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Never Events are "serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations".

Between April 2021 and March 2022, there were nearly eight of these events every week - up from the seven-per-week seen the previous year, according to figures analysed by the PA news agency.

Among the 407 events, there were 98 cases of a foreign object being left inside a patient by mistake - vaginal swabs were left in patients 32 times and surgical swabs were left 21 times.

Other items included a pair of wire cutters, part of a scalpel blade, and the bolt from surgical forceps.

There were three occasions when part of a drill bit was left inside a patient.

One woman had her ovaries removed by mistake

Also, there were 171 cases of surgery being done on the wrong body parts - one woman had her ovaries removed by mistake, six patients had injections to the wrong eye.

The wrong hip implant was done 12 times, a wrong knee implant was done 11 times, and patients were connected to air instead of oxygen 13 times.

Seven people received the wrong blood type in a transfusion and one patient had a breast procedure they had not consented to.

A further 29 cases fell under the "serious incidents" category and are being investigated, so may yet be re-classified as "never events".

Manchester University NHS Foundation Trust reported 11 errors; Nottingham University Hospitals NHS Trust and Sandwell and West Birmingham University Hospitals NHS Trust both reported 10; Gloucestershire Hospitals NHS Foundation Trust, Liverpool University Hospitals NHS Foundation Trust and University Hospitals of Leicester NHS Trust, and Worcestershire Acute Hospitals NHS Trust, all reported nine.

An NHS spokesperson said: "While these events are extremely rare, and NHS staff are working hard to provide safe care to patients, it is important that events are reported and learned from so that they can be prevented in the future."

A Department of Health and Social Care spokesperson said: "Patient safety is a top priority for the government and these unfortunate events - although very rare - can have a serious physical and psychological impact on patients.

"We are implementing the NHS Patient Safety Strategy which is designed to support staff to provide safe care and learn lessons.

"There are record numbers of nurses, doctors and overall staff working in the NHS, and we have set out our plan to tackle the COVID backlog, backed by record investment."

Wire cutters and drill bits among the items left inside NHS patients

"Never events" is the name given to things so serious that they should never happen - but in the NHS in England, there were 407 of them in a year.

18 May 2022

The House of Commons Health and Social Care Select Committee has published the report of its inquiry into NHS litigation reform. The Medical Defence Union (MDU) engaged closely with this inquiry, submitting written evidence.

The MDU welcomes the publication of today’s report but cautioned against too much focus on fundamental and complex structural change, at the expense of reforms which could be implemented with greater speed.

Dr Matthew Lee, MDU chief executive said:

“The cost of clinical negligence is unsustainable.  At a time when the NHS needs those funds more than ever, to recover from the Covid-19 pandemic, reform can no longer be delayed.

“The MDU has long championed a number of changes that would go some way to addressing the problem. It is heartening to see the attention parliamentarians are paying to this important issue.

“Something we have been calling for repeatedly, is the repeal of Section 2(4) of the Law Reform (Personal Injuries) Act 1948. This outdated law requires the courts to disregard the existence of NHS care when determining compensation awards. This provision should have been repealed decades ago, and we are pleased to see the Committee agrees with us and is recommending the government repeals it without further delay.

“We have considerable reservations about the central recommendation of the Committee. The proposal to remove the need to prove clinical negligence following an adverse event in the NHS, and instead establish an administrative body to determine whether the harm was avoidable – would represent a seismic change from the current legal position.

“The Committee’s report rightly notes that designing a scheme of this nature and establishing the criteria would be a complex task and we have significant concerns about the affordability of such a scheme. Nevertheless, we would welcome the opportunity to input on, and scrutinise, any such proposals.

“The time to address the cost of clinical negligence is now. We urge the government and Parliament to maintain a focus on reforms that we know could be delivered at pace, rather than being absorbed on the immensely complex task of designing a new scheme from scratch.

“We call on the government to publish its long-promised proposals on tort reform without further delay. These should include reforms to how compensation awards are calculated, caps on the level of damages awarded for future care, and damages for loss of earnings being brought down to proportionate levels.”

Deliver achievable clinical negligence reform without delay, says MDU

The House of Commons Health and Social Care Select Committee has published the report of its inquiry into NHS litigation reform. The Medical Defence Union (MDU) engaged closely with this inquiry, submitting written evidence.

27 Apr 2022

In a wide-ranging Report on NHS litigation reform, the Health and Social Care Committee finds the current system for compensating injured patients in England ‘not fit for purpose’ and urges a radically different system to be adopted.

