The family of a woman who died after being given three times the recommended dose of a sedative has been awarded £65,000 in compensation.
Nicola Ames, 35, from Middle Mead, Rochford, died at Southend Hospital in December 2009.
She was admitted with acute pancreatitis and Miss Ames, who had a history of alcohol dependency and epilepsy, became agitated and was sedated.
By the following day, medical staff experienced difficulty in dealing with her agitation, confusion and lack of co-operation even though they had given her a significant dose of sedative Haloperidol.
Despite becoming hypoxic, where insufficient oxygen reaches body tissues, she was not transferred to the intensive care department where she would have been put on a ventilator to help her breath properly.
Despite the hypoxia worsening, and the absence of senior medics, staff continued to administer the sedative, eventually giving her more than three times the recommended dose. Miss Ames suffered a cardiac arrest and died shortly after midnight on December 18.
Lawyers, Attwaters Jameson Hill, acted for Miss Ames’ mother, who asked not to be named, against the hospital.
They claimed medical negligence and settled the case, securing damages for pain and suffering, funeral expenses and a dependency claim.
An investigation later established that over ten-and-a-half hours, Miss Ames was given 55mg of Haloperidol, compared to a recommended daily maximum dosage of 15mg.
Sarah Wealleans, of Attwaters Jameson Hill, said: “Hospital staff basically lost control of the situation and were unable to control Nicola’s alcohol withdrawal.
Rather than intubating her, which would have deemed the patient safe and provided the opportunity for effective treatment, they just kept administering sedatives in huge quantities.
This caused her death.”
Jacqueline Totterdell, the hospital’s chief executive said: “We once again offer our sincere condolences to Nicola’s family and recognise the circumstances leading up to and regarding her death in 2009 have made this a particularly difficult time for them.
“We recognise the standard of care we provided at that time was not of the standard we would expect and again we apologise for this.
“With regards the inquest, it would be inappropriate to comment further at this stage as the coroner’s findings will not be known until the case is reopened.”
This article is courtesy of the Echo.
Regularly updated blog featuring news, articles and information relating to clinical/medical negligence.
Friday, 26 September 2014
Wednesday, 24 September 2014
Staffordshire hospital admits liability after woman dies of blood poisoning
Ethel Sanders from Burntwood died at Queen’s Hospital in Burton after suffering from multi organ failure, internal bleeding and blood poisoning due to a two-month delay in receiving surgery and poor care afterwards.
Now the hospital has admitted its mistakes and agreed to pay her family a five-figure sum as compensation.
Her daughters today called on Burton Hospitals NHS Foundation Trust, which runs the hospital, to improve services for the elderly after she suffered months of agony before her death.
The trust has admitted breaching its duty of care to the 85-year-old and has agreed to pay the family an undisclosed five-figure settlement.
Expert evidence commissioned by medical negligence lawyers at Irwin Mitchell found there was a two-month delay in Mrs Sanders having surgery to treat colovescial fistula - a condition which affects the colon and the bladder causing pain and infection.
It also discovered when she did have keyhole surgery to treat the problem, it was performed negligently causing a tear to the ovarian vein.
It was not until the following day that doctors diagnosed her deteriorating condition as being linked to the tear and despite further surgery, it was too late and she died a week later in March 2011.
Mrs Sanders' daughters Linda Ward and Sandra Neal say they remain 'deeply concerned' by standards within the trust and said lessons must be learned.
The trust was placed in special measures by the Care Quality Commission last year as part of a review into death rates at a number of hospitals across the country.
Mrs Ward, aged 61 and from Hednesford, said: "We remain devastated by the loss of our mum - it was extremely difficult to see her suffer like she did. She was in absolute agony for weeks but there seemed to be no hurry to try and help her and we felt completely helpless.
"From start to finish my mum did not receive an acceptable level of care and it is simply not good enough. What makes us so angry is that the trust is clearly not making good enough improvements as it is one of the few hospitals to remain in special measures.
"Mum was vulnerable and elderly and should have been treated with compassion and integrity but we saw none of that and it is heartbreaking to think of how she suffered.
"Action must be taken to improve services for both the elderly, and patients in general to prevent anyone else from going through such a horrific ordeal and to restore faith in the services it provides."
Dr Craig Stenhouse, medical director at the trust, said "This is an extremely sad case and we are truly sorry that the care and treatment given to Mrs Sanders was not of the standard that our patients deserve.
"We completely accept that the quality of care provided was inadequate and we have taken immediate action to make changes."
This article is courtesy of the Express and Star.
Now the hospital has admitted its mistakes and agreed to pay her family a five-figure sum as compensation.
Her daughters today called on Burton Hospitals NHS Foundation Trust, which runs the hospital, to improve services for the elderly after she suffered months of agony before her death.
The trust has admitted breaching its duty of care to the 85-year-old and has agreed to pay the family an undisclosed five-figure settlement.
Expert evidence commissioned by medical negligence lawyers at Irwin Mitchell found there was a two-month delay in Mrs Sanders having surgery to treat colovescial fistula - a condition which affects the colon and the bladder causing pain and infection.
It also discovered when she did have keyhole surgery to treat the problem, it was performed negligently causing a tear to the ovarian vein.
It was not until the following day that doctors diagnosed her deteriorating condition as being linked to the tear and despite further surgery, it was too late and she died a week later in March 2011.
Mrs Sanders' daughters Linda Ward and Sandra Neal say they remain 'deeply concerned' by standards within the trust and said lessons must be learned.
The trust was placed in special measures by the Care Quality Commission last year as part of a review into death rates at a number of hospitals across the country.
Mrs Ward, aged 61 and from Hednesford, said: "We remain devastated by the loss of our mum - it was extremely difficult to see her suffer like she did. She was in absolute agony for weeks but there seemed to be no hurry to try and help her and we felt completely helpless.
"From start to finish my mum did not receive an acceptable level of care and it is simply not good enough. What makes us so angry is that the trust is clearly not making good enough improvements as it is one of the few hospitals to remain in special measures.
"Mum was vulnerable and elderly and should have been treated with compassion and integrity but we saw none of that and it is heartbreaking to think of how she suffered.
"Action must be taken to improve services for both the elderly, and patients in general to prevent anyone else from going through such a horrific ordeal and to restore faith in the services it provides."
Dr Craig Stenhouse, medical director at the trust, said "This is an extremely sad case and we are truly sorry that the care and treatment given to Mrs Sanders was not of the standard that our patients deserve.
"We completely accept that the quality of care provided was inadequate and we have taken immediate action to make changes."
This article is courtesy of the Express and Star.
Monday, 22 September 2014
Facelift scarred me for life: Pensioner tells of botched operation ordeal
A pensioner has told how she was left scarred for life following a botched facelift.
Pearl Richman was awarded more than £43,000 in compensation after her life was ‘almost ruined’ by a procedure carried out in 2010.
After the operation, the 69-year-old developed necrosis – a form of cell injury which results in the premature death of skin cells – and was left with open flesh wounds.
But despite a court finding in favour of Mrs Richman and awarding compensation, she says she still hasn’t received a penny and the surgeon, from Italy, is still believed to be operating in the UK.
Mrs Richman, from Kenilworth, took her civil case to a county court hearing in April, where a judge awarded costs against the doctor for negligence.
Now Mrs Richman is calling for the government to take action over ‘seagull surgeons’ – foreign doctors who fly into the UK and undertake failed procedures before returning home.
“This might sound dramatic to people, but this has almost ruined my life,” said Mrs Richman.
“I always took pride in my appearance and over the years I went from having lots of photos of myself around the house, to having none.
“I had talked about having a facelift but they are expensive and we didn’t have the money. My kids had always talked about buying one for me and one year my daughter Jo, who has her own business, was able to do just that.”
The company which organised the £8,000 facelift has now gone into administration. The centre introduced Mrs Richman to an Italian surgeon before she underwent the procedure at a hospital in London.
She added: “He never talked about necrosis at all. It wasn’t mentioned. He talked about the normal risks but at no point at all did he mention necrosis. I just remember him saying that he would make me happy.
“When they took the drains out of my face it hurt so much, I screamed and it started to go purple. It went from a large purple bruise to a huge black scab that had the feel and look of leather.”
The company contacted the surgeon in Italy and he arranged an emergency appointment with Mrs Richman.
She said: “When he saw me he took me straight into a treatment room and said it had to be treated like first degree burns. He told me he was so sorry and that it did not happen very often.
“He offered laser treatment which I had and he said he would do everything he could to make it better and put it right. That is the last we have ever heard from him.”
Medical negligence solicitor Jeanette Whyman, of law firm Wright Hassall, is now pursuing the case.
She said: “I am aware of ‘seagull surgeons’ but have not come across the issue to such a horrific degree. He does have insurers but because he has not notified them of the incident, they will not cover him.
“His residency outside of the UK shouldn’t, in theory, make a difference. What it means is we can get a judgment here but it has to be enforced abroad which can be expensive. If there are no assets in the UK, you cannot enforce here and it has to be pursued abroad.”
Mrs Richman is now urging anyone contemplating surgery to undertake extensive checks.
She added: “Surgeons should not be limited to their country but the government should make sure there is a level of accountability through qualifications and insurances.
“Clinics should also be responsible for the actions of the surgeons they use. would not want (this) to happen to another single person.”
This article is courtesy of Wright Hassall.
Pearl Richman was awarded more than £43,000 in compensation after her life was ‘almost ruined’ by a procedure carried out in 2010.
After the operation, the 69-year-old developed necrosis – a form of cell injury which results in the premature death of skin cells – and was left with open flesh wounds.
But despite a court finding in favour of Mrs Richman and awarding compensation, she says she still hasn’t received a penny and the surgeon, from Italy, is still believed to be operating in the UK.
Mrs Richman, from Kenilworth, took her civil case to a county court hearing in April, where a judge awarded costs against the doctor for negligence.
Now Mrs Richman is calling for the government to take action over ‘seagull surgeons’ – foreign doctors who fly into the UK and undertake failed procedures before returning home.
