insurer, neither the doctor nor any of the staff present during the delivery are to blame for the mistake.

"We do not believe that there is any responsibility for this unfortunate incident that rests with the hospital and/or staff," the adjuster, Cunningham Lindsey, wrote in a letter dated July 10, 2009, preemptively informing Pannu that any claim for compensation would be denied — even though Pannu hadn't made any official claim.

The hospital refused to comment to CBC News on the Pannu case and said only that "any error that impacts patients is investigated and lessons are developed from the incident and built into action plans for patient safety improvement." Dr. Bhangu declined to comment on the incident.

Surgical errors common

Mistakenly leaving foreign objects in a patient's body is one of the most common errors that occurs during surgeries, followed by operating on the wrong body part. It's one of the reasons why hospitals have adopted surgical safety checklists, intended to ensure that doctors and nurses follow a set of standardized steps before and after each procedure.

Studies suggest surgery accounts for 40 to 50 per cent of all hospital-related adverse events, a catch-all term used to describe unintended injuries, complications or death related to the care received, not a patient's medical condition.

The checklists, devised by the World Health Organization in 2008, have been shown to reduce surgery-associated complications and deaths by more than a third and have been endorsed for use in birthing units by the Society of Obstetricians and Gynecologists of Canada.

The hospital where Pannu had her baby has been using surgical checklists since 2009 and in a statement said it uses two-person teams to perform supply counts and quality checks in its obstetrics units.

Studies spur change

Ever since the 1999 Institute of Medicine report To Err is Human raised awareness of the high incidence of preventable medical errors in the U.S., hospitals in many parts of the world have been trying to change what had long been a duck-and-cover approach to medical mistakes.

In Canada, the seminal study on hospital medical errors is a 2004 paper by Ross Baker, a professor at the University of Toronto's Institute of Health Policy, Management and Evaluation.

It found that 7.5 per cent of patients admitted to acute care hospitals in Canada in 2000 experienced one or more adverse events, which can include everything from reactions to wrongly administered medications to bed sores, falls, infections and surgical errors. Most of these events did not result in any serious harm, the study found, but almost 37 per cent were preventable.

More recent studies have shown rates of adverse events in hospital between 10 and 14 per cent.

"The groundbreaking nature of Dr. Baker's work in Canada and that of some of his colleagues internationally was to bring it out into the light of day," said Deb Jordan, executive director of acute and emergency services for Saskatchewan Ministry of Health.

No consistent reporting

Saskatchewan was one of the first provinces, along with Quebec, to introduce legislation in the early 2000s obliging hospitals to report critical incidents, adverse events that result in serious harm or death.

Most hospitals require critical incidents to be reported at least to the hospital board and the affected patient or family members, but such events represent only a fraction of the mistakes and close calls that occur in any hospital.

In general, Canadian hospitals have only a very vague idea of how many errors are made in the course of delivering care because there is no standardized system for measuring and reporting them.

Many hospitals rely on voluntary reporting of errors by staff, which has been shown to capture only a tiny proportion of errors.

"For most of our hospitals, the amount of staff that are dedicated to supporting patient safety is limited, and they often wear other hats and manage competing responsibilities," said Pat Campbell, president and CEO of the Ontario Hospital Association. "So, we could probably be making more rapid progress if we had more resources at each institution."

Some provinces, such as Ontario, require hospitals to report certain so-called patient safety indicators such as rates of hospital-acquired infections and patient deaths.

In 2002, Quebec became the first province in Canada to require mandatory reporting of what it calls "incidents and accidents," but it only began tracking them through a central online registry in 2011.

Medication-related errors, which are the second-most common medical mistakes after surgical errors, are tracked federally through the National System for Incident Reporting, but reporting is voluntary (although Ontario requires hospitals to report to the registry).

"We don't have a 'Canadian health care system'; we have a series of provincial and territorial systems," said Hugh MacLeod, president of the Canadian Patient Safety Institute, which has established guidelines for how hospitals should disclose errors to patients.

"So, our desire is that people disclose [errors to patients], people report, and we're not too fussed about the mechanisms that they're using. What's important to us is that they're reporting."

Voluntary reports catch less than 15% of errors

But in fact, despite the widespread adoption of "no blame, no shame" policies, health practitioners are not reporting errors as often as they should be — usually because they fear repercussions or have misperceptions about which incidents should be reported.