The full report can be read here: https://publications.parliament.uk/pa/cm5802/cmselect/cmhealth/740/report.html

Reforms would introduce an administrative scheme which would establish entitlement to compensation on the basis that correct procedures were not followed and the system failed to perform rather than clinical negligence which relies on proving individual fault. The new system would prioritise learning from mistakes and would reduce costs.

Currently, litigation offers the only route by which those harmed can access compensation. MPs say in addition to being grossly expensive and adversarial, the existing system encourages individual blame instead of collective learning.

MPs also call for the scrapping of the expected future earnings link in claims for those under 18, a system that leads to ‘manifest unfairness’ with the child of a cleaner receiving less compensation than the child of a banker.

Chair's comment
Jeremy Hunt, Chair of the Health and Social Care Committee, said:

“The system of compensating patients for negligence in the NHS is long overdue for reform. We’re urging the Government to adopt our recommendations to reduce both the number of tragedies and the soaring costs to the NHS.

“It is unsustainable for the NHS in England to pay out more than £2 billion in negligence payments every year – a sum equal to the cost of running four hospitals – a figure that will double in 10 years if left unchecked.

“Under the current system, patients have to fight for compensation, often a bitter, slow and stressful experience with a quarter of the enormous taxpayer-funded sums ending up in the pockets of lawyers.

“We need a better system that learns from mistakes, following the lead of countries like New Zealand and Sweden. We must move away from a culture of blame to one that puts the prevention of future harms at its core.”

MPs urge radical reforms to negligence compensation system that costs NHS billions each year

The Government should remove the need to prove clinical negligence from NHS compensation claims when things go wrong in a radical overhaul of a system which last year paid out £2.17 billion, say MPs.

27 Apr 2022

The House of Commons health and social care committee suggested that an ‘administrative system’ should replace litigation when patients come to harm in the NHS.

During the inquiry the committee heard from GPs that facing a clinical negligence claim is ‘hugely stressful for the accused health care professional’ and ’emotional damage often contributes to healthcare professionals leaving the profession’.

The committee argued that the advantage of a no-blame administrative system would be that ‘criteria can be established to remove uncertainty and turn what otherwise would be an adversarial process into one concerned only with the facts of the case’.

‘Compensation should be based on agreement that correct procedures were not followed and the system failed to perform, rather than the higher threshold that there has been clinical negligence by a hospital or clinician,’ it added.

Admitting that this ‘widens the pool of people entitled to compensation’, the committee noted that ‘the evidence from countries that have adopted such an approach is that overall costs will be lower not higher’.

The committee said there is ‘strong evidence that an administrative compensation scheme would provide better value for money to the taxpayer than clinical negligence litigation’, with ‘significant potential to strip away the vast legal costs which account for over a quarter of all that is paid’ by the NHS for clinical negligence cases.

To further reduce costs, the committee also recommended that the outdated system of assuming any follow-up care for patients that have come to harm would be paid for privately should be abolished.

It argued that ‘allowing NHS care to be included in the calculation of damages and basing calculations of loss of earnings on the national average wage would help to moderate the value of awards’.

Last year, clinical negligence litigation cost the NHS £2.17bn – up from £900m 10 years ago. This is ‘set to double over the next decade to £4.6bn’ with ‘around a quarter of such costs’ going ‘not to families but to lawyers’, the report added.

Key recommendations

*An injured patient or their family should be able to approach an independent administrative body to investigate their case, decide if in the ordinary course of events the harm was avoidable, and determine eligibility for compensation.
*The new independent administrative body should initially be focused on cases related to birth injury which, typically, are the most expensive, have high levels of patient need and take years to resolve.
Once it has become embedded, the new patient compensation system should be expanded to cover all claims made against the NHS by injured patients.
*Assessment of future earnings based on parental income should be scrapped for all NHS-related clinical negligence claims involving children under 18 years of age.
*Compensation should be based on the additional costs necessary to top up care available through the NHS and social care system rather than the current assumption that all care will be provided privately.
The committee concluded: ‘The system for compensating injured patients in England is not fit for purpose. It is grossly expensive, adversarial, and promotes individual blame instead of collective learning.

‘We recommend that when a patient is harmed, they or their family should be able to approach an independent administrative body which would investigate their case and determine whether the harm was caused by the care they received and if, in the ordinary course of events, it was avoidable.

‘The investigation would be inquisitorial, it would look at the facts of the case, and it would focus on how all parts of the system delivered care to the patient in question. Should it be found that the patient suffered harm because of their care, they would receive compensation.’