“This might sound dramatic to people, but this has almost ruined my life,” said Mrs Richman.
“I always took pride in my appearance and over the years I went from having lots of photos of myself around the house, to having none.
“I had talked about having a facelift but they are expensive and we didn’t have the money. My kids had always talked about buying one for me and one year my daughter Jo, who has her own business, was able to do just that.”
The company which organised the £8,000 facelift has now gone into administration. The centre introduced Mrs Richman to an Italian surgeon before she underwent the procedure at a hospital in London.
She added: “He never talked about necrosis at all. It wasn’t mentioned. He talked about the normal risks but at no point at all did he mention necrosis. I just remember him saying that he would make me happy.
“When they took the drains out of my face it hurt so much, I screamed and it started to go purple. It went from a large purple bruise to a huge black scab that had the feel and look of leather.”
The company contacted the surgeon in Italy and he arranged an emergency appointment with Mrs Richman.
She said: “When he saw me he took me straight into a treatment room and said it had to be treated like first degree burns. He told me he was so sorry and that it did not happen very often.
“He offered laser treatment which I had and he said he would do everything he could to make it better and put it right. That is the last we have ever heard from him.”
Medical negligence solicitor Jeanette Whyman, of law firm Wright Hassall, is now pursuing the case.
She said: “I am aware of ‘seagull surgeons’ but have not come across the issue to such a horrific degree. He does have insurers but because he has not notified them of the incident, they will not cover him.
“His residency outside of the UK shouldn’t, in theory, make a difference. What it means is we can get a judgment here but it has to be enforced abroad which can be expensive. If there are no assets in the UK, you cannot enforce here and it has to be pursued abroad.”
Mrs Richman is now urging anyone contemplating surgery to undertake extensive checks.
She added: “Surgeons should not be limited to their country but the government should make sure there is a level of accountability through qualifications and insurances.
“Clinics should also be responsible for the actions of the surgeons they use. would not want (this) to happen to another single person.”
This article is courtesy of Wright Hassall.
Friday, 19 September 2014
Girl, 7, dies after hospital sends her away for third time following repeated misdiagnosis
A seven year-old girl died just two hours after being sent away from hospital for the third time following repeated misdiagnosis.
Little Evelyn Smith was rushed to A&E by her parents last September after falling ill suddenly, suffering from a soaring temperature and vomiting.
The youngster was misdiagnosed and sent away from hospital and her GP's surgery.
After her terrified mum Helen took her daughter to see a doctor for the third time in three days, just two hours after being sent away, Evelyn collapsed and died at her home in Warwick.
An inquest into her death discovered she had died from a rare bacterial infection - Bacterial trachetis - as a result of croup.
Even though a doctor had diagnosed Evelyn with viral croup, they failed to recognise the deadly bacterial complications she was suffering from - and a coroner has ruled that Evelyn's death could have been prevented if she had been diagnosed and treated correctly.
Devastated Helen said: "Losing Evelyn has been totally devastating for us.
"She deteriorated so rapidly, even a year on it doesn't seem real. She was such a happy girl - a real livewire, so happy and always smiling. She's left a huge hole in our family.
"We took her to hospital three times in three days - we repeatedly returned for medical help and that should have been a red flag to doctors and nurses.
"I don't want any other parent to go through what we have been through. Trust your instincts - if you think there's something seriously wrong, insist that it is looked at."
The inquest, at Warwick Coroner's Court, head that Evelyn had woken up with a mild headache on Wednesday, September 11, 2013 - but still went to school that day and her ballet class in the evening. But at 2am the next morning, she came bursting into her parents' bedroom shouting that she couldn't breathe.
Helen rushed her to Warwick Hospital Accident and Emergency department, where her temperature had rocketed to almost 40 degrees. She was examined by a doctor, and despite vomiting, discharged a couple of hours later, with advice on how to reduce her temperature.
But when her daughter was still burning up on Friday morning, Helen took Evelyn to her GP surgery, where she was examined by a nurse, who prescribed her penicillin for her inflamed tonsils.
That afternoon her temperature had risen again and Helen took her back to the GP. Their Dr Susan Martin diagnosed her with oxygen saturations and moderate croup and made an appointment for her to come back on Monday.
Tragically, Evelyn collapsed and died at home two hours later leaving Helen to desperately give CPR while she waited for an ambulance to arrive.
At the inquest assistant coroner for Warwickshire, Dr Richard Brittain said: "Evelyn Mary Smith died from the consequences of both a viral and bacterial infection of her upper respiratory tract.
"Her family sought medical attention three times in the days leading up to her death. There were missed opportunities to diagnose and treat Evelyn appropriately on each of these occasions. However, I am satisfied that none of these consultations were neglectful.
Based on the evidence heard, it is more likely than not that her death was preventable; although it has not been possible to conclude the causative impact of each missed opportunity."
Among those giving evidence at the inquest was Warwick Hospital doctor Emma Sexton, who first examined Evelyn on the day before she died. She said the child did not appear to be displaying signs of respiratory distress and her cough sounded like a viral croup, although she had looked for symptoms of other conditions as well.
Dr Sexton added: "Bacterial trachetis is a very rare condition that arises from these symptoms. I had not come across it prior to this case."
Haidee Vedy, head of medical negligence at Alsters Kelley LLP, who represented the family at the inquest said: "Evelyn's death was an absolutely tragedy and should never have happened.
"Her family put their trust in the hands of the hospital and their local GP surgery and it would appear from the evidence presented at the inquest that they were badly let down.
"We will now be investigating further to find out what more could have been done to prevent Evelyn's death."
But at the inquest, Helen Lancaster, the director of nursing, who had commissioned an independent report which highlighted missed opportunities, did accept its findings.
Dr John Omany, medical director for NHS England (Arden, Herefordshire and Worcestershire), who oversee GPs' surgeries, accepted "opportunities were missed" to identify the seriousness of Evelyn's condition.
Mr Omany added: "We have looked into the circumstances of this tragic case and our priority now is to ensure that GPs across our area are aware of the dangers of croup.
"We have also contacted all GP surgeries and all out-of-hours providers to highlight some of the difficulties in identifying seriously ill children, and encourage them to refer children for specialist care as a precaution as soon as they have any concerns.
Evelyn's parents Helen and Trevor are now trying to raise awareness about complications of croup and encouraging parents to trust their instincts.
Helen Smith said: "When she first showed signs of being unwell, it was just a mild headache and that's something that all parents encounter.
"But when she burst into our room at 2am saying 'I can't breathe', that was when we knew it was something serious so I took her straight to A&E.
"We feel bitterly disappointed in the trust for failing to acknowledge that changes in their practice needed to be made to reduce the risk of deaths in the future.
"This has added unnecessary distress to our family. This was compounded by a total absence of any aftercare once we had left the hospital after Evelyn died."
This article is courtesy of the Mirror.
Little Evelyn Smith was rushed to A&E by her parents last September after falling ill suddenly, suffering from a soaring temperature and vomiting.
The youngster was misdiagnosed and sent away from hospital and her GP's surgery.
After her terrified mum Helen took her daughter to see a doctor for the third time in three days, just two hours after being sent away, Evelyn collapsed and died at her home in Warwick.
An inquest into her death discovered she had died from a rare bacterial infection - Bacterial trachetis - as a result of croup.
Even though a doctor had diagnosed Evelyn with viral croup, they failed to recognise the deadly bacterial complications she was suffering from - and a coroner has ruled that Evelyn's death could have been prevented if she had been diagnosed and treated correctly.
Devastated Helen said: "Losing Evelyn has been totally devastating for us.
"She deteriorated so rapidly, even a year on it doesn't seem real. She was such a happy girl - a real livewire, so happy and always smiling. She's left a huge hole in our family.
"We took her to hospital three times in three days - we repeatedly returned for medical help and that should have been a red flag to doctors and nurses.
"I don't want any other parent to go through what we have been through. Trust your instincts - if you think there's something seriously wrong, insist that it is looked at."
The inquest, at Warwick Coroner's Court, head that Evelyn had woken up with a mild headache on Wednesday, September 11, 2013 - but still went to school that day and her ballet class in the evening. But at 2am the next morning, she came bursting into her parents' bedroom shouting that she couldn't breathe.
Helen rushed her to Warwick Hospital Accident and Emergency department, where her temperature had rocketed to almost 40 degrees. She was examined by a doctor, and despite vomiting, discharged a couple of hours later, with advice on how to reduce her temperature.
But when her daughter was still burning up on Friday morning, Helen took Evelyn to her GP surgery, where she was examined by a nurse, who prescribed her penicillin for her inflamed tonsils.
That afternoon her temperature had risen again and Helen took her back to the GP. Their Dr Susan Martin diagnosed her with oxygen saturations and moderate croup and made an appointment for her to come back on Monday.
Tragically, Evelyn collapsed and died at home two hours later leaving Helen to desperately give CPR while she waited for an ambulance to arrive.
At the inquest assistant coroner for Warwickshire, Dr Richard Brittain said: "Evelyn Mary Smith died from the consequences of both a viral and bacterial infection of her upper respiratory tract.
"Her family sought medical attention three times in the days leading up to her death. There were missed opportunities to diagnose and treat Evelyn appropriately on each of these occasions. However, I am satisfied that none of these consultations were neglectful.
Based on the evidence heard, it is more likely than not that her death was preventable; although it has not been possible to conclude the causative impact of each missed opportunity."
Among those giving evidence at the inquest was Warwick Hospital doctor Emma Sexton, who first examined Evelyn on the day before she died. She said the child did not appear to be displaying signs of respiratory distress and her cough sounded like a viral croup, although she had looked for symptoms of other conditions as well.
Dr Sexton added: "Bacterial trachetis is a very rare condition that arises from these symptoms. I had not come across it prior to this case."
Haidee Vedy, head of medical negligence at Alsters Kelley LLP, who represented the family at the inquest said: "Evelyn's death was an absolutely tragedy and should never have happened.
"Her family put their trust in the hands of the hospital and their local GP surgery and it would appear from the evidence presented at the inquest that they were badly let down.
