Family could receive up to £6.5 million compensation after baby was born with brain damage at Yorkshire Hospital

The trust which runs Grimsby's hospital has agreed to pay compensation which could eventually amount to £6.5 million after admitting that mistakes caused a baby to be born with brain damage.

The money was awarded to Cody Lyster-Hughes, formerly of Louth, after an eight-and-a-half year legal battle.

Cody’s mother Caroline Lyster was admitted to Diana Princess of Wales Hospital, Grimsby in April 2005 with an infection when she was seven-and-a-half months pregnant. She was treated with antibiotics and steroids but was discharged from hospital and sent home, before a pathology report was produced.

In fact tests showed that she had e-coli. By the time she was re-admitted to hospital four days later the infection had already passed to the foetus. She gave birth seven weeks premature and Cody was delivered with brain damage.

Wendy Booth, director of performance assurance across Northern Lincolnshire and Goole NHS Foundation Trust, said: “The Trust is pleased that agreement has been reached with the parents of Cody Lyster-Hughes in respect of his claim arising from the antenatal management which led to premature labour and Cody’s cerebral palsy.

“An apology has been provided and a settlement agreed which will be used to secure Cody’s future and provide him with the care and therapies he requires.

“The Trust regrets the lapse in standards which led to Cody suffering this injury and wishes Cody and his family well for the future.”

This article is courtesy of the Grimsby Telegraph.

Seven-year-old awarded £2.25m compensation over bungle in his mother's care

A seven-year-old boy who was born too early after his mother was fitted with a contraceptive device while she was pregnant has been awarded £2.25 million damages.

Cian Bowen suffered brain damage because of his birth at 29 weeks and now has cerebral palsy although his intellect is intact.

Cian, who Mr Justice Spencer described as a “very delightful little boy”, was at London’s High Court with his parents, Stephen Bowen and Tracy Ann Hughes, for the settlement of his damages action against GP Helen Claire Jenkins.

The family’s counsel, Martin Spencer QC, said that the case arose from the admitted negligence of the doctor, who fitted Ms Hughes with an intrauterine device (IUD) or coil in March 2007, when she was already 14 weeks pregnant.

Ms Hughes suffered from bleeding and, seven weeks later, realised she was in fact pregnant, which was particularly devastating as she and her partner had regarded their family as complete.

No termination was possible at that stage and the pregnancy continued until Cian, who would not have sustained damage if he had gone to term, was born prematurely.

“He is now of course a much-loved and precious member of the family”, said counsel.

If the case had not settled but continued to trial, he added, there would have been a major dispute between the medical experts as to whether the presence of the IUD was causative of the premature labour and delivery.

It had been agreed that Ms Hughes should receive £200,000 of the damages, which are funded by the Medical Defence Union, in relation to her own personal injury claim and to compensate her and Mr Bowen for their past care.

The family, who live in Carmarthenshire, intended to pay off their mortgage and take a much-needed holiday.

The judge said he was satisfied that the settlement was in Cian’s best interests and paid tribute to the devotion and loving care shown by the family.

“I can see for myself he is a very delightful little boy - very bright and cheerful despite his difficulties.

“His parents, sisters and grandparents must be very proud of him.

“This settlement will bring the family the peace of mind they have been seeking and I wish them well. There will be more challenges, I’m sure, but now they have financial security.”

This article is courtesy of Wales Online.

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.

Teen twin awarded £3.9m compensation over brain damage at birth

A twin who was left brain damaged due to complications during birth at Hemel Hempstead Hospital has been awarded a compensation package worth £3.9m after settling her case against a health trust.

Rachel Hartley and her twin brother Thomas were born prematurely at Hemel Hospital 14 years ago in 1999. Both suffered cerebral palsy as a result of being born early.

It was the twins’ case that staff at the hospital were negligent in failing to realise that their mother was in premature labour when she attended the hospital.

West Hertfordshire Hospitals NHS Trust denied liability but agreed to settle the case with each twin.

Today the Royal Courts of Justice approved an award for Rachel of approximately £3.9m, comprised of a lump sum and annual payments to be made for the remainder of her life.

The money will be held in a trust so Rachel can manage her own affairs when she is old enough.

Rachel’s award follows the award in March 2011 of a £2m lump sum to her brother Thomas in settlement of his case.

The twins, now 14 and attending Longdean School, were represented by clinical negligence specialist solicitor Sue Jarvis of BL Claims Solicitors.

Sue said: “This was a complicated case but the settlement today is an excellent one in the circumstances, where liability was never admitted.

“The twins’ family has cared for Rachel and Thomas lovingly over the years but they brought the claim because of concerns about the provision of the degree of care and attention that the twins will need for the rest of their lives.

“Each twin will require care, aids and appliances as they go through their lives and I am pleased to have helped them reach settlements that will ensure they are provided for.”

The twins’ mother attended Hemel Hempstead Hospital on October 25, 1999 complaining of stomach pains.

It was the twins’ case that staff should have spotted that she was in premature labour and given drugs to preserve the pregnancy long enough so that steroids could be given to strengthen the babies’ lungs before birth.

Both Thomas and Rachel suffered brain damage at birth, causing severe spastic quadriplegic cerebral palsy. Both need wheelchairs, have some learning difficulties and have trouble with fine motor hand movements.

It was their case that if appropriate treatment had been given then Rachel would have suffered no brain damage and most of Thomas’ damage would have been avoided.

The Trust argued that the treatment given to Mrs Hartley was reasonable and that even if they had realised she was in labour and given drugs, the twins would still have suffered disability.

In a statement, the twins’ parents said: “We’re delighted to have reached this settlement which will help secure the future for Rachel. It means we are reassured that she will be given the care she needs in the future.

“We’d like to thank Sue Jarvis of BL Claims Solicitors who has been a fantastic support to us over the 12 years since we started this case.”

This article is courtesy of the Hemel Today.

The Irish State is facing €1 billion bill for medical negligence claims

The State is facing a potential financial liability of more than €1 billion to deal with medical negligence claims in public hospitals and HSE facilities.

Official Department of Health briefing material maintains that the number of clinical claims under active management by the State Claims Agency increased from 1,792 at the end of 2012 to 3,061 at the end of 2013.

“The estimated potential liability has similarly risen over the same period from €642 million to €1,037 million.”

The documents state that increased costs are also due to the fact that the courts will not agree to structured periodic payment orders until legislation is introduced – through the Department of Justice – for this purpose.

The State Claims Agency manages the State’s clinical indemnity scheme, which provides cover in respect of clinical negligence claims occurring in public hospitals and HSE facilities around the country.

Birth-related claims

The agency meets the cost of awards and expenses and is subsequently reimbursed from the HSE budget.

While 20 per cent of claims relate to obstetrics, this area represents 55 per cent of estimated liability due to high settlement costs associated with cerebral palsy and other serious birth-related claims.

The Department of Health briefing documents, drawn up in June and seen by The Irish Times, state that independent actuarial projections for the year forecast that the cost of settling clinical indemnity claims overall in 2014 will be in the region of €200 million.

The department’s documents also suggest that the bill for dealing with clinical negligence cases will get higher in the years ahead.

“The cost of clinical indemnity scheme claims will continue to rise over the next number of years.

“This is in line with the actuarial prediction that the claims portfolio is still immature and will not reach steady state, in terms of yearly cost, for a number of years.”

This article is courtesy of the Irish Times.

QMC error sees £8m payout for Nottingham boy

A seven-year-old boy who was left with "catastrophic" brain damage after his birth will receive £8m compensation.

The youngster, who cannot walk or speak, was left with "profound lifelong" cerebral palsy after doctors at Nottingham's Queen's Medical Centre mishandled attempts to resuscitate him.

London's High Court heard there were deficiencies in the way medics dealt with the boy's birth in November 2006.

The hospital trust publicly apologised and said changes had since been made.

Mr Justice Lewis said the boy, from Nottingham, had "suffered complications" following his birth after which hospital staff "failed to provide adequate treatment for him".

He said the settlement would meet the boy's lifetime needs.

Dedication commended
 
"There were deficiencies in the way the hospital dealt with the need to resuscitate him," the judge added.

He said the hospital had "since taken steps to correct what went wrong so other families won't be faced with the same difficulties".

Lawyers representing the boy's family said he has acute learning difficulties and needs a team of carers.

The case had reached the High Court after his parents sought approval for a compensation package to be met by the hospital's managers, the Nottingham University Hospitals NHS Trust, which admitted liability.

The trust's barrister, William Wraight, publicly apologised for the errors.

"There were deficiencies in the provision of resuscitation on that day but these problems have been identified and corrected," he said.

The trust's chief executive Peter Homa added: "Whilst no amount of money can compensate for, nor undo the harm and distress the family have experienced as a result of this tragic case, we hope this settlement provides the family with financial security for the future."