Commenting on the report, health and social care committee chair Jeremy Hunt said: ‘The system of compensating patients for negligence in the NHS is long overdue for reform. We’re urging the Government to adopt our recommendations to reduce both the number of tragedies and the soaring costs to the NHS.’

He added: ‘We need a better system that learns from mistakes, following the lead of countries like New Zealand and Sweden. We must move away from a culture of blame to one that puts the prevention of future harms at its core.’

However the the GP indemnity provider the MDU said it has ‘considerable reservations about the central recommendation’ from the report.

MDU chief executive Dr Matthew said: ‘The proposal to remove the need to prove clinical negligence following an adverse event in the NHS, and instead establish an administrative body to determine whether the harm was avoidable – would represent a seismic change from the current legal position.

‘The Committee’s report rightly notes that designing a scheme of this nature and establishing the criteria would be a complex task and we have significant concerns about the affordability of such a scheme. Nevertheless, we would welcome the opportunity to input on, and scrutinise, any such proposals.’

Stressing that the ‘time to address the cost of clinical negligence is now’, he added: ‘We urge the Government and Parliament to maintain a focus on reforms that we know could be delivered at pace, rather than being absorbed on the immensely complex task of designing a new scheme from scratch.’

Medical Protection Society (MPS) medical director Dr Rob Hendry welcomed the report, adding that ‘we need reforms to make legal costs more proportionate, and make things more fair and transparent which will in turn reduce soaring costs’.

‘The Government committed to publishing a proper strategy on clinical negligence in 2018 and while there have been more pressing priorities, we cannot lose sight of this. We need commitment to some bold and swift steps if we are going to get close to addressing this issue.’

Last year, NHS Resolution estimated that Covid-related clinical negligence claims alone will amount to £885m, £44m which could relate to general practice.

Influential MPs want no-blame investigations to replace clinical negligence lawsuits

The UK should abolish the system of having to prove clinical negligence for harmed patients to receive financial compensation, a committee of influential MPs has recommended.

27 Apr 2022

The Association of Personal Injury Lawyers (APIL) and other groups representing the legal profession used the now-closed consultation on the proposed fixed costs cap for “lower value” clinical negligence claims and a new streamlined system to argue for significant changes. 

The UK government proposed a new cap “to ensure legal costs for lower value clinical negligence cases are proportionate and fair” earlier this year, claiming that such a system will save £500 million for the NHS.

The proposed cap will apply to “lower value” clinical negligence claims valued up to and including £25,000 in England and Wales.

A new streamlined process to ensure claims are processed more quickly, ensuring faster resolution and reducing the need to go to court, was also proposed.

In response to the consultation, APIL called the proposed changes “unfair and inconsistent”.

Suzanne Trask, executive committee member at APIL, continued: “Protected parties are excluded from other low value schemes, such as for road traffic collisions and workplace injuries, because of the complexity of their cases. Additional work is required to help people without the capacity to manage their own claims and it is extremely difficult to anticipate the amount of extra time and work required.”  

“And cases where patients have died at the hands of the NHS certainly need more time and greater sensitivity than is afforded by this scheme.”

APIL also criticised the proposed limits on costs available to pay for representation for injured patients under the new system, and the ethos behind the changes.

Trask said: “In the main, a streamlined two track approach to clinical negligence cases with a value of up to £25,000 has merit. But the costs have been proposed by the defendants, in a breathtaking display of self-interest, putting unfair restrictions on patients, bereaved families, and their representatives. The proposed fees need to be looked at again, urgently.”  

She added: “In its obsession with the financial cost of clinical negligence to the NHS, the government repeatedly fails to recognise that the NHS’s negligence is the reason why patients must claim compensation for their injuries. Yet again, any effort to tackle that problem is conspicuously absent from this consultation.” 

The Chartered Institute of Legal Executives (CILEX) said in its response to the consultation that introducing fixed recoverable costs for clinical negligence claims valued up to £25,000 will imperil access to justice by limiting victims’ ability to achieve the redress they deserve.

CILEX chair Professor Chris Bones said: “Whilst we recognise progress has been made since the initial consultation on fixed costs almost five years ago, concerns over access to justice and the ability to of victims to gain redress still remain.”

“Faster resolution for claimants is something we all wish to see but this cannot come at the expense of the ability to make that claim in the first place. As it stands the scheme risks drastically shrinking the pool of lawyers available to take on such work, limiting the ability of victims to seek redress and removing the opportunity for the NHS to learns valuable care lessons as a result.”