"We will now be investigating further to find out what more could have been done to prevent Evelyn's death."
But at the inquest, Helen Lancaster, the director of nursing, who had commissioned an independent report which highlighted missed opportunities, did accept its findings.
Dr John Omany, medical director for NHS England (Arden, Herefordshire and Worcestershire), who oversee GPs' surgeries, accepted "opportunities were missed" to identify the seriousness of Evelyn's condition.
Mr Omany added: "We have looked into the circumstances of this tragic case and our priority now is to ensure that GPs across our area are aware of the dangers of croup.
"We have also contacted all GP surgeries and all out-of-hours providers to highlight some of the difficulties in identifying seriously ill children, and encourage them to refer children for specialist care as a precaution as soon as they have any concerns.
Evelyn's parents Helen and Trevor are now trying to raise awareness about complications of croup and encouraging parents to trust their instincts.
Helen Smith said: "When she first showed signs of being unwell, it was just a mild headache and that's something that all parents encounter.
"But when she burst into our room at 2am saying 'I can't breathe', that was when we knew it was something serious so I took her straight to A&E.
"We feel bitterly disappointed in the trust for failing to acknowledge that changes in their practice needed to be made to reduce the risk of deaths in the future.
"This has added unnecessary distress to our family. This was compounded by a total absence of any aftercare once we had left the hospital after Evelyn died."
This article is courtesy of the Mirror.
Wednesday, 17 September 2014
Mother in £400,000 deep vein thrombosis compensation
A mother is to be awarded £400,000 in compensation for a hospital's failures around her developing a potentially fatal blood clot after giving birth.
The 41-year-old will receive the payout to settle her medical negligence case against South Eastern Health Trust.
She developed deep vein thrombosis in her leg after her first child was born at the Ulster Hospital in June 2009.
She had claimed that as a pregnant woman over the age of 35, she was not properly assessed as being at risk.
Further alleged negligence occurred when she first went to accident and emergency following the birth with symptoms of deep vein thrombosis.
“It's affected every aspect of my life, I just feel old before my time”
With women more likely to develop blood clots of this type during pregnancy, they can be fatal if they dislodge and travel to the lungs.
The woman, who has since had two more children, said she was told it was probably just her hormones.
Liability was admitted before the level of compensation was agreed.
Speaking after the case was settled at the High Court in Belfast, the civil servant said there had been an ongoing traumatic impact.
"It's affected every aspect of my life, I just feel old before my time," she said.
"I find walking for more than 10-15 minutes very hard to endure and stairs are incredibly difficult."
She had to undergo further operations following the births of her other two children due to associated issues.
"If it had clotted again I could have lost my leg," she added.
As well as her medication, the woman says she now has to wear tight stockings "the equivalent of a wetsuit".
This article is courtesy of BBC News.
The 41-year-old will receive the payout to settle her medical negligence case against South Eastern Health Trust.
She developed deep vein thrombosis in her leg after her first child was born at the Ulster Hospital in June 2009.
She had claimed that as a pregnant woman over the age of 35, she was not properly assessed as being at risk.
Further alleged negligence occurred when she first went to accident and emergency following the birth with symptoms of deep vein thrombosis.
“It's affected every aspect of my life, I just feel old before my time”
With women more likely to develop blood clots of this type during pregnancy, they can be fatal if they dislodge and travel to the lungs.
The woman, who has since had two more children, said she was told it was probably just her hormones.
Liability was admitted before the level of compensation was agreed.
Speaking after the case was settled at the High Court in Belfast, the civil servant said there had been an ongoing traumatic impact.
"It's affected every aspect of my life, I just feel old before my time," she said.
"I find walking for more than 10-15 minutes very hard to endure and stairs are incredibly difficult."
She had to undergo further operations following the births of her other two children due to associated issues.
"If it had clotted again I could have lost my leg," she added.
As well as her medication, the woman says she now has to wear tight stockings "the equivalent of a wetsuit".
This article is courtesy of BBC News.
Monday, 15 September 2014
Awareness during surgery can cause long-term harm, says report
At least 150 and possible several thousand patients a year are conscious while they are undergoing surgery in the operating theatre, according to a report which warns that some people suffer long-term psychological damage as a result.
In the vast majority of cases, patients have been given muscle-relaxing drugs that temporarily paralyse them, preventing them from warning theatre staff that they are awake. It happens most often during caesarean sections under general anaesthetic and during heart surgery.
A three-year investigation carried out by the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland found that usually the experience of awareness was short-lived, at the beginning or end of the operation.
Half of those who were aware of what was happening to them were distressed by the experience, and 41% said they suffered long-term psychological harm. The sensations they experienced included tugging, stitching, pain, paralysis and choking.
Patients described feelings of dissociation, panic, extreme fear and suffocation. Some said they feared they had been entombed, buried alive or were dead.
Prof Jaideep Pandit, consultant anaesthetist at the John Radcliffe hospital in Oxford and one of the authors of the report, said the Royal College and Association had "recognised the problem officially for the first time".
He said: "For a long time it has been a discussion on the periphery. This is real. We need to understand it and tackle it."
Not all experiences were traumatising, he said. Some patients spoke of feeling removed from what was happening. The drugs did not cause unconsciousness but made them feel detached. Sometimes they felt this was acceptable, and Pandit said there was an unanswered question as to whether all patients would want oblivion during surgery or whether some might prefer pain-free awareness.
It was vital, however, he said, that patients are told before they have surgery that there is a possibility, however remote, of having some consciousness of what is going on.
Estimates of how often this happens vary, says the report. When patients are asked after surgery whether they had any awareness, one in 600 say yes. But only one in 19,000 will come forward to talk about it voluntarily after the surgery. That would put the numbers at between 150 and 4,500 a year.
The team looked at three million episodes where a general anaesthetic was given in a hospital and reviewed in detail 300 cases of awareness reported by patients.
In 97% of cases, patients received muscle-relaxing drugs as well as the general anaesthetic. This makes it harder for an anaesthetist to be sure the patient is unconscious.
Around 10% of cases were caused by drug errors. In some, the muscle relaxant had been given without the general anaesthetic, which meant the patient was fully conscious but paralysed throughout their operation.
Where that happened, says the report, there were organisational as well as individual errors. "These included ill-considered policies for drug management, similar-looking ampoules, poorly organised operating lists, high workload, distraction and hurriedness," says the report.
"These patients were severely distressed and severely harmed in the long term," said Pandit. The report recommends a checklist before surgery, which would require the anaesthetist to line up the drugs they intend to administer and point to each one in turn. Pandit said mistakes "seem to occur in a highly pressured environment"
This article is courtesy of The Guardian.
In the vast majority of cases, patients have been given muscle-relaxing drugs that temporarily paralyse them, preventing them from warning theatre staff that they are awake. It happens most often during caesarean sections under general anaesthetic and during heart surgery.
A three-year investigation carried out by the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland found that usually the experience of awareness was short-lived, at the beginning or end of the operation.
Half of those who were aware of what was happening to them were distressed by the experience, and 41% said they suffered long-term psychological harm. The sensations they experienced included tugging, stitching, pain, paralysis and choking.
Patients described feelings of dissociation, panic, extreme fear and suffocation. Some said they feared they had been entombed, buried alive or were dead.
Prof Jaideep Pandit, consultant anaesthetist at the John Radcliffe hospital in Oxford and one of the authors of the report, said the Royal College and Association had "recognised the problem officially for the first time".
He said: "For a long time it has been a discussion on the periphery. This is real. We need to understand it and tackle it."
Not all experiences were traumatising, he said. Some patients spoke of feeling removed from what was happening. The drugs did not cause unconsciousness but made them feel detached. Sometimes they felt this was acceptable, and Pandit said there was an unanswered question as to whether all patients would want oblivion during surgery or whether some might prefer pain-free awareness.
It was vital, however, he said, that patients are told before they have surgery that there is a possibility, however remote, of having some consciousness of what is going on.
Estimates of how often this happens vary, says the report. When patients are asked after surgery whether they had any awareness, one in 600 say yes. But only one in 19,000 will come forward to talk about it voluntarily after the surgery. That would put the numbers at between 150 and 4,500 a year.
The team looked at three million episodes where a general anaesthetic was given in a hospital and reviewed in detail 300 cases of awareness reported by patients.
In 97% of cases, patients received muscle-relaxing drugs as well as the general anaesthetic. This makes it harder for an anaesthetist to be sure the patient is unconscious.
Around 10% of cases were caused by drug errors. In some, the muscle relaxant had been given without the general anaesthetic, which meant the patient was fully conscious but paralysed throughout their operation.
Where that happened, says the report, there were organisational as well as individual errors. "These included ill-considered policies for drug management, similar-looking ampoules, poorly organised operating lists, high workload, distraction and hurriedness," says the report.
"These patients were severely distressed and severely harmed in the long term," said Pandit. The report recommends a checklist before surgery, which would require the anaesthetist to line up the drugs they intend to administer and point to each one in turn. Pandit said mistakes "seem to occur in a highly pressured environment"
This article is courtesy of The Guardian.
Friday, 12 September 2014
NHS faces huge compensation bill after dozens of patients were left with sight problems when it hired private firm to complete cataract surgery
A hospital could face a huge compensation bill after it hired a private firm to remove cataracts and half the patients treated suffered complications.
Musgrove Park Hospital in Taunton hired private provider Vanguard in May to help reduce a backlog.
But the hospital terminated the contract after only four days after 31 of the 62 patients who had the operation reported complications including blurred vision, pain and swelling.
One 84-year-old man claimed he has lost his sight and his family is calling for a full independent inquiry.
Some of the patients, including the 84-year-old man, have contacted lawyers to discuss seeking compensation, which raises the prospect of an NHS hospital picking up the bill for procedures done by a private health company.
Taunton and Somerset NHS Foundation Trust refused to talk in detail or discuss pay-outs when approached by The Guardian Newspaper, but a senior member of staff told the local newspaper that the hospital would be liable for any payments.
Colin Close, Musgrove Park’s medical director, told the Somerset Country Gazette: ‘Any financial responsibility would rest with us.