Mr Justice Lewis said he was satisfied the settlement was "just and appropriate" and commended the boy's parents and family for their dedication to his care.

This article is courtesy of BBC News.

USA Military Care, a pattern of errors but not scrutiny

Jessica Zeppa, five months pregnant, the wife of a soldier, showed up four times at Reynolds Army Community Hospital here in pain, weak, barely able to swallow and fighting a fever. The last time, she declared that she was not leaving until she could get warm.

Without reviewing her file, nurses sent her home anyway, with an appointment to see an oral surgeon to extract her wisdom teeth.

Mrs. Zeppa returned the next day, in an ambulance. She was airlifted to a civilian hospital, where despite relentless efforts to save her and her baby, she suffered a miscarriage and died on Oct. 22, 2010, of complications from severe sepsis, a bodywide infection. Medical experts hired by her family said later that because she was young and otherwise healthy, she most likely would have survived had the medical staff at Reynolds properly diagnosed and treated her.

“She was 21 years old,” her mother, Shelley Amonett, said. “They let this happen. This is what I want to know: Why did they let it slip? Why?”

The hospital doesn’t know, either.

Since 2001, the Defense Department has required military hospitals to conduct safety investigations when patients unexpectedly die or suffer severe injury. The object is to expose and fix systemic errors, often in the most routine procedures, that can have disastrous consequences for the quality of care. Yet there is no evidence of such an inquiry into Mrs. Zeppa’s death.

The Zeppa case is emblematic of persistent lapses in protecting patients that emerged from an examination by The New York Times of the nation’s military hospitals, the hub of a sprawling medical network — entirely separate from the scandal-plagued veterans system — that cares for the 1.6 million active-duty service members and their families.

Internal documents obtained by The Times depict a system in which scrutiny is sporadic and avoidable errors are chronic.

As in the Zeppa case, records indicate that the mandated safety investigations often go undone: From 2011 to 2013, medical workers reported 239 unexpected deaths, but only 100 inquiries were forwarded to the Pentagon’s patient-safety center, where analysts recommend how to improve care. Cases involving permanent harm often remained unexamined as well.

At the same time, by several measures considered crucial barometers of patient safety, the military system has consistently had higher than expected rates of harm and complications in two central parts of its business — maternity care and surgery.

More than 50,000 babies are born at military hospitals each year, and they are twice as likely to be injured during delivery as newborns nationwide, the most recent statistics show. And their mothers were more likely to hemorrhage after childbirth than mothers at civilian hospitals, according to a 2012 analysis conducted for the Pentagon.

In surgery, half of the system’s 16 largest hospitals had higher than expected rates of complications over a recent 12-month period, the American College of Surgeons found last year. Four of the busiest hospitals have performed poorly on that metric year after year.

Surgical Complications
 
Half of the military’s largest hospitals performed worse than established benchmarks in categories such as infections or improperly done procedures, according to a review from the American College of Surgeons. The college compared each hospital with an expected rate of complications based on the procedures it performed and what kinds of patients it served from July 2012 to June 2013.

Little known beyond the confines of the military community, the Pentagon’s medical system has recently been pushed into the spotlight. In late May, Defense Secretary Chuck Hagel ordered a review of all military hospitals, saying he wanted to determine if they had the same problems that have shaken the veterans system.

Mr. Hagel said the review would study not just access to treatment, the focus of investigations at the veterans hospitals, but also quality of care and patient safety — issues that The Times has been looking at, and asking the Pentagon about, for months.

Defense Department health officials say their hospitals deliver treatment that is as good as or better than civilian care, while giving military doctors and nurses the experience they may one day need on the battlefield. In interviews, they described their patient-safety system as evolving but robust, even if regulations are not always followed to the letter.

“We strive to be a perfect system, but we are not a perfect system, and we know it,” said Dr. Jonathan Woodson, assistant secretary of defense for health affairs. He added, “We must learn from our mistakes and take corrective actions to prevent them from reoccurring.”

The Times’s examination, based on Pentagon studies, court records, analyses of thousands of pages of data, and interviews with current and former military health officials and workers, indicates that the military lags behind many civilian hospital systems in protecting patients from harm. The reasons, military doctors and nurses said, are rooted in a compartmentalized system of leadership, a culture of interservice secrecy and an overall failure to make patient safety a top priority.

The investigations of unforeseen deaths or permanent harm, called root-cause analyses, are widely regarded as a centerpiece of efforts to make care safer. Asked about the military’s missing inquiries, Dr. James P. Bagian, director of the University of Michigan’s Center for Healthcare Engineering and Patient Safety, said, “If in fact unexpected deaths were reported and ignored, there would appear to be no good answer for that except that someone is sleeping at the switch.”

Avoidable errors can and do occur at the best of hospitals. But the military’s reports show a steady stream of the sort of mistakes that patient-safety programs are designed to prevent.

The most common errors are strikingly prosaic — the unread file, the unheeded distress call, the doctor on one floor not talking to the doctor on another. But there are also these, sprinkled through the Pentagon’s 2011 and 2012 patient-safety reports:

A viable fetus died after a surgeon operated on the wrong part of the mother’s body.

A 41-year-old woman’s healthy thyroid gland was removed because someone else’s biopsy result had been recorded on her chart.

A 54-year-old retired officer suffered acute kidney failure and permanent hearing loss after an incorrect dose of chemotherapy.

Such treatment failures are known as “never events,” because they are potentially so grave — and so preventable. They do not happen frequently. But a persistent rate of such mistakes can indicate broader patterns of slipshod care.

Malpractice suits can also be a rough indicator of risk. From 2006 to 2010, the government paid an annual average of more than $100 million in military malpractice claims from surgical, maternity and neonatal care, records show. It would be paying far more if not for one salient reality of military health care: Active-duty service members are required to use military hospitals and clinics, but unlike the other patients, they may not sue. If they could, the Congressional Budget Office estimated in 2010, the military’s paid claims would triple.

Experience in civilian hospitals, and in the veterans system, has shown that stricter procedures and more sophisticated surveillance can limit errors, sometimes markedly. Among some in the military network, concerns about patient safety are longstanding, if rarely acknowledged in public. But calls for change have consistently foundered in the convoluted bureaucracy.

The military health system is split into three major branches, with the Army, Navy and Air Force each controlling its own hospitals and clinics. The Pentagon’s Defense Health Agency also runs the Walter Reed National Military Medical Center and Fort Belvoir Community Hospital, both outside Washington. Any systemwide change involves a carefully calibrated consensus of three equally ranked surgeons general, as well as the Defense Health Agency. Dr. Woodson, who oversees the system, cannot order the surgeons general to act. He can only recommend.

Progress can be glacial: In 2007, for example, the military started rewriting regulations for handling events that harmed or endangered patients. It finished only last October. Several former Pentagon officials said embarrassing statistics were often filtered out, glossed over or buried amid larger data sets before they reached senior health leaders. Two measures used in major civilian hospitals to monitor quality of care — rates of death and readmission, adjusted for seriousness of illness — are simply not tracked.

“The patient-safety system is broken,” Dr. Mary Lopez, a former staff officer for health policy and services under the Army surgeon general, said in an interview.

“It has no teeth,” she added. “Reports are submitted, but patient-safety offices have no authority. People rarely talk to each other. It’s ‘I have my territory, and nobody is going to encroach on my territory.’ ”

In an internal report in 2011, the Pentagon’s patient-safety analysts offered this succinct conclusion about military health care: “Harm rate — unknown.”

Lethal Medical Errors
Katie Guill checked into the hospital at Fort Leonard Wood, Mo., on Christmas morning 2008, expecting to give birth to a healthy baby boy. She left with an infant so severely brain-damaged that at age 5, he cannot crawl, speak or swallow. He must be fed through a pump.

In the three hours before a doctor finally delivered their son, Justen, by cesarean section, the Guills said in a lawsuit, a monitor sounded 32 alerts that the baby’s heart rate had slowed. The suit also said the nurse had warned the doctor on duty four times that the baby was in distress before he arrived at Mrs. Guill’s bedside. The family’s lawyer, Laurie Higginbotham, said she believed the outcome might have been different had the nurse alerted the doctor’s superiors.

The government settled the case for $10 million, but Pentagon records give no indication that a safety investigation was conducted. Nor is there a record of any action taken against the doctors and nurses involved. A spokeswoman said the Defense Department was legally prohibited from discussing how any specific case had been handled.

“We don’t know what went wrong because no one has ever told us,” said Justen’s father, Jon Guill, a former Army mechanic who served 18 months in Iraq.

The Pentagon had promised to look harder at such mistakes.

In 1999, the Institute of Medicine estimated that medical errors killed between 44,000 and 98,000 patients at hospitals nationwide every year. Those numbers — which most experts now consider an undercount — stunned the medical community and kick-started an aggressive effort to protect patients from accidental harm.