The Association of Costs Lawyers (ACL), meanwhile, argued that the proposed new process, which aims to speed up how these claims are handled, should be introduced on its own without fixed recoverable costs (FRC) “to enable a full and proper analysis to take place as to efficacy of this proposal and to also consider the potential costs savings”. 

It said: “The ACL believes that this will achieve the intended objectives as set out in the consultation whilst avoiding the implementation of a FRC scheme. The ACL considers that a FRC scheme is wholly inadequate when applied to clinical negligence claims due to the significant negative impact it will have on the access and administration of justice and certainly with claims involving vulnerable and protected parties.”

A survey of its members found most believed costs would fall through implementing a new process: “There are concerns that FRC are never suitable for clinical negligence matters given how different each claim can be and the unique investigations that need to be conducted. An overwhelming majority of respondents considered that the FRC proposed are not fit for purpose.”

Kris Kilsby, the ACL council member who headed up the working party that drafted the response, said: “Though we recognise that the government wants to reduce what the NHS spends on clinical negligence claims, this debate boils down to what is right for the injured person. These claims may be relatively low value, but they are not low impact and negligence victims need to be able to seek justice.”

“Fixed recoverable costs are a very blunt instrument that may work in areas where the course of claims is relatively predictable—such as road traffic accidents—but not in a much more complex area like clinical negligence.”  

“Our members are experienced and knowledgeable about costs and are able to greatly assist the court to ensure that costs in such cases are kept to reasonable and proportionate amounts. Introducing FRC will remove this level of check and balance and could lead to unjust results in respect of costs recovery which could ultimately lead to an impact on access to justice.”

Legal profession reacts to proposed fixed costs cap for clinical negligence claims

Fixed cost proposals for Clinical Negligence

25 Apr 2022

Maria Caulfield MP, under-secretary of state for patient safety and primary care, told an evidence session of the health and social care select committee in February that rising legal costs were to blame for the increasing burden of litigation on the NHS.  However last week Caulfield wrote to the committee to retract her comment that legal costs were ‘the significant piece of why they are rising’. In fact, the minister conceded later, claimant costs have levelled out for the past five years - and in fact fell in 2020/21.

‘Although rising legal costs have been an important driver of costs over the last 15 years, the main driver has for the last few years been rising compensation payments,’ said Caulfield.

The mistake may seem minor, but provides an insight into government thinking on claimant costs. Consultation has begun on imposing fixed recoverable costs for cases worth less than £25,000, and ministers may come under pressure to address the issue further when the health committee publishes its report on the future of NHS litigation.

Claimant representatives have urged the government not to be blindsided by the fact that claimant costs are higher than defence costs, saying the comparison is irrelevant because it will always cost more to discharge the burden of proof.

In written evidence submitted to the committee on fixed costs, the Society of Clinical Injury Lawyers said the government’s plan was a ‘flawed approach’ and disproportionately affects poorer injured patients.

The SCIL submission said: ‘Wealthier clients can afford to ‘top up’ inadequate levels of fixed costs. The consultation is wrong to say it has no impact upon damages – clients will have to pay the shortfall in their costs, versus the fixed costs proposed, from their damages and so will end up with less.’

A straw poll of SCIL members found 70% of firms would be forced to withdraw from working in the field if the government’s proposals were to be introduced.

The Association of Personal Injury Lawyers accused the government, effectively the defendant in most clinical negligence cases, of a ‘breathtaking display of self-interest, putting unfair restrictions on patients, bereaved families and their representatives’.

APIL executive committee member Suzanne Trask added: ‘In its obsession with the financial cost of clinical negligence to the NHS, the government repeatedly fails to recognise that the NHS’s negligence is the reason why patients must claim compensation for their injuries. Yet again, any effort to tackle that problem is conspicuously absent from this consultation.’

Minister apologises for misleading parliament on negligence costs

A health minister has had to apologise after twice misleading MPs about the biggest driver of rising clinical negligence cost

24 Apr 2022

The parents of a baby who died two days after being born have questioned whether staffing issues contributed to their son's death, an inquest heard.

Cassian Curry died at Sheffield Teaching Hospitals' Jessop Wing neo-natal unit in April 2021.
Cassian was born at 28 weeks and weighed 1lb 10oz (750g).

His parents said they had several concerns about his treatment, including reports the unit was understaffed due to it being the Easter weekend.

The inquest at Sheffield's Medico Legal Centre heard Cassian died on 5 April 2021.