‘If any patients wish to pursue compensation, we would work with them.’
He added: ‘We still don’t know exactly what the cause is – we’re trying to identify that at the moment. There could be a range of causes.’
Dr Close said he would normally expect one in 400 patients to experience these complications.
A spokesman for Musgrove Park told The Guardian: ‘Due to the ongoing nature of our investigations it would be inappropriate for us to comment on the sequence of events surrounding the unfortunate complications experienced by our patients receiving cataract surgery with Vanguard Healthcare in their mobile theatre onsite at Musgrove Park hospital.
‘Our first and foremost concern has always been our patients, and particularly those who have experienced complications.
'We have been in very close contact with them since the incident to ensure they are fully informed with our progress and receive the highest quality aftercare and treatment.
'We will want to discuss the outcomes of our investigations with them first, once they have reached conclusion.’
Ian Gillespie, chief executive of Vanguard Healthcare Solutions, said: ‘Patient care is our number one priority and we’re working closely with the trust to understand and fully investigate the root causes of any complications.
‘This investigation is still ongoing, making it inappropriate to comment on specific issues or on individual patient cases.
'Operations were carried out in Vanguard’s operating theatre by highly qualified surgeons, approved by the hospital, and with many years’ experience of working in the NHS.’
This article is courtesy of the Daily Mail.
Musgrove Park Hospital in Taunton hired private provider Vanguard in May to help reduce a backlog.
But the hospital terminated the contract after only four days after 31 of the 62 patients who had the operation reported complications including blurred vision, pain and swelling.
One 84-year-old man claimed he has lost his sight and his family is calling for a full independent inquiry.
Some of the patients, including the 84-year-old man, have contacted lawyers to discuss seeking compensation, which raises the prospect of an NHS hospital picking up the bill for procedures done by a private health company.
Taunton and Somerset NHS Foundation Trust refused to talk in detail or discuss pay-outs when approached by The Guardian Newspaper, but a senior member of staff told the local newspaper that the hospital would be liable for any payments.
Colin Close, Musgrove Park’s medical director, told the Somerset Country Gazette: ‘Any financial responsibility would rest with us.
‘If any patients wish to pursue compensation, we would work with them.’
He added: ‘We still don’t know exactly what the cause is – we’re trying to identify that at the moment. There could be a range of causes.’
Dr Close said he would normally expect one in 400 patients to experience these complications.
A spokesman for Musgrove Park told The Guardian: ‘Due to the ongoing nature of our investigations it would be inappropriate for us to comment on the sequence of events surrounding the unfortunate complications experienced by our patients receiving cataract surgery with Vanguard Healthcare in their mobile theatre onsite at Musgrove Park hospital.
‘Our first and foremost concern has always been our patients, and particularly those who have experienced complications.
'We have been in very close contact with them since the incident to ensure they are fully informed with our progress and receive the highest quality aftercare and treatment.
'We will want to discuss the outcomes of our investigations with them first, once they have reached conclusion.’
Ian Gillespie, chief executive of Vanguard Healthcare Solutions, said: ‘Patient care is our number one priority and we’re working closely with the trust to understand and fully investigate the root causes of any complications.
‘This investigation is still ongoing, making it inappropriate to comment on specific issues or on individual patient cases.
'Operations were carried out in Vanguard’s operating theatre by highly qualified surgeons, approved by the hospital, and with many years’ experience of working in the NHS.’
This article is courtesy of the Daily Mail.
Wednesday, 10 September 2014
Misdiagnosis: can it be remedied?
Misdiagnosis -- diagnosing a patient with the wrong disease, or with the correct one too late -- continues to be a big issue for healthcare providers. And despite continuing efforts to reduce it, the problem isn't going to go away any time soon.
The major areas of misdiagnosis -- commonly defined as "a diagnosis that is missed, wrong, or delayed, as detected by some subsequent definitive test or finding" -- have not changed much over the years, according to Mark Graber, MD, founder and president of the Society to Improve Diagnosis in Medicine (SIDM), who coined the definition in 2005.
For example, when looking at malpractice cases filed over the years involving diagnostic errors, "there is consistency: it's ... cancers; cardiovascular disease -- including strokes, heart attacks, and aortic dissections; and infections, things like sepsis and meningitis," he told MedPage Today.
Graber, a senior fellow at RTI International in Rockville, Md., and his colleagues who are interested in reducing misdiagnosis founded SIDM 3 years ago to draw more attention to the issue. They are hoping that the society's work -- plus an upcoming report on misdiagnosis from the Institute of Medicine -- will bring more interest from the medical community.
Autopsy Findings
In trying to better define the problem, autopsies are one place researchers turn to as a source of misdiagnosis data. In 2002, the Agency for Healthcare Research and Quality published an evidence report by Kaveh G. Shojania, MD, of the University of California San Francisco, and colleagues entitled "The Autopsy as an Outcome and Performance Measure."
"At the level of the individual clinician, the chance that autopsy will reveal important unsuspected diagnoses in a given case remains significant," the authors noted. "Moreover, clinicians do not seem able to predict the cases in which such findings are likely to occur."
Furthermore, they said, "While 'newer diseases' such as opportunistic infections have undoubtedly increased in recent decades and account for some of the misdiagnoses detected at autopsy, clinically missed diagnoses continue to include common diagnoses such as myocardial infarction, pulmonary embolism, bowel perforation, and other common conditions."
Another study, published in 2000 by Franco Salomon, MD, of the University of Zurich in Switzerland, and colleagues, looked at diagnosis errors found via autopsy in 1972, 1982, and 1992. The researchers looked at results from 100 autopsies done in each of the 3 years studied.
The authors found that the rate of diagnostic errors was halved over the course of the study (1972, 30%; 1982, 18%; 1992, 14%; P=0.007); however, the types of diagnoses missed continued to fall into the same categories: cardiovascular diseases, cancers, and infectious diseases, with the drop in error rate mainly due to improved detection of cardiovascular disease.
A third autopsy study, published in 2008 by Fabio Tavora, MD, of the University of Maryland in Baltimore, and colleagues, looked at autopsy results from three different institutions from 1999 through 2006. The investigators found that "the largest single category of unsuspected diagnoses was pulmonary embolism followed by undiagnosed infections, including cases of tuberculosis; cardiovascular disease, including undiagnosed coronary artery disease and ruptured aneurysms; and ... undiagnosed neoplasms."
That study found an overall rate of major discrepancy involving the cause of death was 17.2%. Although misdiagnosis rates in general are hard to quantify, "we think in general practice it's at least 10%," Graber said.
Many of the most common diagnosis errors haven't changed much in frequency over the years because "the symptoms are nonspecific, and too often the presentation is atypical," he continued. Besides, he added, "Diagnosis is hard!"
Physician-Reported Errors
Studies of physician-reported diagnosis errors are less common, though there are a few. A 2009 study by Gordon Schiff, MD, then of Cook County Hospital in Chicago, and colleagues, analyzed 583 physician-reported errors from hospitals nationwide and found that the five most common misdiagnoses were:
Types of misdiagnosis are very specialty-dependent, noted Paul Epner, executive vice-president of SIDM. "If you ask emergency physicians for their top 10 list, it's different than if you ask pediatricians [about] their top 10 list," he said, adding that "many of the most common diagnoses are where we find the highest number of diagnostic errors."
In the emergency department (ED), "the common diagnoses we miss are heart attacks, acute coronary syndrome ... ruptured abdominal aneurysms, and appendicitis," said David Meyers, MD, an emergency physician at Sinai Hospital in Baltimore. "We also miss strokes."
For the most part, the most common ED misdiagnoses haven't changed much since the first monographs were published on them 30 years ago, Meyers told MedPage Today.
There are a few exceptions, however. "We're not missing as many ectopic pregnancies, because the ease of getting pregnancy tests has improved over the years," said Meyers. "Also, childhood meningitis is very rare now -- [malpractice] claims in that area have gone down significantly because kids get vaccinated against the bugs that cause that disease."
And some newer entries have crept up as well. "Sepsis and necrotizing fasciitis were very rare in previous eras, and, now, it's not that they're common, but they're much more common than they used to be," Meyers added. "Maybe by overprescribing antibiotics, we're allowing stronger bacteria to take over and become more prevalent. We're also able to keep sicker people alive longer with drugs that compromise their immune system."
Error Types Vary
In addition to specific diseases, misdiagnosis errors also vary by the type of error. For example, in the radiology department, there are two types of errors, Leonard Berlin, MD, of Skokie Hospital in Illinois, explained at an Aug. 7 meeting in Washington on diagnostic error in healthcare.
First, there are perceptual errors (not seeing what is on the film), which account for 70% of errors; and then there are cognitive errors (seeing what's on the film but attaching minimal significance to it), which make up the other 30%, Berlin said.
Perceptual errors come in several different types, he continued. One is called "satisfaction of search," meaning that once an abnormality is found on a radiology film, physicians become less likely to find additional abnormalities.
In one study involving 25 residents and staff members at an Ohio hospital, participants had a 75% chance of seeing one abnormality on a film that only contained one, and a 75% chance of seeing at least one abnormality on a film that contained multiple abnormalities, but the chance of seeing a second or third one dropped to around 40%.
Another type of error is known as an "alliterative" error, in which physicians who see a particular finding listed on previous radiology reports for a particular patient tend to make the same finding themselves, even when it is in error.
The overall rate of radiology errors is around 4% and has not changed greatly over the years, according to Berlin.
One barrier to improving misdiagnosis rates is that generally speaking, "physicians are lousy at reporting errors," Robert Trowbridge, MD, of the Maine Medical Center in Portland, said at the meeting, which was sponsored by the Institute of Medicine.
Part of the reason for that is the "blaming" culture of medicine, Michael Kanter, MD, medical director for quality and clinical analysis at Southern California Permanente Medical Group in Pasadena, Calif., said at the meeting.
Kanter is running a program to try to reduce missed follow-up opportunities at Kaiser facilities; his philosophy is that instead of focusing on who is to blame for a particular error, "you need to get the physicians engaged to fix that problem, so they need to feel comfortable in the process and cooperate."