Simply penalizing doctors and nurses for malpractice had failed, the institute concluded, because most mistakes arose from weak procedures, not reckless individuals. It called for new strategies, including mandating that medical workers report mistakes and hospitals investigate and correct the lapses that allowed them to occur.

The Pentagon embraced the report, requiring that military treatment facilities produce a written root-cause analysis within 45 days in all cases of unexpected serious injury or death. “Such events are called ‘sentinel’ because they signal the need for immediate investigation and response,” the regulations state. Military hospitals must also report sentinel events to the Joint Commission, an independent accreditation group. Specialists at the Pentagon’s patient-safety center, created in 2001, were told to review the analyses and recommend changes.

Certainly it is difficult to assess such a divided and diverse medical system, with 56 hospitals, domestic and overseas, ranging from the flagship, Walter Reed, to a hospital in the middle of the Mojave Desert with an average of three inpatients a day. They serve not only young, typically healthy active-duty families but also the longest-serving military retirees and their families. Even so, experts say safety reviews can reveal trouble spots as well as patterns of error across an entire system.

But annual patient-safety reports and other internal documents obtained by The Times show that, for years, the center’s analysts have often found themselves staring into darkness.

As early as 2003, a Pentagon audit noted that medical workers had reported 80 cases of severe harm or death in the preceding 12 months, but that only 32 root-cause analyses had been forwarded to the center. Five years later, another audit concluded, “Unfortunately, R.C.A.s are used relatively infrequently.”

The most recent safety reports paint a similar — and more detailed — picture.

In 2011, 50 unexpected deaths were identified but only 25 analyses submitted.

The next year, the center was informed of 110 deaths but received only 44 root-cause analyses.

And in 2013, the report documented 79 deaths and 31 root-cause analyses.

The safety audits also make clear that of the root-cause analyses that are done, the cases of clearest-cut blame — the “never events” — make up the largest group. Even so, the reports show, those mistakes have not subsided.

In 2010, the safety center had sounded a hopeful note. For the first time in nine years, it said, “all surgeries and procedures were performed on the right person.” But the next year, the center said surgeons were still performing the wrong procedure or operating on the wrong patient or part of the body at an “alarming” rate. It called for intensive hospital audits to lower it.

Last year, medical workers reported virtually the same number of errors. They also reported more cases in which medical devices were inadvertently left inside patients than they had four years earlier.

In a written response to questions from The Times, the Pentagon acknowledged that it had taken a decade before the reporting system was “operational and collecting data in a uniform manner.” Not until last October, for instance, were the Army, Navy and Air Force required to identify the facilities where patients were severely harmed or died.

Senior defense health officials say the missing investigations are not a true measure of attention paid to serious harm. “There are many mechanisms for reviewing significant adverse events,” the Pentagon said in a statement.

In an interview, Dr. Woodson said a different kind of inquiry that hospitals conduct — a risk-management investigation — might have gotten to the bottom of what went wrong. Those investigations focus on whether individual doctors or nurses provided substandard care for which the government could be liable.

“I feel confident that we capture and investigate the overwhelming majority of these adverse events,” Dr. Woodson said. “The key is having a robust system and that you pick all of them up and make the changes that are appropriate.”

But military regulations specifically require both types of inquiries, and for good reason, patient-safety experts say: Otherwise, even catastrophic errors — mistakes for which no one is specifically to blame, but that instead result from systemic lapses — can be easily swept under the rug.

Busy but Troubled Hospital

Womack Army Medical Center in Fort Bragg, N.C., is one of the system’s largest, busiest hospitals. Lately it has also been one of its more troubled.

For three years, it has had a higher-than-average rate of surgical complications, and in March it suspended all elective surgery for two days after inspectors found problems with surgical infection controls. Then last month, the Army ousted the hospital’s leadership after the unexpected deaths of two patients in their 20s: a mother of three who had undergone a low-risk surgical procedure and a soldier who had been sent home from the emergency room.

That same day, Defense Secretary Hagel ordered the systemwide review.

At Womack and elsewhere, some doctors and nurses complain that no one listens to their safety warnings. One staff member interviewed by The Times recalled filing roughly 50 reports of safety problems since 2007, each time providing contact information. Only once, the worker said, did a supervisor respond, and then only to express irritation at the fusillade of filings.

“It is an exercise in futility,” said the staff member, speaking on condition of anonymity for fear of job repercussions. “We can jump up and down and shake our fists, but nothing changes.”

Dr. Lopez, the former Army staff officer, said some hospital officials had told her that they felt pressure from superiors to focus on budget cutting and efficiency, while patient safety got a cursory nod.

Across the system, Pentagon officials cite some signs of progress. In 2008, for instance, the composite rate of 11 types of harm — like pressure ulcers and postoperative hemorrhages — was more than twice that of civilian hospitals with a similar patient mix. Last year, it was better than the civilian average, although the Pentagon’s own analysts warned results might be skewed by reporting problems.

Even so, the most recent patient-safety report complained of a general lack of headway in building a safer system. While the number of reports of harm has varied over the last decade, and “there are certainly pockets of excellence,” it noted, “The leading trends remain consistent.” What was needed was “enterprisewide change.”

The operating room has been one focus of concern.

The study by the American College of Surgeons found that in addition to Womack, three other major hospitals — Madigan Army Medical Center in Tacoma, Wash.; San Antonio Military Medical Center in Texas; and Portsmouth Naval Hospital in Virginia — have had high rates of surgical complications for two or three years in a row. Five of the eight cited last year had also been flagged repeatedly for high rates of infection related to surgery.

Dr. Brian Lein, the Army’s deputy surgeon general, said hospitals that fell below the benchmark “have dug deep into the data to find the actual issues and are addressing those issues.” The Navy echoed that response.

With so many young military families, the system’s maternity wards are among its busiest. Pentagon officials say maternity care is top notch, and on some leading measures of safe childbirth, the military hospitals indeed compare well with their civilian counterparts.

For example, their rate of infant mortality was equal to or lower than that of civilian hospitals in the most recent data analyzed by the National Perinatal Information Center, a private group with a Pentagon contract. In routine vaginal births, the rate of injury to the mother has consistently been below the national average.

On other measures, though, the military system lags.

In 40 percent of the military hospitals, mothers were significantly more likely to suffer hemorrhages after birth than at the civilian hospitals tracked by the perinatal center. The hemorrhages can lead to hysterectomies or even death. About 2,500 cases were recorded in military hospitals in 2012, roughly 760 more than if the military had met the civilian benchmark.

If doctors used instruments such as forceps to assist the delivery, mothers in military hospitals were about 15 percent more likely to be injured than mothers nationally, the most recent data shows.

One of the broadest measures of safe childbirth is the rate of injuries to babies, ranging from cerebral hemorrhages to small cuts on babies’ scalps. From 2009 to 2011, according to a Times analysis, the rate at military hospitals was twice the national average.

In 2011, nearly five in every 1,000 babies born at military hospitals suffered some kind of birth trauma. Had the military met the national average, 107 newborns would have been injured instead of 239.

Dr. Woodson said the military is looking “closely at areas where we are falling short” on maternity care and measuring its hospitals against civilian ones in order to improve.

Ordeal Giving Birth

When Stephanie King felt labor pains on Easter in 2004, she drove to Reynolds Army Community Hospital. She was 34, a kindergarten teacher and mother of two. Her husband, an Army artillery officer, was serving six months in Iraq, so her 12-year-old son accompanied her to the hospital.

Her contractions were coming every three to five minutes, court records show, but a resident on the maternity ward refused to admit her, saying her cervix was not sufficiently dilated. The attending physician agreed.

Mrs. King spent the next two hours in the hospital’s first-floor lobby, waiting room, cafeteria and bathroom. She wanted to seek care at the civilian hospital 15 minutes away, but her military insurance would not cover it. In the midst of her ordeal, her husband called from Baghdad to say he was being airlifted to Germany after an emergency appendectomy.

Finally, fearful that she would deliver on the bathroom floor, she took the elevator back to maternity. A nurse greeted her with what seemed to be a joke: " ‘Oh, Mrs. King, you are back,’ ” she recalled the nurse saying. " ‘You don’t look as good as you did when you first came in.’ ”

Any amusement vanished, however, when staff members realized not only that Mrs. King was about to give birth — but that her file showed she carried a common but symptomless strain of group B streptococcus bacteria. Women in labor must be given antibiotics at least an hour before delivering to avoid transmitting the infection to their newborns, hospital workers later testified.

Dawson King was born just 42 minutes after his mother was admitted. Doctors soon determined that he had contracted an infection, and warned Mrs. King that the only effective medication could cause deafness. Four months later, when Dawson did not turn his head when his parents walked into the room, it became clear that he was profoundly deaf.

Only three years later, after Mrs. King filed a malpractice claim, was the case discussed at Reynolds, court records indicate. The attending physician said a risk-management meeting was held to ensure that the standard of care was met. No report was written, and the doctors and the nurse emerged with spotless licenses.