Jurisdictions like Quebec, Saskatchewan and Manitoba that have been tracking critical incidents for years have found that while the number of incidents being reported has risen since reporting became mandatory, it still remains far below what research indicates it should be.

And without a systematic way of spotting errors, it's likely to remain that way.

A 2012 study by the inspector general of the U.S. Department of Health and Human Services found that voluntary reporting caught only 14 per cent of adverse events suffered by Medicare patients in U.S. hospitals.

But a method called the Global Trigger Tool, which relies on systematic reviews of patient charts by at least two health care professionals, was able to catch 90 per cent of the errors.

"A trigger could be a notation indicating, for example, a medication stop order, an abnormal lab result, or use of an antidote medication," the study authors wrote of the tool, developed by the Institute for Healthcare Improvement in the U.S. "Any notation of a trigger leads to further investigation into whether an adverse event occurred and how severe the event was."

A flaw in the system

Getting hospitals to examine the processes that lead to errors and near misses is a huge challenge, one that countries like Australia and New Zealand have been better at meeting than Canada, says Wendy Levinson, chair of the department of medicine at the University of Toronto.

"We have very much a philosophy inside medicine of 'We will try harder'; learning is trying harder to do it better," she said. "But what we haven't inculcated until recently is that instead of individuals trying harder, systems need to be redesigned in order to help individuals in the systems do better, not just try harder. It's a big distinction for us."

One hospital that has dramatically redesigned its approach to medical errors is the University of Michigan Health System (UMHS) in Ann Arbor, which includes three hospitals and dozens of clinics and care centres.

"I knew that we were not learning any lessons from what was happening to our patients," said Richard Boothman, a trial lawyer who instituted the overhaul in 2001.

"I had represented hospitals for 20 years in Michigan and Ohio and not a single hospital asked what we should have learned from the cases I handled."

Boothman, the UMHS's head of clinical safety, put in place a new system of reviewing patient charts and getting each clinical service to report regularly on a series of patient safety indicators specific to their department.

"We asked every single clinical service to give us the 10 things that if you heard them happening in your service, you would have to at least raise an eyebrow about the quality of the care," Boothman said.

Red flags include things like the number of emergency department patients who end up in intensive care after being admitted to a ward or the percentage of surgical patients who are back in the operating room with 72 hours.

Voluntary reporting has increased from 2,400 incidents in 2006/07 to 20,000 last year, Boothman said.

Full disclosure

UMHS also adopted a full disclosure policy when telling patients about errors and changed its malpractice strategy from an adversarial "deny and defend" approach to one in which it tries to resolve cases without going to court.

The health centre now preemptively offers patients financial compensation when it feels the standard of care has not been met, a method pioneered by the Veterans Administration Medical Center in Lexington, Ky.

The strategy has significantly reduced UMHS's malpractice costs, cutting the average cost per lawsuit by nearly a half, and decreasing the number of claims that wind up in court.

A similar compensation strategy is used by the Winnipeg Regional Health Authority — although it has not been as frequently applied as the Michigan model.

It's a brave approach, says Baker, the author of the 2004 Canadian study on adverse events.

"Not many organizations want to do that," he said. "It's an admission that we're not perfect."

Posting error data online

Part of changing the instinct to hide or contest errors is a willingness to disclose mistakes not just to patients but also to the public, and more and more hospitals are doing so on their own websites.

Montreal's Jewish General Hospital was the first hospital in Quebec to start posting information about adverse events online in 2011, following in the footsteps of what the Ontario Ministry of Health had started doing a few years earlier.

"The initial reaction was a lot of concern from other institutions because it's not a requirement in Quebec for us to do this, so it wasn't something that individuals believed was the way to go," said Markirit Armutlu, co-ordinator of the hospital's quality program. "There was a lot of resistance because of fear of media reaction and public reaction."

Since then, other hospitals have come around to the idea and have started posting their own medical error data online.

Most don't reveal specifics but give only annual tallies divided into broad categories such as "medication," "falls" or "equipment-related" (though the Winnipeg Regional Health Authority reveals some details in the "learning summaries" it posts online).

Giving a public accounting of errors is a sign hospitals are being more accountable but doesn't necessarily mean they're any safer, warns Baker.

"The critical measure is how many changes are we making in the system as a result of what we're learning about these events," he said. "Saying how many reports we have is sort of like saying how many speeding tickets you got, not how many accidents you got."

This article is courtesy of CBC News.