Ideally, reducing misdiagnosis would start early in physicians' careers, Graber said. "We'd like to do things in medical education that will make doctors better diagnosticians. If they realize they make mistakes, they are less likely to make them."
To help achieve that goal the SIDM has established an education committee, and one of its major projects is to develop a consensus curriculum for medical students that will help them spot and reduce errors, he said.
This article is courtesy of Medpage Today.
The major areas of misdiagnosis -- commonly defined as "a diagnosis that is missed, wrong, or delayed, as detected by some subsequent definitive test or finding" -- have not changed much over the years, according to Mark Graber, MD, founder and president of the Society to Improve Diagnosis in Medicine (SIDM), who coined the definition in 2005.
For example, when looking at malpractice cases filed over the years involving diagnostic errors, "there is consistency: it's ... cancers; cardiovascular disease -- including strokes, heart attacks, and aortic dissections; and infections, things like sepsis and meningitis," he told MedPage Today.
Graber, a senior fellow at RTI International in Rockville, Md., and his colleagues who are interested in reducing misdiagnosis founded SIDM 3 years ago to draw more attention to the issue. They are hoping that the society's work -- plus an upcoming report on misdiagnosis from the Institute of Medicine -- will bring more interest from the medical community.
Autopsy Findings
In trying to better define the problem, autopsies are one place researchers turn to as a source of misdiagnosis data. In 2002, the Agency for Healthcare Research and Quality published an evidence report by Kaveh G. Shojania, MD, of the University of California San Francisco, and colleagues entitled "The Autopsy as an Outcome and Performance Measure."
"At the level of the individual clinician, the chance that autopsy will reveal important unsuspected diagnoses in a given case remains significant," the authors noted. "Moreover, clinicians do not seem able to predict the cases in which such findings are likely to occur."
Furthermore, they said, "While 'newer diseases' such as opportunistic infections have undoubtedly increased in recent decades and account for some of the misdiagnoses detected at autopsy, clinically missed diagnoses continue to include common diagnoses such as myocardial infarction, pulmonary embolism, bowel perforation, and other common conditions."
Another study, published in 2000 by Franco Salomon, MD, of the University of Zurich in Switzerland, and colleagues, looked at diagnosis errors found via autopsy in 1972, 1982, and 1992. The researchers looked at results from 100 autopsies done in each of the 3 years studied.
The authors found that the rate of diagnostic errors was halved over the course of the study (1972, 30%; 1982, 18%; 1992, 14%; P=0.007); however, the types of diagnoses missed continued to fall into the same categories: cardiovascular diseases, cancers, and infectious diseases, with the drop in error rate mainly due to improved detection of cardiovascular disease.
A third autopsy study, published in 2008 by Fabio Tavora, MD, of the University of Maryland in Baltimore, and colleagues, looked at autopsy results from three different institutions from 1999 through 2006. The investigators found that "the largest single category of unsuspected diagnoses was pulmonary embolism followed by undiagnosed infections, including cases of tuberculosis; cardiovascular disease, including undiagnosed coronary artery disease and ruptured aneurysms; and ... undiagnosed neoplasms."
That study found an overall rate of major discrepancy involving the cause of death was 17.2%. Although misdiagnosis rates in general are hard to quantify, "we think in general practice it's at least 10%," Graber said.
Many of the most common diagnosis errors haven't changed much in frequency over the years because "the symptoms are nonspecific, and too often the presentation is atypical," he continued. Besides, he added, "Diagnosis is hard!"
Physician-Reported Errors
Studies of physician-reported diagnosis errors are less common, though there are a few. A 2009 study by Gordon Schiff, MD, then of Cook County Hospital in Chicago, and colleagues, analyzed 583 physician-reported errors from hospitals nationwide and found that the five most common misdiagnoses were:
- Pulmonary embolism (4.5% of all misdiagnoses)
- Drug reaction or overdose (4.5%)
- Lung cancer (3.9%)
- Colorectal cancer (3.3%)
- Acute coronary syndrome (3.1%)
Types of misdiagnosis are very specialty-dependent, noted Paul Epner, executive vice-president of SIDM. "If you ask emergency physicians for their top 10 list, it's different than if you ask pediatricians [about] their top 10 list," he said, adding that "many of the most common diagnoses are where we find the highest number of diagnostic errors."
In the emergency department (ED), "the common diagnoses we miss are heart attacks, acute coronary syndrome ... ruptured abdominal aneurysms, and appendicitis," said David Meyers, MD, an emergency physician at Sinai Hospital in Baltimore. "We also miss strokes."
For the most part, the most common ED misdiagnoses haven't changed much since the first monographs were published on them 30 years ago, Meyers told MedPage Today.
There are a few exceptions, however. "We're not missing as many ectopic pregnancies, because the ease of getting pregnancy tests has improved over the years," said Meyers. "Also, childhood meningitis is very rare now -- [malpractice] claims in that area have gone down significantly because kids get vaccinated against the bugs that cause that disease."
And some newer entries have crept up as well. "Sepsis and necrotizing fasciitis were very rare in previous eras, and, now, it's not that they're common, but they're much more common than they used to be," Meyers added. "Maybe by overprescribing antibiotics, we're allowing stronger bacteria to take over and become more prevalent. We're also able to keep sicker people alive longer with drugs that compromise their immune system."
Error Types Vary
In addition to specific diseases, misdiagnosis errors also vary by the type of error. For example, in the radiology department, there are two types of errors, Leonard Berlin, MD, of Skokie Hospital in Illinois, explained at an Aug. 7 meeting in Washington on diagnostic error in healthcare.
First, there are perceptual errors (not seeing what is on the film), which account for 70% of errors; and then there are cognitive errors (seeing what's on the film but attaching minimal significance to it), which make up the other 30%, Berlin said.
Perceptual errors come in several different types, he continued. One is called "satisfaction of search," meaning that once an abnormality is found on a radiology film, physicians become less likely to find additional abnormalities.
In one study involving 25 residents and staff members at an Ohio hospital, participants had a 75% chance of seeing one abnormality on a film that only contained one, and a 75% chance of seeing at least one abnormality on a film that contained multiple abnormalities, but the chance of seeing a second or third one dropped to around 40%.
Another type of error is known as an "alliterative" error, in which physicians who see a particular finding listed on previous radiology reports for a particular patient tend to make the same finding themselves, even when it is in error.
The overall rate of radiology errors is around 4% and has not changed greatly over the years, according to Berlin.
One barrier to improving misdiagnosis rates is that generally speaking, "physicians are lousy at reporting errors," Robert Trowbridge, MD, of the Maine Medical Center in Portland, said at the meeting, which was sponsored by the Institute of Medicine.
Part of the reason for that is the "blaming" culture of medicine, Michael Kanter, MD, medical director for quality and clinical analysis at Southern California Permanente Medical Group in Pasadena, Calif., said at the meeting.
Kanter is running a program to try to reduce missed follow-up opportunities at Kaiser facilities; his philosophy is that instead of focusing on who is to blame for a particular error, "you need to get the physicians engaged to fix that problem, so they need to feel comfortable in the process and cooperate."
Ideally, reducing misdiagnosis would start early in physicians' careers, Graber said. "We'd like to do things in medical education that will make doctors better diagnosticians. If they realize they make mistakes, they are less likely to make them."
To help achieve that goal the SIDM has established an education committee, and one of its major projects is to develop a consensus curriculum for medical students that will help them spot and reduce errors, he said.
This article is courtesy of Medpage Today.
Monday, 8 September 2014
Surgeon rendered patient infertile by giving him a vasectomy by mistake during minor operation
A surgeon has rendered a patient infertile by giving him a vasectomy when he went into hospital for a minor operation.
The patient was the victim of what hospital chiefs have called a 'never event' - a medical mistake that should never happen.
The man, who had the original procedure at Broadgreen Hospital in Liverpool earlier this year, has been told that an operation to reverse the vasectomy was unsuccessful. He could now be entitled to more than £100,000 in compensation.
It is understood that the surgeon who performed the surgery has since been fired, according a report.
The urology department at Broadgreen Hospital, part of the Royal Liverpool and Broadgreen University Hospitals NHS Trust, has admitted the error was just one of five botched operations - and two 'never events' - in the last 12 months.
Another mistake involved a medical swab being left inside a patient during an operation.
The Royal Liverpool Hospital 'apologised unreservedly' to the man when details of the mistake, which they termed 'wrong site surgery', emerged earlier this year.
The vasectomy - and the failed reversal - means that the patient will not be able to conceive naturally.
Ian Cohen, clinical negligence lawyer at Slater & Gordon, said the vasectomy patient could be eligible for more than £100,000 in compensation, but it would depend on how old he is and whether or not he has been left infertile.
Mr Cohen said: 'This is a truly shocking and worrying case. From what we know there has been a catastrophic breakdown in procedure, as simple checks designed to ensure the correct operation is carried out on the right patient seem to have failed.
'If a 25-year-old who wants a family is told he won’t be able to father children, it will be devastating.'
Hospital bosses say the blunders have been reported to NHS chiefs and that investigations are under way to establish how they happened.
Dr Peter Williams, medical director at Royal Liverpool and Broadgreen University Hospitals NHS Trust said: 'Our urology department is the biggest in Cheshire and Merseyside, caring for over 4,000 patients a year.
'The vast majority of feedback from these patients is overwhelmingly positive.
'We have excellent, highly regarded clinical teams who treat the most difficult urological cases, many of which are referred to us by other hospitals for our expertise and leading edge surgical techniques.
'In the last 12 months, three serious incidents and two never events occurred in our urology department and these were reported to the appropriate bodies.
'We are still in the process of investigating some of these incidents, including looking at how to improve the processes and systems in place and are taking appropriate action.
'We cannot comment on the outcomes of these investigations at this stage.
'Patient safety is always our priority and we use the lessons learnt from any incident to continually improve our standard of care.'
This article is courtesy of the Daily Mail.