That result that would appear to point to a lapse in hospital procedures. But both the resident and the nurse testified that they had never attended a meeting at Reynolds to discuss what had gone wrong.

“That’s the disturbing part,” Mrs. King said, while Dawson draped himself over the arm of his father’s chair, looking at photos of himself as a 1-year-old, his head swathed in bandages from surgery for cochlear implants. “Doesn’t the hospital want to know what happened?”

Mrs. King believes that she knows: Her file documented her history of strep B infection and the fact that her second child had been born after a 90-minute labor. And the resident testified that he could not recall if he had read her record before declining to admit her. “It boils down to they did not even read my records,” Mrs. King said.

The government settled the Kings’ case in 2009 for $300,000. Mrs. King describes her son, now an engaging, soccer-playing 10-year-old, as “a success story.” Still, she said, “it was devastating how easily it could have been prevented.”

The Kings’ malpractice payout was relatively modest. An examination of court records and Pentagon data from Reynolds and seven other hospitals turned up dozens of settlements, ranging from $30,000 to $10 million, but no record of a root-cause analysis.

Flying Blind on Safety

On Dec. 7, 2011, Dr. Woodson summoned senior health officials to a Pentagon conference room to discuss the safety of military hospitals and clinics. The deputy surgeons general of the Army, Navy and Air Force were present. So was Dr. Ronald Wyatt, then the director of the Pentagon’s patient-safety center.

According to accounts from several people familiar with the session, Dr. Wyatt suggested that the center was flying blind. Without knowing the facilities’ death and harm rates, as well as the rates of paid malpractice claims, he argued, his staff was unable to identify safety lapses — much less correct them.

And serious lapses did exist, he said, for “this system, like many systems throughout the country, hurts and kills people every day.” Angered, Dr. Richard A. Stone, then the Army’s deputy surgeon general, shot back: “I demand that you retract those statements.”

Dr. Warren Lockette, the deputy assistant secretary for clinical policy, stood by Dr. Wyatt. “What I am hearing is you are all satisfied with the status quo,” he said. Dr. Woodson tried to defuse the tension with a compromise: He would recommend that the services turn over the data.

Asked about the meeting, Dr. Stone said that data should be shared but that Dr. Wyatt’s statement was “inflammatory.”

The standoff was typical, former Defense Department officials say, of a continual tug-of-war between health care officials in the Pentagon and in the individual armed services that has crippled efforts to improve patient safety. In such a politicized system, data can be a weapon.

“Why should the Army safety system want to play with D.O.D., because then I have less control over my data, less control over my kingdom, and potentially D.O.D. is going to tell me what to do?” said Dr. Lopez, the former Army health policy officer.

To keep Pentagon overseers at bay, surgeons general have often relied on a provision in a 1986 law, known as 1102, that prohibits disclosure of medical quality assurance records. Originally adopted to ensure that medical personnel could be honestly evaluated without fear of publicity, former department officials say, it became a tool to withhold a broad range of data from the Pentagon itself.

And from the public. In response to Freedom of Information Act requests, the Pentagon provided The Times with thousands of pages of data. But much information was redacted and some reports were withheld as confidential, including all reports by the Navy’s inspector general on patient safety or quality of care. By contrast, the veterans system posts the reports on a public website.

While infighting held the military’s patient-safety programs in check, some civilian hospital systems cut death and harm rates. At Ascension Health and Kaiser Permanente, two of the nation’s biggest nonprofit systems, investigating workers’ reports was just a first step. The companies also analyze a vast array of data, including readmission and mortality rates.

The death rate is a broad measure that cannot pinpoint where care falls short. Nonetheless, “mortality is the mother of all outcomes,” said Ascension’s chief medical officer, Dr. Ziad Haydar. Measured over time, a death rate, adjusted for seriousness of illness, can show if a medical system is getting more or less safe.

Officials at Ascension and Kaiser say their hospitals have gotten safer. Ascension estimates that its safety measures have saved 1,500 lives in the last six years. Doug Bonacum, Kaiser’s vice president for quality, safety and resource management, said the mortality rate at Kaiser’s 38 hospitals had fallen more than 30 percent in the last four years.

The Pentagon does not routinely track the total number of deaths, and has no method yet to calculate adjusted rates. “Frankly it is not yet a helpful measure for assessing quality,” Dr. Woodson said.

As a result, why some military hospitals report many more deaths than others with similar numbers of patients is a mystery. The Army, Navy and Air Force each said that hospitals with above-average death rates treated older, sicker patients, but did not produce statistical evidence to verify that.

When it comes to gauging the frequency of errors, systems like the military’s that rely on workers to report harm have been shown invariably to undercount. Kaiser has long used another technique, called the Global Trigger Tool, that winnows out indicators of poor care from randomly selected patient files.

Using that technique, researchers concluded in 2010 that one-third of patients at three major civilian hospitals had suffered some kind of harm. A similar pilot study by the Pentagon last year found that nearly half the patients whose files were reviewed at a major military hospital had been harmed at least once. The study suggested 99 percent of harm at that hospital was not reported by medical workers.

Communiation Breakdowns

When patients die unexpectedly, medical workers often cite a breakdown in communications.

That appears to be the overriding explanation for the delay three and a half years ago in treating Jessica Zeppa, a case that ended with a $1.25 million malpractice settlement. But that is only conjecture. Her death was apparently never subjected to a patient-safety examination.

Mrs. Zeppa had been married and living at Fort Sill for only nine months when her husband, James, an air defense tactician, was deployed to the United Arab Emirates. She had their two dogs and a cat for company. And to her delight, she was pregnant. “She was just out of this world about it,” said her mother, Mrs. Amonett.

But five months into the pregnancy, Mrs. Zeppa became so weak that she struggled to climb stairs. She complained that it hurt to drink or swallow.

At Reynolds Army Community Hospital, she was initially treated in the obstetrics and gynecology unit, where an ear infection was diagnosed and she was prescribed antibiotics and ear drops, court records show. Three days later, she arrived at the emergency room at 4:51 a.m.; she was prescribed a painkiller for erupting wisdom teeth.

She returned that same evening and was found to have a fever, a fast pulse and an elevated white blood cell count — possible symptoms of serious infection. The emergency room physician, Dr. Raul Young-Rodriguez, treated her intravenously with fluids and a powerful antibiotic and sent her upstairs to the obstetrics and gynecology unit for possible admission.

No one called the obstetrician on duty to inform her of the patient’s condition, the Zeppas’ lawyers, Heather Mitchell and Steven Clark, said in court papers. Nor did the obstetrician, Dr. Debra A. Carson, call Dr. Young-Rodriguez.

As far as she knew, Dr. Carson later testified, Mrs. Zeppa was there for “obstetrical clearance.” She examined her and sent her home within 20 minutes. Mrs. Amonett said she protested but was told her daughter could not be admitted if the fetus was not in distress.

Dr. Carson testified that she had not checked the military’s electronic record system for Mrs. Zeppa’s history, because all too often she had found patient records missing. In Mrs. Zeppa’s case, lab results were posted less than an hour after she left. Had she seen them, Dr. Carson testified, “I would more than likely have admitted her.”

Two days later, Mrs. Zeppa returned to the obstetrics and gynecology unit, insisting that she would not leave until she got warm. A nurse midwife, Kelly West, treated her with intravenous fluids and again released her. Ms. West testified that she did not review Mrs. Zeppa’s records either.

The next afternoon, with Mrs. Zeppa struggling to breathe, her mother summoned an ambulance. Mrs. Zeppa was airlifted the following morning to a civilian hospital in Oklahoma City, where she miscarried 10 days later and died the next month.

Five months after that, facing a malpractice claim, Reynolds officials conducted a risk-management investigation. In an interview, Ms. West, the nurse, said she had been cleared of violating the standard of care. Nor is there any public indication that the two doctors were penalized. They did not respond to requests for comment.

Medical experts hired by the family’s lawyers said that had the Fort Sill doctors recognized that Mrs. Zeppa was suffering from septic shock and immediately hospitalized and aggressively treated her, she and the baby probably would have survived. The government’s experts disagreed, noting that civilian doctors had been unable to save Mrs. Zeppa in five weeks of treatment.

Justice Department lawyers called Mrs. Zeppa’s death a “unique and tragic case, but not a case of bad and actionable medicine.” Beyond the risk-management assessment, they said, they knew of no other inquiry. Ms. West also said she knew of none in the roughly eight months before she left Fort Sill.

That left any missteps that contributed to Mrs. Zeppa’s death unexplained.

“She was really pretty, and she had a really big heart,” James Zeppa, Mrs. Zeppa’s husband, said. Now, he said, he no longer trusts military medicine.

Mrs. Zeppa’s father, Mike Amonett, had one thing to say about the Fort Sill hospital: “I just want that place shut down.”