The patient was the victim of what hospital chiefs have called a 'never event' - a medical mistake that should never happen.
The man, who had the original procedure at Broadgreen Hospital in Liverpool earlier this year, has been told that an operation to reverse the vasectomy was unsuccessful. He could now be entitled to more than £100,000 in compensation.
It is understood that the surgeon who performed the surgery has since been fired, according a report.
The urology department at Broadgreen Hospital, part of the Royal Liverpool and Broadgreen University Hospitals NHS Trust, has admitted the error was just one of five botched operations - and two 'never events' - in the last 12 months.
Another mistake involved a medical swab being left inside a patient during an operation.
The Royal Liverpool Hospital 'apologised unreservedly' to the man when details of the mistake, which they termed 'wrong site surgery', emerged earlier this year.
The vasectomy - and the failed reversal - means that the patient will not be able to conceive naturally.
Ian Cohen, clinical negligence lawyer at Slater & Gordon, said the vasectomy patient could be eligible for more than £100,000 in compensation, but it would depend on how old he is and whether or not he has been left infertile.
Mr Cohen said: 'This is a truly shocking and worrying case. From what we know there has been a catastrophic breakdown in procedure, as simple checks designed to ensure the correct operation is carried out on the right patient seem to have failed.
'If a 25-year-old who wants a family is told he won’t be able to father children, it will be devastating.'
Hospital bosses say the blunders have been reported to NHS chiefs and that investigations are under way to establish how they happened.
Dr Peter Williams, medical director at Royal Liverpool and Broadgreen University Hospitals NHS Trust said: 'Our urology department is the biggest in Cheshire and Merseyside, caring for over 4,000 patients a year.
'The vast majority of feedback from these patients is overwhelmingly positive.
'We have excellent, highly regarded clinical teams who treat the most difficult urological cases, many of which are referred to us by other hospitals for our expertise and leading edge surgical techniques.
'In the last 12 months, three serious incidents and two never events occurred in our urology department and these were reported to the appropriate bodies.
'We are still in the process of investigating some of these incidents, including looking at how to improve the processes and systems in place and are taking appropriate action.
'We cannot comment on the outcomes of these investigations at this stage.
'Patient safety is always our priority and we use the lessons learnt from any incident to continually improve our standard of care.'
This article is courtesy of the Daily Mail.
Friday, 5 September 2014
Safety of private hospitals questioned as report reveals hundreds die unexpectedly
Patients in Britain's private hospitals may be put at unnecessary risk and the NHS is left to pick up the pieces, a report has warned, as 800 people died unexpectedly and a further 921 suffered serious injury following private medical treatment.
Private hospitals rarely have intensive care beds, dedicated resuscitation teams and the surgeons and anaesthetists often work in isolation, the report by a think tank said.
When things go wrong in private hospitals, patients are often transferred to the NHS to pick up the pieces, it was warned, with 2,600 patients transferred as emergencies and 6,000 patients moved in total in 2012/13.
It is not known how much this costs the taxpayer, the report said.
The Centre for Health and the Public Interest cited examples where an anaesthetist covered two operating theatre lists simultaneously, risking the lives of both sets of patients and a surgeon operated in an unsuitable setting because the main operating theatre was not available, putting a patient at serious risk.
In addition surgeon, Ian Paterson undertook dangerous breast surgery and colonoscopies he was not qualified to perform at spire Wellesley and little Aston hospitals in Solihull.
Mr Paterson was suspended by the GMC and the police called in after he was found to be carrying out 'cleavage sparing' mastectomies which breached guidelines because the technique risked the cancer returning.
The report said that a lack of data available from private hospitals makes it difficult for patients to judge the safety of their care.
This is despite many private hospitals treating NHS patients, funded by the taxpayer.
The CHPI obtained from the regulator, the Care Quality Commission, under the Freedom of Information Act figures on patient safety relating to private hospitals.
It was found that 802 people died unexpectedly and a further 921 suffered serious injuries in England in the last four years. It was not possible to determine if these cases could have been avoided, the report said, but private hospitals tended to carry out relatively low risk procedures in which complications should be rare.
The report said: "This could mean that the mortality rates of private hospitals are actually higher than reported here and the mortality rates for NHS hospitals include deaths which were the result of procedures carried out in private hospitals."
There are around 1.61 admissions to private hospitals in England per year for surgery, one quarter of which are funded by the taxpayer.
Report co-author Professor Colin Leys, emeritus professor at Queen’s University, Canada, and an honorary professor at Goldsmiths, University of London, said: “The public and regulators have access to more information than ever before about how NHS services are performing but this report shows that the same cannot be said for private hospitals.
"The Government has recognised the crucial role of transparency in making hospitals safer but reporting requirements should apply wherever patients are treated. With the taxpayer now providing over a billion pounds a year to private hospitals, this is too important to be left to the industry to address.”
Report co-author Professor Brian Toft, visiting professor of Patient Safety at Brighton and Sussex Medical School and member of the World Health Organisation’s European Regional Advisory Council on patient safety and healthcare, said: “The report highlights some sobering examples of what can happen to patients without the right staffing, equipment and facilities.
"When patients choose to have an operation in a private hospital they may be unaware of the difference in terms of risk between a big NHS hospital with surgical teams and intensive care beds and a private hospital with neither. Consent forms should make clear to patients the inherent potential risks in the way these facilities are run.”
Peter Walsh, chief executive of the charity Action Against Medical Accidents, said: “In our experience, there is plenty that can and does go wrong in private healthcare and it is usually the NHS that ends up picking up the pieces.
"This report confirms it is time for the same level of scrutiny, regulation and protection of patients’ safety and rights to be afforded to private patients as is now being done for NHS patients. A comparable complaints procedure and access to independent advice on complaints would be a good starting point.
"Over the years AvMA has seen private patients let down time and time again. For all its problems, the NHS has far more developed systems for patient safety and investigating incidents and complaints.
"It is time for private hospitals to be scrutinised much more closely and patients to have consistent rights wherever they are treated."
The report recommends that private providers should be subject to the same requirements as the NHS to report patient safety incidents, and to report on their performance.
Private hospitals should warn patients, before treatment, of the risks that may be posed by their facilities, equipment or staffing such as the lack of resuscitation team when taking consent prior to an operation.
The hospitals should have on-site registrar-level surgeon or doctor for every specialty for which NHS patients are treated, for an anaesthetist to be on call, and for medical records to be kept on the ward, the report said.
In addition the Department of Health should carry out a review of the nature and cost of admissions to the NHS from private hospitals, and the NHS should have the power to recoup costs resulting from a failure by a private hospital.
A spokesman for the Care Quality Commission said: "We will soon start inspecting Independent Hospitals using the new style inspections that are being carried out in the NHS. CQC will expect from Independent Health equivalent information about performance that it receives from NHS hospitals."
David Hare, chief executive of NHS Partners Network, which represents private hospitals treating NHS patients said: “Patient safety is the number one priority for all independent sector providers of NHS clinical services. Under the robust regulatory regime overseen by the Care Quality Commission independent sector providers are treated in the same way as publicly-owned providers. The Care Quality Commission will assess a provider’s incident reporting processes and crucially examine how patient safety incidents are addressed.
“In the latest available Care Quality Commission State of Care report major and moderate safety and safeguarding breaches in independent sector hospitals are lower than the NHS average and compliance rates better than average. The overwhelming majority of NHS care delivered by independent sector hospitals is safe, efficient and of excellent quality.”
This article is courtesy of the Telegraph.
Private hospitals rarely have intensive care beds, dedicated resuscitation teams and the surgeons and anaesthetists often work in isolation, the report by a think tank said.
When things go wrong in private hospitals, patients are often transferred to the NHS to pick up the pieces, it was warned, with 2,600 patients transferred as emergencies and 6,000 patients moved in total in 2012/13.
It is not known how much this costs the taxpayer, the report said.
The Centre for Health and the Public Interest cited examples where an anaesthetist covered two operating theatre lists simultaneously, risking the lives of both sets of patients and a surgeon operated in an unsuitable setting because the main operating theatre was not available, putting a patient at serious risk.
In addition surgeon, Ian Paterson undertook dangerous breast surgery and colonoscopies he was not qualified to perform at spire Wellesley and little Aston hospitals in Solihull.
Mr Paterson was suspended by the GMC and the police called in after he was found to be carrying out 'cleavage sparing' mastectomies which breached guidelines because the technique risked the cancer returning.
The report said that a lack of data available from private hospitals makes it difficult for patients to judge the safety of their care.
This is despite many private hospitals treating NHS patients, funded by the taxpayer.
The CHPI obtained from the regulator, the Care Quality Commission, under the Freedom of Information Act figures on patient safety relating to private hospitals.
It was found that 802 people died unexpectedly and a further 921 suffered serious injuries in England in the last four years. It was not possible to determine if these cases could have been avoided, the report said, but private hospitals tended to carry out relatively low risk procedures in which complications should be rare.
The report said: "This could mean that the mortality rates of private hospitals are actually higher than reported here and the mortality rates for NHS hospitals include deaths which were the result of procedures carried out in private hospitals."
There are around 1.61 admissions to private hospitals in England per year for surgery, one quarter of which are funded by the taxpayer.
Report co-author Professor Colin Leys, emeritus professor at Queen’s University, Canada, and an honorary professor at Goldsmiths, University of London, said: “The public and regulators have access to more information than ever before about how NHS services are performing but this report shows that the same cannot be said for private hospitals.
"The Government has recognised the crucial role of transparency in making hospitals safer but reporting requirements should apply wherever patients are treated. With the taxpayer now providing over a billion pounds a year to private hospitals, this is too important to be left to the industry to address.”
Report co-author Professor Brian Toft, visiting professor of Patient Safety at Brighton and Sussex Medical School and member of the World Health Organisation’s European Regional Advisory Council on patient safety and healthcare, said: “The report highlights some sobering examples of what can happen to patients without the right staffing, equipment and facilities.