This article is courtesy of The New York Times.

Brain injured girl, 11, wins right to compensation payout

Millie Bowers will never lead a fully independent life due to brain injuries blamed on mistakes by medics at Guildford's Royal Surrey County Hospital.

An 11-year-old girl, stricken by "catastrophic" brain injuries blamed on mistakes by medics at the Royal Surrey County Hospital, has won the right to a compensation pay-out in London's High Court.

Millie Bowers cannot walk unaided and will never lead a fully independent life due to a brain fever that developed in the months after her birth in September 2002.

Although a ‘sparky and animated’ youngster, she has lifelong learning difficulties, Mrs Justice Carr told the court on Wednesday June 25.

Millie was born prematurely while her parents were on holiday in Turkey in autumn 2002, and she developed a meningitis-like infection in the weeks after her delivery.

The family lived in Surrey at the time, and she was rushed to the Royal Surrey when just 25 days old, her QC, James Badenoch, told the court, and seemed to be making ‘satisfactory’ progress after being given antibiotics.

However, the barrister claimed medical staff at the hospital negligently failed to refer her for specialist neurological treatment to deal with a dangerous build-up of fluid within her brain.

By the time she was referred to London’s Kings College Hospital for surgery in December 2002 it was too late to save her from brain damage, it was claimed.

Millie – who is suing through her father Andrew Bowers – claimed damages from the Royal Surrey County Hospital NHS Foundation Trust, which admitted negligence.

Mrs Justice Carr said the trust had made an ‘early admission of breach of duty’ in failing to refer Millie to a specialist unit by late November 2002.

She said the issue of precisely what caused Millie's permanent disabilities remained ‘very much in issue,’ since lawyers for the NHS Trust insisted that her injuries were all but irreversible by late November.

Mr Badenoch acknowledged that, had the case gone to trial, Millie would have faced substantial ‘litigation risks’.

However, he described the process of referring Millie to specialists as ‘frankly shambolic’.

Michael De Navarro QC, for the trust, said the referral delay may have been due to fault on the part of other hospitals.

Mr Badenoch told the judge both sides had finally been able to hammer out a settlement which eliminated the need for a contested trial from which Millie could have come away with nothing.

The trust agreed to compensate the youngster on the basis of 75% of the full value of her claim.

Approving the deal, Mrs Justice Carr paid tribute to Millie and her parents’ ‘selfless devotion’ over the years.

The amount of Millie’s compensation will be assessed at a later date. Even after a 25% deduction, her award is likely to run well into seven figures in order to pay the lifetime of care and assistance she will need.

“The assessment of damages can hopefully be completed as soon as possible to bring some finality to this case,” said Justice Carr.

This article is courtesy of Get Surrey.

Boy, 7, awarded £8 million compensation package after care "deficiencies"

A seven-year-old boy stricken by catastrophic brain damage after his birth at Queen’s Medical Centre has won an £8 million compensation package - plus a public apology for the "deficiencies" in his care.

The boy, who cannot walk or speak, was left with profound lifelong cerebral palsy after medics mishandled desperate attempts to resuscitate him following his delivery at the hospital in November 2006, London's High Court heard.

Mr Justice Lewis, who approved a settlement designed to meet all the youngster's lifetime needs, said he had "suffered complications" following his birth, after which hospital staff "failed to provide adequate treatment for him".

"There were deficiencies in the way the hospital dealt with the need to resuscitate him", said the judge, who added that the hospital has "since taken steps to correct what went wrong so that other families won't be faced with the same difficulties".

The boy, from Nottingham, is able to smile and respond to his large family - whose devoted care was today praised by the judge.

But he also needs a team of carers to get him through the day and has acute learning difficulties, his lawyers disclosed after the short hearing.

The case reached the High Court as his parents sought the judge's approval for a compensation package to be met by the hospital's managers, the Nottingham University Hospitals NHS Trust, which admitted liability.

The lad's mum was in court to hear the NHS Trust's barrister, William Wraight, publicly apologise for the post natal blunders.

"There were deficiencies in the provision of resuscitation on that day but these problems have been identified and corrected," said Mr Wraight.

Mr Justice Lewis approved a settlement which takes the form of a £3.25 million lump sum, plus annual, index-linked and tax-free payments to cover the enormous costs of his care for life.

Those payments will start at £146,500-a-year, rising to £230,000 beyond the age of 19. Lawyers estimate the total settlement will be worth between £8 million and £9 million over the boy's lifetime.

Mr Justice Lewis said he was satisfied the settlement was "just and appropriate", also commending the boy's parents and family, saying: "He is really lucky to have a family like this. I wish them all well."

Nottingham University Hospitals NHS Trust has apologised to the family.

Chief executive Peter Homa, said: “We reiterate our sincere and unreserved apologies to the family.

“Whilst no amount of money can compensate for nor undo the harm and distress the family have experienced as a result of this tragic case, we hope this settlement provides the family with financial security for the future.”

This article is courtesy of the Nottingham Post.

Parents of brain damaged woman tell of lifelong struggle to care for daughter and why they blame 'forgotten Thalidomide' pill for her condition

Parents of brain damaged woman tell of lifelong struggle to care for daughter and why they blame 'forgotten Thalidomide' pill for her condition

Rose and Bobby Stallard were thrilled when their longed-for daughter Elizabeth was born after a normal pregnancy and uncomplicated, natural home delivery.

The couple already had two boys and baby Elizabeth was another blessing in their family.

But just months later they were told their daughter had brain damage. Then their lives changed forever.

Now they have spoken about their lifelong struggle to care for their daughter, who they believe was damaged by a commonly prescribed pill known as the “forgotten Thalidomide”.

It was prescribed to pregnant women in the 1960s and 1970s.

Now Rose and Bobby, of Chapelhall, Lanarkshire – along with numerous other families who claim the pill caused miscarriages and birth defects – are relaunching a fight to get compensation for their daughter, who is now 44 years old.

But most of all they want answers as to why they were given a drug that was removed from the market in 1978 after 1.5million pregnant women in the UK had taken it.

Rose, 67, was given Primodos, an oral hormone test, which was used to determine if women were pregnant.

She said: “I was told to take one Primodos tablet in the morning and one at night.

“The doctor said if I didn’t bleed then I was pregnant but I did and it wasn’t until I went back weeks later that it turned out I really was having a baby.

“My pregnancy with Elizabeth went without a hitch.

“She was delivered at home in June 1970 without any drugs and my husband Bobby and I were happy to have our little bundle.”

But Rose, also mum to George, 48, William, 47, and Bobby, 41, said that within the first year they noticed Elizabeth was not progressing at the same rate as her niece of the same age.

She said: “I went to the doctor who examined her, then sent us to Yorkhill where a doctor flatly told me, ‘Your daughter is brain damaged’. Bobby and I were in pieces. We didn’t know what to do. Something had happened to our child and no one could tell me what, when or why.”

For years Rose felt she had nowhere to turn until she read the plight of another mother in the Daily Record in the late 1970s who, like her, had taken Primodos and had a child with disabilities.

And Rose believed Elizabeth could have been damaged by the drug, too.

As she looked into it, she found women across the UK who took the drug had given birth to babies with missing limbs, problems with their organs and other birth defects. The couple then got in touch with the Association For Children Damaged By Hormone Pregnancy Testing.

Rose said: “There were people who have been born without limbs, some deformed, women who had miscarried – the list was just endless.

“But what we all had in common was that we had taken the Primodos drug during pregnancy with no warnings.”

Primodos was used by GPs to determine whether a woman was pregnant until 1978.

Rose only took Primodos when she was expecting Elizabeth.

Bobby, 68, said: “Elizabeth was a beautiful little girl and, with two boys by that point, we were so excited to have a daughter. Instead, she has been so badly affected she cannot feed, bathe or dress herself.

“I’ll never be able to walk my little girl down the aisle, she will never have a family of her own and, as we get older, we worry about who will care for her when we are not here to look after her.

“We trusted in the National Health Service. I’d like to know why this drug was ever given the go-ahead.”

The couple are also waiting for Elizabeth, who was diagnosed by doctors at Yorkhill sick children’s hospital in Glasgow as having brain damage, to have a brain scan – something she’s never been offered.

Rose said: “I understand that handing out brain scan appointments wasn’t the norm 40 years ago but we are still asking for one now.

“But no matter how we ask, the doctors have not as yet, in four decades, given her a brain scan. We feel like they’ve already written her off.”

In 1982, a group action against Schering Chemicals, the pharmaceutical company that produced Primodos, was shelved.

But the recent discovery of documents at the National Archives in London has prompted victims to demand a government investigation and a review of a legal action that failed more than 30 years ago.

It has now emerged that 26 studies from 1960 onwards suggested the drug may have caused miscarriages and birth defects, yet it remained on the market.

Campaigners are now pushing for a public inquiry and compensation for victims.

Rose added: “I hope that it is proved the drug was responsible for what happened to all these children.

“I hope that finally gives families like ours some relief that someone has owned up for what they have done to our lives.”

Marie Lyon, chairperson of the Association For Children Damaged By Hormone Pregnancy Testing, said: “Our aim is to finally obtain the facts hidden in sealed files to prove the negligence of the Committee On Safety Of Medicines. An all-party parliamentary group are holding a meeting today in the House of Commons, after delivering a petition to Downing Street.

“Our determination to obtain the truth about the failure of the Committee On Safety Of Medicines is unshakeable.”

A spokesperson for Bayer, which acquired Schering in 2006, said: “Bayer denies Primodos was responsible for causing any deformities in children.

“UK litigation in respect of Primodos against Schering ended in 1982 when the claimants’ legal team, with the approval of the court, decided to discontinue the litigation on the grounds that there was no realistic possibility of showing that Primodos caused the congenital abnormalities alleged.

“Since the discontinuation of the legal action in 1982, no new scientific knowledge has been produced that would call into question the validity of the previous assessment.”

A spokesperson for NHS Lanarkshire said: “While we cannot discuss the details of individual cases due to patient confidentiality, we are fully aware of this family’s situation and are continuing to work with them to reach a satisfactory conclusion.

“Any decision to refer a patient for any further investigation is based on a range of factors, which take into consideration the patient’s overall condition.

“We would urge the family to contact our patient affairs department directly.”

This article is courtesy of the Daily Record.

Maternity services under pressure

A case in which I advised the parents of a four-day old baby who died in 2012 after being deprived of oxygen has recently been in the news as the family has only just received a five-figure settlement and an apology from Warwick Hospital. An inquest, held in June 2013, heard how failings in Daniel’s care during labour had led to his death. These included three different midwives failing to read his mother’s antenatal notes which would have revealed her as a medium risk patient; one of the midwives having a history of making mistakes; and a failure by staff to monitor the foetal heart properly.
 
The testimony of Sarah Kunigiskis, mother of baby Daniel, makes harrowing reading. In addition to the grief of losing her baby was the refusal of the hospital to admit they were at fault while implying that there was something wrong with the baby before delivery. As she noted, the refusal of the hospital to acknowledge that a catastrophic error had occurred, made an awful situation far worse. One of the reasons Sarah was willing to speak out was to help put pressure on hospitals and NHS Trusts to be more accountable for their actions when mistakes are made by encouraging others in 
similar situations to challenge the experts if they feel things are not right.
 
NAO report into maternity services in England
 
The situation endured by the Kunigiskis family is not unfamiliar to medical negligence solicitors. Obstetrics is a particularly challenging area of medicine where there is, on the one hand, a desire not to medicalise a perfectly natural event but, on the other, a need to step in as soon as things start going wrong. A report released by the National Audit Office in November 2013 highlighted that some of the problems faced by maternity services in England were reflected in the fact that a third of the NHS litigation budget was absorbed by medical negligence cases relating to birth complications. In 2012 there were almost 700,000 live births, the highest rate for 40 years, putting considerable pressure on resources. There has also been a noticeable increase in the number of ‘high risk’ births including multiple births, women over 40 and women with obesity or pre-existing medical conditions. Although mortality rates have improved, the NAO report noted that there were ‘wide, unexplained variations in the performance of individual trusts in relation to complication rates and medical intervention rates, even after adjustment for maternal characteristics and clinical risk factors’.
 
Need to improve safety
 
The number of maternity-related medical negligence claims increased by 80% in the five years to 2012-13 resulting in a litigation bill for maternity claims alone amounting to £482m in 2012-13. This figure represents about a fifth of all spending on maternity services which is a sobering fact by anyone’s standards. The NAO report flagged a number of areas which might help to explain why medical negligence claims were so high: more than half the obstetric units in England did not have the number of consultants on site as recommended by the Royal College of Obstetricians and Gynaecologists; and midwife staffing levels fell below that recommended by a national benchmark of 29.5 births per midwife. In order to achieve this ratio, another 2,300 midwives would need to be recruited although even this would be further complicated by the fact that a large number of midwives were reaching retirement age and a growing proportion of student midwives were failing to complete their courses.
 
More cooperation, better data
 
Although, sadly, the Kunigiskis case is, by no means, an isolated incident, and despite the upward pressure on maternity services generally across the country, most women do have positive experiences of giving birth in a NHS hospital. However, there is clearly scope for major improvement, not least in order to reduce the phenomenal amount being paid out in medical negligence claims. Among the NAO recommendations is a call for more and better data on maternity services in order to track trends, outcomes and experiences; and clinical commissioning groups should look at how services are delivered in their area and look to cooperate with neighbouring trusts to ensure all available resources are used efficiently. Last but not least, hospitals need to own up to mistakes at the outset and endeavour to give the families a full an explanation of what went wrong. It is the very least they can do and might even help to reduce the number of claims made against them.
 
This article is courtesy of Jeanette Whyman, a solicitor who specialises in securing NHS compensation for people who have experienced medical negligence and poor treatment.

The family of a baby who died after hospital failings has won a five-figure pay-out

Daniel Kunigiskis died aged just four days after errors made at Warwick Hospital during the baby’s delivery in October 2012.

An inquest in June 2013 heard how Daniel suffered a lack of oxygen at birth, resulting in a severe brain injury. Following legal action, the family has now received a five-figure settlement and apology.

Speaking out for the first time about the case, mum Sarah, who lives in Warwick with her husband Tyron, said: “The death of Daniel has been so traumatic and that pain has been increased by the hospital taking such a long time to admit they were in the wrong.

“The hospital initially tried to imply that there was something wrong with the baby before delivery and would not admit they were at fault. During the labour I had a feeling things were going wrong, because I had given birth before, and I was saying ‘he’s not coming out, he’s not coming out’ and they were saying ‘oh no you are fine’.”

The inquest heard how three different midwives failed to read Sarah’s antenatal notes which would have revealed her as a medium risk patient, one of the midwives having a history of making mistakes and a failure by staff to monitor the foetal heartbeat properly.

Daniel was transferred from Warwick Hospital to Coventry’s University Hospital but sadly died on October 13. A consultant obstetrician indicated that if he had been aware of problems during Daniel’s birth he could have ensured delivery 45 minutes earlier – which would have meant Daniel would have survived.

“You put your faith in them getting it right and then they make these kind of catastrophic mistakes,” added Sarah.

“It’s then made worse when they won’t admit to it.

“By speaking out now about what happened to Daniel, I hope it can help to put pressure on hospitals and NHS Trusts to be more accountable for their actions when mistakes are made. I hope it also raises awareness to individual patients to feel more confident in following their instincts in questioning the process when they believe that things are not right.

“It’s difficult to feel comfortable in making that challenge but I hope my case gives people the strength and courage to challenge those decisions.”

Sarah’s feelings of anger bubbled to the surface recently when her mum was admitted to the ward opposite the maternity ward at Warwick Hospital and was nervous about the care she would receive.

“Thankfully she received fantastic care and even the aftercare was excellent,” added Sarah.
Jeanette Whyman, Sarah’s solicitor and part of Leamington solicitors Wright Hassall’s clinical negligence team, said: “One of the most alarming and frustrating aspects of Sarah’s case was the length of time it took the hospital to admit their mistakes.

“The hospital refused to admit for a long time that the delay in delivery had resulted ultimately in Daniel’s death.

“They admitted there were issues with the birth but they didn’t say that had caused the terrible injuries Daniel suffered.

“There was a total refusal to admit to their negligence.’’

Helen Lancaster, director of nursing said: “At the inquest the Trust accepted that mistakes were made during the delivery of Daniel Kunigiskis, which we sincerely regret. I apologised to the family at the inquest. On behalf of the Trust I would like to apologise again and offer my condolences to Daniel’s family.”

Pregnant woman died after 'delay by trainee medics’

A pregnant woman bled to death after trainee paramedics waited 40 minutes to take her to hospital, an inquest has heard.

Trudy Glenister, 38, told family she feared she was “losing the baby” after suffering vomiting and abdominal pains in April 2011.

An inquest at Chelmsford Coroner’s Court heard how trainee paramedics waited 40 minutes before leaving for Southend Hospital and refused to use emergency sirens.

Mrs Glenister, who was five weeks pregnant, went into cardiac arrest after suffering internal bleeding due to a suspected ectopic pregnancy. She was pronounced dead shortly after arriving at the hospital.

Mark Elms, an ambulance trainee, told the court he and a student colleague had arrived at the home in Great Wakering, Essex, at 7.29pm on April 11, 2011, and began making observations at 7.35pm.