"When patients choose to have an operation in a private hospital they may be unaware of the difference in terms of risk between a big NHS hospital with surgical teams and intensive care beds and a private hospital with neither. Consent forms should make clear to patients the inherent potential risks in the way these facilities are run.”
Peter Walsh, chief executive of the charity Action Against Medical Accidents, said: “In our experience, there is plenty that can and does go wrong in private healthcare and it is usually the NHS that ends up picking up the pieces.
"This report confirms it is time for the same level of scrutiny, regulation and protection of patients’ safety and rights to be afforded to private patients as is now being done for NHS patients. A comparable complaints procedure and access to independent advice on complaints would be a good starting point.
"Over the years AvMA has seen private patients let down time and time again. For all its problems, the NHS has far more developed systems for patient safety and investigating incidents and complaints.
"It is time for private hospitals to be scrutinised much more closely and patients to have consistent rights wherever they are treated."
The report recommends that private providers should be subject to the same requirements as the NHS to report patient safety incidents, and to report on their performance.
Private hospitals should warn patients, before treatment, of the risks that may be posed by their facilities, equipment or staffing such as the lack of resuscitation team when taking consent prior to an operation.
The hospitals should have on-site registrar-level surgeon or doctor for every specialty for which NHS patients are treated, for an anaesthetist to be on call, and for medical records to be kept on the ward, the report said.
In addition the Department of Health should carry out a review of the nature and cost of admissions to the NHS from private hospitals, and the NHS should have the power to recoup costs resulting from a failure by a private hospital.
A spokesman for the Care Quality Commission said: "We will soon start inspecting Independent Hospitals using the new style inspections that are being carried out in the NHS. CQC will expect from Independent Health equivalent information about performance that it receives from NHS hospitals."
David Hare, chief executive of NHS Partners Network, which represents private hospitals treating NHS patients said: “Patient safety is the number one priority for all independent sector providers of NHS clinical services. Under the robust regulatory regime overseen by the Care Quality Commission independent sector providers are treated in the same way as publicly-owned providers. The Care Quality Commission will assess a provider’s incident reporting processes and crucially examine how patient safety incidents are addressed.
“In the latest available Care Quality Commission State of Care report major and moderate safety and safeguarding breaches in independent sector hospitals are lower than the NHS average and compliance rates better than average. The overwhelming majority of NHS care delivered by independent sector hospitals is safe, efficient and of excellent quality.”
This article is courtesy of the Telegraph.
Wednesday, 3 September 2014
Dad was not told his cancer had spread until day before he died
A patient was not told his cancer had spread until the day before he died, a new report reveals.
The case is one of three complaints about care delivered by Coventry and Warwickshire hospitals which have been probed by the Parliamentary and Health Service Ombudsman.
Yesterday, the ombudsman published a summary of its investigations for the first time to highlight cases concluded in February and March.
George Eliot Hospital in Nuneaton was investigated twice, and the trust in charge of University Hospital in Coventry once.
In one case bosses at George Eliot Hospital awarded compensation in relation to a male patient, referred to as Mr B, who had been diagnosed with prostate cancer.
The patient was admitted to the hospital when he became unwell and while there underwent a scan on his back.
The scan showed the prostate cancer had spread to his spine – but the patient was not told and Mr B was discharged home, growing more ill until he was eventually readmitted to hospital the following month.
It was only then that the patient and his family were informed that the cancer had spread.
Sadly Mr B died the next day.
His daughter later complained to the ombudsman about the lack of information, the fact her father’s pain was not managed properly in hospital and was not offered support to manage at home.
The ombudsman found in the daughter’s favour, ruling that the consultant in charge of Mr B’s care should have told him his cancer had spread before discharging him from hospital and that staff should have given the man better pain relief.
The ombudsman also found that Mr B should have been assessed for home care support.
The report says: “The fact that they did not do this meant Mr B was left without support when he needed it, which was distressing for his daughter to see. She now has to live with the fact that more should have been done for her father.”
The ombudsman also found the trust’s response to the complaint “inadequate”.
The trust has now acknowledged the failings in Mr B’s care and its handling of the complaint, paid the daughter £1,250 in compensation and drawn up an action plan for improvements.
In the second case, the ombudsman found doctors at George Eliot Hospital delayed acting on a patient’s low oxygen levels for as long as 12 days.
The patient, referred to as Mrs L, was admitted to the hospital at the end of 2011 for stroke rehabilitation and was discharged to a care home after a six-month stay.
She was readmitted to the hospital after five weeks and died a week later.
Her daughters complained the trust did not provide adequate care and that their mother was not in a fit state to be discharged, and complained that nurses did not administer oxygen properly.
The ombudsman found there was a 12-day delay in doctor’s taking action on Mrs L’s low oxygen levels, which the report says “fell so far below the applicable standards that it was a service failure”.
The ombudsman partly upheld the daughters’ complaint about doctors’ failure to treat Mrs L’s chest condition but found no other failings in the case of Mrs L.
Following the ombudsman’s final report, the trust wrote to the daughters to acknowledge the failing.
Kevin McGee, chief executive of George Eliot Hospital, said: “We welcome the publication of these complaints as we appreciate the need for transparency and to be held to account when mistakes are made.
“We have carried out thorough internal investigations and demonstrated to the Ombudsman that we have satisfactorily improved our procedures to avoid further similar problems."
The trust in charge of Coventry’s University Hospital has also been probed by the health service ombudsman.
The ombudsman found University Hospitals Coventry and Warwickshire NHS Trust, which also runs St Cross Hospital in Rugby, failed to properly assess a male patient before discharging him from hospital.
The man, referred to as Mr B, suffered heart failure along with other chronic illnesses and was left to go home in a taxi.
He was readmitted to hospital the same evening but sadly died the following day.
The patient’s son complained his father was too poorly to leave hospital. He believed this led to his father’s death.
The son was also unhappy that his father was left to get a taxi by himself and no-one contacted the family to let them know.
The ombudsman found medical records supported the trust’s response that Mr B was medically suitable for discharge.
But the report says “it found that the trust should have assessed Mr B’s social needs before he was sent home to make sure he could get home safely and had support in place.
“We upheld this aspect of the complaint,” it adds.
On the trust’s actions following the ombudsman’s findings, the report continues: “The trust agreed to acknowledge and apologise for not assessing Mr B’s social needs, and the distressing impact this had on his family.
“It also agreed to confirm what action it had taken to make sure that assessments were carried out in future.”
The Parliamentary and Health Service Ombudsman is the final step for people who want to complain about being treated unfairly or receiving poor service from the NHS in England, or a UK government department or agency. It investigated 2,199 cases in 2013/14 compared to 384 the previous financial year.
Andrew Hardy, chief executive officer at University Hospitals Coventry and Warwickshire NHS trust, said: “On this occasion the ombudsman agreed that the patient was suitable for discharge but that the trust should have assessed their social needs before being sent home.
“The trust has further apologised to the family and provided them with a copy of our action plan in line with the recommendations made by the ombudsman.”
This article is courtesy of the Coventry Telegraph.
The case is one of three complaints about care delivered by Coventry and Warwickshire hospitals which have been probed by the Parliamentary and Health Service Ombudsman.
Yesterday, the ombudsman published a summary of its investigations for the first time to highlight cases concluded in February and March.
George Eliot Hospital in Nuneaton was investigated twice, and the trust in charge of University Hospital in Coventry once.
In one case bosses at George Eliot Hospital awarded compensation in relation to a male patient, referred to as Mr B, who had been diagnosed with prostate cancer.
The patient was admitted to the hospital when he became unwell and while there underwent a scan on his back.
The scan showed the prostate cancer had spread to his spine – but the patient was not told and Mr B was discharged home, growing more ill until he was eventually readmitted to hospital the following month.
It was only then that the patient and his family were informed that the cancer had spread.
Sadly Mr B died the next day.
His daughter later complained to the ombudsman about the lack of information, the fact her father’s pain was not managed properly in hospital and was not offered support to manage at home.
The ombudsman found in the daughter’s favour, ruling that the consultant in charge of Mr B’s care should have told him his cancer had spread before discharging him from hospital and that staff should have given the man better pain relief.
The ombudsman also found that Mr B should have been assessed for home care support.
The report says: “The fact that they did not do this meant Mr B was left without support when he needed it, which was distressing for his daughter to see. She now has to live with the fact that more should have been done for her father.”
The ombudsman also found the trust’s response to the complaint “inadequate”.
The trust has now acknowledged the failings in Mr B’s care and its handling of the complaint, paid the daughter £1,250 in compensation and drawn up an action plan for improvements.
In the second case, the ombudsman found doctors at George Eliot Hospital delayed acting on a patient’s low oxygen levels for as long as 12 days.
The patient, referred to as Mrs L, was admitted to the hospital at the end of 2011 for stroke rehabilitation and was discharged to a care home after a six-month stay.
She was readmitted to the hospital after five weeks and died a week later.
Her daughters complained the trust did not provide adequate care and that their mother was not in a fit state to be discharged, and complained that nurses did not administer oxygen properly.
The ombudsman found there was a 12-day delay in doctor’s taking action on Mrs L’s low oxygen levels, which the report says “fell so far below the applicable standards that it was a service failure”.
The ombudsman partly upheld the daughters’ complaint about doctors’ failure to treat Mrs L’s chest condition but found no other failings in the case of Mrs L.
Following the ombudsman’s final report, the trust wrote to the daughters to acknowledge the failing.
Kevin McGee, chief executive of George Eliot Hospital, said: “We welcome the publication of these complaints as we appreciate the need for transparency and to be held to account when mistakes are made.
“We have carried out thorough internal investigations and demonstrated to the Ombudsman that we have satisfactorily improved our procedures to avoid further similar problems."
The trust in charge of Coventry’s University Hospital has also been probed by the health service ombudsman.
The ombudsman found University Hospitals Coventry and Warwickshire NHS Trust, which also runs St Cross Hospital in Rugby, failed to properly assess a male patient before discharging him from hospital.
The man, referred to as Mr B, suffered heart failure along with other chronic illnesses and was left to go home in a taxi.
He was readmitted to hospital the same evening but sadly died the following day.