Observations continued until 8.09pm, before they set off without emergency lights or sirens, as Mr Elms claimed that he feared using them might “increase the patient’s anxiety”. The court heard that, following the 15-minute journey, the crew queued up behind other ambulances, unaware of the emergency at hand. Mr Elms admitted that he had been training for only a year and his knowledge of ectopic pregnancies was restricted to two brief paragraphs in training manuals.

He claimed he had followed his training by carrying out two sets of observations before taking the patient to hospital.

A post mortem examination revealed Mrs Glenister had four to five litres of blood in her abdominal area in what pathologist Dr Ian Caulder described as an “acute medical surgical emergency”.

The foetus in her Fallopian tube had ruptured her ovarian artery, causing heavy internal bleeding.

Roger Wicks, a solicitor, who represented Mrs Glenister’s family, called on the coroner, Caroline Beasley-Murray, to record medical negligence as a factor in her death. He said the trainee’s actions amounted to “gross failings in the provision of basic care”. The inquest was adjourned ahead of summing up next week.

Dave Hill, representing the ambulance trust, said the incident had not been investigated and no procedures had been changed since Mrs Glenister’s death.

The hearing was adjourned until next week.

This article is courtesy from The Telegraph.

Wokingham schoolboy wins six-figure compensation payout after hospital blunders left him deaf

A schoolboy who was left deaf because of sub-standard care he received in hospital as a baby has won a six-figure compensation payout from the NHS.

Raphael Hemmings, six, of Wokingham, developed a permanent hearing disability after Royal Berkshire Hospital failed to probe and adequately treat the jaundice he suffered shortly after his birth in May 2007.

Through his father, Raphael launched a claim for damages against Royal Berkshire NHS Foundation Trust, which later admitted liability for his injuries.

On Monday, a judge at London’s High Court approved a compensation settlement worth hundreds of thousands of pounds, which will pay for equipment and educational support to help Raphael “maximise his potential”.

Raphael’s lawyers claimed that medics failed to investigate a bilirubin build-up in his system days after his delivery.

The problem was so serious it left Raphael with permanently damaged hearing.

The trust admitted liability for Raphael’s debilitating condition and agreed to pay him a damages package his lawyers say will allow his family to “look ahead and rest assured that his future needs will be met”.

Judge Stephen Oliver-Jones QC approved the settlement because Raphael is too young to agree it himself.

Shaheen Rahman, representing the NHS, said: “The trust acknowledges the care Raphael received was not of the standard he was entitled to expect.

“I would like to express my sincere apologies, on behalf of the trust, to Raphael and his family.

“We are very pleased a settlement has been reached and we would like to offer Raphael and his family all our best wishes for the future.”

Judge Oliver-Jones said that, despite Raphael’s disability, he has done “very well indeed” at school and that he is in the “top percentage in his year”.

He added: “I have no doubt that with the determination and care he has, he will be able to cope and manage his disability.

“And with the assistance which can be provided in his educational years, he will come out of it, hopefully, with a good career ahead of him.”

Judge Oliver-Jones also paid tribute to the support Raphael has received from his family, telling his father, who was in court: “Money represents inadequate recompense but it is the only way the court can deal with it.”

The judge said he was “perfectly willing and able to approve the settlement”, describing it as a “reasonable” package to secure Raphael’s future.

Speaking after the hearing, Raphael’s solicitor, Leena Savjani, of Irwin Mitchell, said: “The settlement will ensure Raphael has access to the best possible support and that his disability does not prevent him from maximising his potential.”

Ms Savjani said the payout will provide Raphael with “audiological equipment and educational provision” to help him add to his already-impressive achievements at school.

She added: “We hope lessons have been learned by the trust to prevent any other babies from suffering unnecessary disabilities that have a significant impact on their lives.”

This article is courtesy from Get Reading.

Southend Hospital apologises to Tracy Godwin after her baby was left to die in her arms

A mum whose premature baby boy died less than an hour after he was born says she can finally move on after an inquest found Southend Hospital had failed to give her proper care.

Coroner Caroline Beasley- Murray highlighted four lapses in care when Tracy Godwin gave birth to her son Tomat 22 weeks and two days into her pregnancy on March 6, 2010.

The baby lived for 46 minutes before dying in his mother’s arms with no hospital staff present attempted to resuscitate him or comfort her.

The hospital’s policy of not resuscitating babies born before 23 weeks had not been explained to Miss Godwin.

She has received an unreserved apology from the hospital which has fully accepted its failings and put in place new guidelines and training to ensure it never happens again.

An inquest at Chelmsford Coroners Court found Southend Hospital failed in its provision of care on four grounds: ! Delays in providing an obstetric review when Miss Godwin was admitted to hospital.

She was not reviewed by a consultant until the next day.

! Inadequate counselling despite the death of her baby in extremely traumatic circumstances.

! Poor communication. Miss Godwin was not told what the hospital’s policywas for babies born so prematurely, so she was unaware Tom would not be resuscitated or what would happen when he was born.

Miss Godwin, who received undisclosed damages from the hospital in January, welcomed the findings of the inquest and the apology from the hospital.! The absence of a paediatrician to explain to Miss Godwin before the birth the baby would not be resuscitated and what would happen. The paediatrician should also have been present after the birth.

She said: “I am ecstatic with the results. They have said sorry and the inquest is over.

That is a milestone from which I can move, but it doesn’t bring Tom back.

“It has been an incredibly difficult four years since the death of my baby, Tom, in horrendous circumstances.

“I have finally received an apology and the coroner has found the trust failed in its care of me and my baby. This means a lot to me, for what I went through, but also to Tom’s memory.”

Above all, Miss Godwin said she welcomed the implementation the new procedures, dding: “This ordeal has brought about change at the hospital and the fact no other mother will go through what I went through is a positive that I will cherish.

“There are now new policies and guidelines in place, known by all maternity staff and which I have had an assurance will be followed at all times.”

New guidelines introduced for premature births after incident

Southend Hospital has new guidelines telling staff what to do in such cases.

The hospital also carries out annual training, so staff are aware of the procedures that must be followed.

In addition, it is making the guidelines available for all staff to access at all times, and providing bereavement counselling training to a large number of midwives, so there is always someone on duty who is able to provide it.

Sue Hardy chief nurse said: “We again offer our sincere condolences to Miss Godwin on the loss of her baby and are truly sorry her experience of care did not meet the high standard we strive to provide.

“We have carried out a great deal of work to improve our policy for babies born under 24 weeks old and have increased the level of training and awareness among staff of how to better support families.”

Johanne Turner, clinical negligence partner at BTMK Solicitors in Southend, who
acted for Ms Godwin, said: “This was one of the worst cases of clinical negligence arising out of maternity care I have ever worked on.

“Four years on from the tragic death of Tracy’s baby I am absolutely delighted she has received an admittance of fault and an apology.”

Mother left without help or comfort

Tracy Godwin experienced a normal pregnancy with a due date of July 8, 2010.

On March 4, however, when she was 22 weeks pregnant, she experienced severe abdominal pain and was devastated to be told she was in labour.

She suffered three days of excruciating pain and contractions in hospital and, when told her baby was unlikely to survive being born at 23 weeks, told staff they should do everything possible to keep it alive.

Tom was eventually born after a midwife forcibly broke her waters. He weighed only one pound and had difficulty breathing, but no consultant came to assist.

Tracy asked for help and asked why there was no incubator in the room, but medical staff refused to take the child to the baby care unit and he died in her arms 46 minutes later.

After six weeks, Tracy was told resuscitating her baby was against hospital policy.

Following her ordeal, she has since given birth to daughter Isla at a different hospital. Isla was also premature, born at 24 weeks, but is a healthy girl.

This article is courtesy from Southend Standard.

Liverpool Women's Hospital - we need more money for delivering babies

Merseyside's specialist women's hospital is warning they will be forced to make cuts or go into the red because they are not getting enough money for each baby they deliver.

Chief executive of Liverpool Women’s Hospital, Kathryn Thomson, backed by their board of directors, claimed the maternity tariff – the money paid to them by the NHS for the work they do – is too low.

And they said if it is not increased soon it could start to have a detrimental effect on patient care. She said so far they had managed to balance the books without any negative effect.

But she said, if the situation was not resolved, as they juggle having to make the cost savings demanded by government, it will force them into the red or cause them to make cuts.

Mrs Thomson said safe staffing was their priority and the trust’s board of directors was not prepared to cut into that at all.

But, without action to address the issue, she said it may result in the loss of other services which enhance the experience of women during pregnancy, childbirth and the early days of motherhood – like breast feeding support in the community.

Mrs Thomson said all hospitals providing maternity services experience the same shortfall in funding. However, as Liverpool Women’s is the largest single site maternity unit in the UK, they feel the impact of this more than other trusts who can offset the shortfall with surpluses gained from other specialities.

The hospital is leading a collective of hospitals nationally in lobbying the Department of Health (DoH) for extra funding.