The patient’s son complained his father was too poorly to leave hospital. He believed this led to his father’s death.
The son was also unhappy that his father was left to get a taxi by himself and no-one contacted the family to let them know.
The ombudsman found medical records supported the trust’s response that Mr B was medically suitable for discharge.
But the report says “it found that the trust should have assessed Mr B’s social needs before he was sent home to make sure he could get home safely and had support in place.
“We upheld this aspect of the complaint,” it adds.
On the trust’s actions following the ombudsman’s findings, the report continues: “The trust agreed to acknowledge and apologise for not assessing Mr B’s social needs, and the distressing impact this had on his family.
“It also agreed to confirm what action it had taken to make sure that assessments were carried out in future.”
The Parliamentary and Health Service Ombudsman is the final step for people who want to complain about being treated unfairly or receiving poor service from the NHS in England, or a UK government department or agency. It investigated 2,199 cases in 2013/14 compared to 384 the previous financial year.
Andrew Hardy, chief executive officer at University Hospitals Coventry and Warwickshire NHS trust, said: “On this occasion the ombudsman agreed that the patient was suitable for discharge but that the trust should have assessed their social needs before being sent home.
“The trust has further apologised to the family and provided them with a copy of our action plan in line with the recommendations made by the ombudsman.”
This article is courtesy of the Coventry Telegraph.
Monday, 1 September 2014
The most devastating failures by public services revealed
A woman whose husband died hours after one of England’s biggest NHS hospitals missed several chances to diagnose his fatal condition was given just £2,000 in compensation, according to files published today, that highlight “devastating” failures by public services.
University Hospitals Birmingham NHS Foundation Trust mistakenly said the man was suffering from a blood clot when he actually had a tear in the blood vessel from his heart to his body, which resulted in his death. The case is one of 81 anonymised summaries of complaints - 58 healthcare and 23 Parliamentary cases – revealed by the Parliamentary and Health Service Ombudsman so “valuable lessons” can be learned.
It is the first time the public can search the watchdog’s website to see the range of complaints it deals with. The Ombudsman investigated 2,199 cases in 2013/14 compared to 384 the previous year.
A geographical breakdown of healthcare cases showed that the East of England had the highest number of complaints dealt with between February and March this year with a total of 15. West Midlands’ hospitals received 13 complaints, East Midlands had seven and London six. The North East and South West had the fewest complaints with just one each.
The report said that regarding Mr F’s case in Birmingham, his symptoms were not typical for his condition, which made it more difficult to diagnose. It concluded: “However, the Trust missed several chances to correctly diagnose Mr F, including taking account of his previous medical history and unusual symptoms, carrying out a chest X-ray and misreporting a scan. While we cannot say that Mr F’s death was avoidable (because his condition was very serious), it is clear that the Trust lost the chance to give him treatment that might have prevented or delayed his death.”
In another case two Trusts failed to communicate effectively when a woman suffering from bladder cancer had her wishes for surgery ignored leading the watchdog to describe the last six months of her life as “wasted just waiting”. It concluded an “unacceptable delay” had taken place as Bedford Hospital NHS Trust and Cambridge University Hospitals NHS Foundation Trust could not agree on the best course of treatment, although the Ombudsman concluded that due to Mrs C’s condition the delays did not affect her prognosis.
The Trusts paid £1,750 compensation to Mrs C’s family “for the upset and frustration they experienced as a result of the poor care given to their mother”.
The Home Office was among the Government departments criticised in the files after a teenage asylum seeker spent 10 years in the UK without legal status waiting for his case to be decided. The 17-year-old applied for permission to stay with his mother, who had fled from her home country, but was told he would need to reapply after he turned 18 and was left in administrative limbo.
Repeated requests from his MP were also ignored by the Home Office until a decade had passed. He eventually received an apology from the Home Office and £7,500 compensation for the “serious mistakes” that occurred.
Ombudsman Dame Julie Mellor said: “Our investigations highlight the devastating impact that failures in public services can have on the lives of individuals and their families. We are modernising the way we do things so we can help more people with their complaints and to help bodies in jurisdiction learn from mistakes other organisations have made to help them decide what action to improve their services.
“We will continue to work with others including consumer groups, public service regulators and Parliament, using the insight from our casework to help others make a real difference in public sector complaint handling and improve services.”
A Department of Health spokeswoman said: “Listening to patients is one of the best ways to improve standards and we welcome this increased transparency around complaints. Hospitals should make sure patients, their families and carers know how to complain - including displaying information on the complaints system in every ward.”
Other cases
A woman in her late 90s died on the toilet at home in her granddaughter’s arms after doctor discharged her without examining her abdomen. She had perforated diverticulitis. Miss T complained to East Kent Hospitals University NHS Foundation Trust and said that the Trust had failed to provide an adequate response regarding her grandmother’s death and had tried to ‘cover up’ its failings, but no evidence was found to support the claim. The Ombudsman recommended the Trust pay £500 in compensation for Miss T's distress.
Harrogate and District NHS Foundation Trust failed to spot signs of sepsis when Mr L arrived at hospital in the early hours of the morning from his care home. After being seen in A&E he was assessed as being safe for discharge back to his care home with some antibiotics, but died the following day. His wife complained to the Trust and said that if her husband had been admitted for treatment, he might have survived. The Ombudsman said because Mr L’s full diagnosis was not known, it could not say for certain whether his death was preventable. The Trust apologised and paid Mrs L compensation of £2,000.
A patient’s death from deep-vein thrombosis could have been avoided after a London GP practice failed to properly investigate her symptoms or refer her for further tests over two appointments. At both appointments the GPs who saw Mrs G failed to follow the relevant medical guidelines on investigating a possible DVT. They also failed to investigate her symptoms properly. The practice provided Mrs G’s relatives with evidence of what they had learnt from the complaint and apologised to them.
This article is courtesy of the Independent.
University Hospitals Birmingham NHS Foundation Trust mistakenly said the man was suffering from a blood clot when he actually had a tear in the blood vessel from his heart to his body, which resulted in his death. The case is one of 81 anonymised summaries of complaints - 58 healthcare and 23 Parliamentary cases – revealed by the Parliamentary and Health Service Ombudsman so “valuable lessons” can be learned.
It is the first time the public can search the watchdog’s website to see the range of complaints it deals with. The Ombudsman investigated 2,199 cases in 2013/14 compared to 384 the previous year.
A geographical breakdown of healthcare cases showed that the East of England had the highest number of complaints dealt with between February and March this year with a total of 15. West Midlands’ hospitals received 13 complaints, East Midlands had seven and London six. The North East and South West had the fewest complaints with just one each.
The report said that regarding Mr F’s case in Birmingham, his symptoms were not typical for his condition, which made it more difficult to diagnose. It concluded: “However, the Trust missed several chances to correctly diagnose Mr F, including taking account of his previous medical history and unusual symptoms, carrying out a chest X-ray and misreporting a scan. While we cannot say that Mr F’s death was avoidable (because his condition was very serious), it is clear that the Trust lost the chance to give him treatment that might have prevented or delayed his death.”
In another case two Trusts failed to communicate effectively when a woman suffering from bladder cancer had her wishes for surgery ignored leading the watchdog to describe the last six months of her life as “wasted just waiting”. It concluded an “unacceptable delay” had taken place as Bedford Hospital NHS Trust and Cambridge University Hospitals NHS Foundation Trust could not agree on the best course of treatment, although the Ombudsman concluded that due to Mrs C’s condition the delays did not affect her prognosis.
The Trusts paid £1,750 compensation to Mrs C’s family “for the upset and frustration they experienced as a result of the poor care given to their mother”.
The Home Office was among the Government departments criticised in the files after a teenage asylum seeker spent 10 years in the UK without legal status waiting for his case to be decided. The 17-year-old applied for permission to stay with his mother, who had fled from her home country, but was told he would need to reapply after he turned 18 and was left in administrative limbo.
Repeated requests from his MP were also ignored by the Home Office until a decade had passed. He eventually received an apology from the Home Office and £7,500 compensation for the “serious mistakes” that occurred.
Ombudsman Dame Julie Mellor said: “Our investigations highlight the devastating impact that failures in public services can have on the lives of individuals and their families. We are modernising the way we do things so we can help more people with their complaints and to help bodies in jurisdiction learn from mistakes other organisations have made to help them decide what action to improve their services.
“We will continue to work with others including consumer groups, public service regulators and Parliament, using the insight from our casework to help others make a real difference in public sector complaint handling and improve services.”
A Department of Health spokeswoman said: “Listening to patients is one of the best ways to improve standards and we welcome this increased transparency around complaints. Hospitals should make sure patients, their families and carers know how to complain - including displaying information on the complaints system in every ward.”
Other cases
A woman in her late 90s died on the toilet at home in her granddaughter’s arms after doctor discharged her without examining her abdomen. She had perforated diverticulitis. Miss T complained to East Kent Hospitals University NHS Foundation Trust and said that the Trust had failed to provide an adequate response regarding her grandmother’s death and had tried to ‘cover up’ its failings, but no evidence was found to support the claim. The Ombudsman recommended the Trust pay £500 in compensation for Miss T's distress.
Harrogate and District NHS Foundation Trust failed to spot signs of sepsis when Mr L arrived at hospital in the early hours of the morning from his care home. After being seen in A&E he was assessed as being safe for discharge back to his care home with some antibiotics, but died the following day. His wife complained to the Trust and said that if her husband had been admitted for treatment, he might have survived. The Ombudsman said because Mr L’s full diagnosis was not known, it could not say for certain whether his death was preventable. The Trust apologised and paid Mrs L compensation of £2,000.
A patient’s death from deep-vein thrombosis could have been avoided after a London GP practice failed to properly investigate her symptoms or refer her for further tests over two appointments. At both appointments the GPs who saw Mrs G failed to follow the relevant medical guidelines on investigating a possible DVT. They also failed to investigate her symptoms properly. The practice provided Mrs G’s relatives with evidence of what they had learnt from the complaint and apologised to them.
This article is courtesy of the Independent.
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