It is also in talks with local commissioners about the problem. Mrs Thomson said: "If you take a normal delivery, we will get paid around £1,400

“£700 of that will automatically go on insurance because maternity services are high risk and can result in high medical negligence claims.

“Over the last four years we have reduced our costs by £22m by becoming more efficient . As we go forward, unless the maternity tariff changes, it's going to be increasingly difficult to maintain our position with respect to staffing levels. And we as a board are not prepared to compromise on staffing levels.

“We have done as much as we can do to keep staffing at reasonable levels and have managed so far to subsidise the NHS services through our private patient income But it's not sustainable long term and because of that we are in conversation with commissioners."

Problems with the maternity tariff were highlighted by Parliament’s Public Accounts Committee earlier this year. The PAC is recommending the Government takes another look at the maternity tariff to see if it is set at the right level.

A spokeswoman for local commissioners of maternity services Liverpool Clinical Commissioning Group said: “We want Liverpool patients to receive the very best care from all parts of the NHS, including maternity services. We're currently working with those organisations who provide care locally and other commissioners to develop plans for the next five years.

“This will focus on making sure that services are both high quality and financially sustainable for the future."

A DoH spokesperson said: "The Department and NHS England are currently considering the recommendations set out in the PAC's report on maternity services in England. The Government will publish its response in April."

This article is courtesy from The Liverpool Echo.

Lincolnshire hospitals paid out £7m last year for birthing negligence

Lincolnshire hospitals paid out more than £7.2 million last year in obstetrics and maternity compensation relating to medical negligence.

The figure has been obtained by The Lincolnite through a Freedom of Information (FOI) request to United Lincolnshire Hospitals Trust (ULHT).

Between January 1 and December 31, 2013, ULHT spent a total of £7,225,000 in relation to four cases.

The sum is paid out by the NHS Litigation Authority, and includes resolution to a case which originated several years ago.

Throughout the year, two of the four cases were made public through the courts.

One boy was awarded one of the highest settlements in NHS history after his birth at Lincoln County Hospital.

Aaron Crosby (9) from Lincoln was awarded £10 million in compensation, with a £3.25 million immediate payout, after his mother was given an overdose of a contraction stimulant, starving the baby of oxygen.

Aaron was left with brain damage, athetoid cerebral palsy and epilepsy.

He is wheelchair bound, cannot talk and cannot use any of his limbs. He requires 24-hour care.

ULHT admitted liability for the case and apologised to Aaron and his family.

The second reported case involved a teenage boy from Lincoln who suffered severe brain damage during his birth at Lincoln County Hospital. He was awarded an upfront sum of £2.65 million.

The boy, who was not named for legal reasons, suffered severe cerebral palsy due to being starved of oxygen while being born in the 1990s.

ULHT denied liability for the boy’s delivery, stating midwives worked “diligently”, but agreed to the multi-million settlement.

Compensation for the two other cases, which have not been disclosed, amounts to more than £1.3 million.

Addressing standards

Between April 2004 and October 2013, ULHT dealt with 162 clinical negligence claims in the obstetrics and maternity department.

The Trust said that it has received a recent uplift of 10 new midwives and that there are no current vacancies.

Across Lincolnshire, the birth to midwife ratio now stands at 1:28 – a figure just below the recognised benchmark of one midwife to 29.5 births.

A ULHT spokesperson said: “Our maternity and obstetrics departments follow National Institute for Health and Care Excellence guidelines and have measures in place to manage clinical risks.

“As well as the new birthing pool at Lincoln County Hospital and the recruitment of additional midwives, we are in the process of developing an antenatal day care setting to reduce length of stay for antenatal patients, and we regularly review any incidents and share lessons learned.

“The Lincoln County Hospital is one of few units in the East Midlands that provide a 60 hour consultant presence on the labour ward.

“This is a national standard recommended by the Royal College of Obstetricians and Gynaecologists. This ensures that a senior obstetrician is physically present during peak times of activity on the labour ward.

“The hospital has been providing a 7-day consultant presence even before it became a national requirement.

“Practices and guidelines regularly change, and we always ensure our practices are in line with national guidance,” the ULHT statement added.

This article is courtesy from The Lincolnite.

The hospital blunders that allowed a new mother to die

Rosida Etwaree loved being a mother, so when she became pregnant again in late 2009 — this time with twins — she was excited and looking forward to holding her new babies for the first time. Tragically, she never got the chance.

Mrs Etwaree died shortly after giving birth to two girls, Nabilah and Nuha, when a caesarean section she underwent at a south London hospital went disastrously wrong.

She was one of five mothers to die in childbirth at the Mayday Hospital, now called Croydon University Hospital, in 2010 — a victim of a catalogue of errors by medical staff.

In a further tragedy, Nabilah died of a heart condition just before her second birthday.

Now Mrs Etwaree’s widower, Ahamud, left looking after the couple’s five children, wants those responsible for his wife’s death to face the consequences.

“Rosida was a wonderful, devoted mother who loved her kids so much,” Mr Etwaree told The Telegraph. “Now I want to make sure whoever was responsible for her death is brought to justice, because I would never want anyone to suffer the way me and my family have done.”

Last week, he received an undisclosed sum in compensation after Croydon Health Services NHS Trust admitted liability for a series of failings in its treatment of Mrs Etwaree.

The Crown Prosecution Service is examining evidence, to consider manslaughter charges against the trust.

The other women who died shortly after giving birth at the Mayday in 2010 included Malgorzata Doniec, who suffered fatal bleeding on the brain, just weeks after giving birth. An inquest heard there were failings in her care, including missed opportunities to save her life.

Following the deaths, the hospital was put on a warning by the health regulator, the Care Quality Commission.

Speaking in detail for the first time about his wife’s case, Mr Etwaree said: “To be honest, when Rosida died, it seemed like a terrible tragedy at first. It was only when the police got in contact in January to say they were investigating possible manslaughter that I realised how serious it really was. Now I want to know exactly what happened.

“I want to be told the truth, because for all this time I’ve been kept in the dark.”

Mrs Etwaree, 45, had gone into hospital on June 23 2010, and had the twins following a caesarean section recommended by her consultant, both because of a heart condition in one of the babies and because Mrs Etwaree had raised blood pressure.

The babies were shown to her before being taken away for cleaning and monitoring.

“She was happy and she smiled to them, but she was too weak to hold them,” said Mr Etwaree, 42.

“I started to get worried. Other mums were being transferred out of the recovery room before Rosida, and she’d been in there longer.

“After three or four hours, she still wasn’t looking at all well, and by 6pm she was looking really distressed and in pain. She just wasn’t being monitored properly.

“I begged the doctors and nurses to help her, but they made me feel that I was panicking over nothing and that they had everything under control with the blood transfusions they had given her.”

At 7pm, Mrs Etwaree suffered the first of two cardiac arrests. Staff resuscitated her after the first, but the second, a short time later, was fatal.

“I just sat there in shock,” said Mr Etwaree. “It didn’t seem real. My first thought was how was I going to raise the children without their mother.

“Then, when I was led in to see her body and I hugged and kissed her, her forehead was cold. That was the moment I really knew she was gone.”

A post mortem examination found that the cardiac arrests had been triggered by prolonged and severe internal bleeding after the caesarean.

Mrs Etwaree’s case shocked even legal professionals familiar with cases of medical negligence.

Evidence commissioned by Mr Etwaree’s solicitors found that hospital staff:

Þ Failed accurately to record the extent of Mrs Etwaree’s loss of blood in the operating theatre or to adequately monitor her following surgery;

Þ Did not provide regular blood transfusions or identify the severity of her condition and return her to theatre for further investigations

Þ Failed to provide appropriate supervision and guidance to junior staff during and after the caesarean section.

In January, John Goulston, the chief executive of Croydon Health Services NHS Trust, wrote to Mr Etwaree to apologise and admitted that the death was “avoidable”.

Mr Etwaree described his wife as “the most devoted wife and mother possible”.

The couple, both from Mauritius, met in London in 1991, and married three years later.

“She always loved children,” said Mr Etwaree, speaking at the family’s home, barely half a mile from Croydon University Hospital.

The couple’s first child, Nadeem, born in 1995, is studying plumbing at college. He was followed by Nadia, now 16, Nadir, 12, and Nadil, 9.

“Rosida loved being a mum. She loved taking the children out, she loved dressing the girls up, she loved cooking for all of them. I wasn’t allowed near the kitchen,” said Mr Etwaree.

He used to have two jobs but now has been forced to give up work to devote himself to caring for the children.

“The last four years have been hard,” he admitted. “I’ve had to learn to cook, with the help of Rosida’s friends.

“There’d be times I’d only sleep a couple of hours a night before getting up again to prepare everyone for school. I had no option. I’ve had to step in for the children and learn to be both a mother and a father to them.

“The settlement money will help. But it won’t replace my children’s mum.”

This article is courtesy from The Telegraph.