The previous month the Trust's maternity services had been rated inadequate by the Care Quality Commission (CQC), though the neo-natal unit was not part of the inspection.

In a statement Karolina Curry said she and her husband, James, had concerns following reports the unit was short staffed and that medics failed to act on her concerns, including about her son's raised heart rate. "We still can't get our heads around any of this and how a bank holiday means your child dies," she said. We cannot understand why they can't have life-saving checks or the right number of staff because of a bank holiday."

Following his birth on 3 April, Cassian was placed on total parental nutrition, a routine step for premature babies, which was delivered by an umbilical venous catheter. The inquest will examine whether the catheter was incorrectly sited too close to Cassian's heart and if there was a failure to review its position and move it.

Mrs Curry said she twice noted that her son's heart rate increased to more than 200 beats per minute but was told by medical staff that it was nothing to worry about. She said she also worried that Cassian had not produced any bowel movements and this was a sign that he was not feeding properly.

In the statement read by assistant coroner Abigail Combes, Mrs Curry she said the "whole process" from her son's birth to his death "seemed chaotic".

A CQC inspection of maternity services found the it did not have enough midwifery staff with the "right qualifications, skills, training and experience".

Ms Combes said the findings will be referred to in the inquest but stressed that the two inquiries had different remits.

UPDATE PUBLISHED BY THE SHEFFIELD STAR NEWSPAPER

'Small but strong' Cassian was born in Sheffield Teaching Hospitals' Jessop Wing maternity unit on April 3 last year at 28 weeks, weighing 1lb 10oz.

An inquest last week heard how Cassian deteriorated rapidly on April 5 and died from a cardiac tamponade, which is when fluid builds up in the space around the heart, eventually preventing it from pumping. The coroner then ruled that hospital failings and 'neglect' contributed to the death of the baby boy.

The hearing was also told how an umbilical venous catheter inserted into Cassian's abdomen to help him feed was in a ‘suboptimal’ position near his heart when it was inserted by two junior doctors.

Neonatal consultant Dr Elizabeth Pilling told the inquest she had intended to have it re-positioned within 24 hours, but waited because of the dangers of repeatedly handling a baby as premature as Cassian. Dr Pilling said she had no explanation as to why she then forgot to make sure his feeding line was moved.

Giving her conclusion, Ms Combes said the decision to pause the procedure and reassess it in 24 hours was ‘reasonable and appropriate’, but was ‘not adequately recorded and communicated’ in Cassian's notes, or on the ward round. The plan should have been recorded on Cassian's ‘pink sheet’, she said, and communicated to his parents. Ms Combes said this amounted to a ‘gross failure’ in Cassian's care, which contributed to his death. She added: "But for this incident, Cassian would not have died of what he died of, when he died."

The coroner recorded a narrative conclusion, which said Cassian's death was ‘contributed to by neglect’.

In a statement at the start of the hearing, Cassian's mother, Karolina Curry, said she and her husband James had a number of questions about her son's treatment, including reports that the unit was understaffed due to it being the Easter weekend. But Ms Combes concluded: "There were no systemic failures in the form of staffing issues which caused or contributed to Cassian's death." She said the staffing levels were above the national requirement that weekend, and although there were a number of junior staff present, they were ‘appropriately qualified and able to support the unit adequately’.

The medical director of Sheffield Teaching Hospitals NHS Foundation Trust, Dr Jennifer Hill, has said the trust is ‘so very sorry for what happened’ to Cassian, admitting there was ‘human error in terms of the management of Cassian's umbilical venous catheter’. Following the inquest, Dr Hill said there had been a full review, changes had already been made and it would take on board any further recommendations from the coroner.

She said: "This was a very rare incident to have happened and everyone involved in his care is devastated.
"There has been a full review of what happened, and changes have already been made to limit the chances of this happening again including additional consultant support at weekends and ongoing improvements to the documentation used. "We will also be taking on board any further recommendations from the coroner and ensuring we respond with appropriate actions."

Mr and Mrs Curry have said Cassian was ‘a miracle for us’ when they found out he was on his way after six cycles of IVF. Following the conclusion, the boy's parents said: "Cassian was a beacon of light and our hearts blossomed under his pure and innocent love. He was everything that we dreamed of. Today, the coroner concluded that he died because of neglect, and had it not been for the gross failings of those in charge of his care, he would still be with us today. Cassian was a true miracle, and we will love and miss him forever."

Fay Marshall, a solicitor at Switalskis Solicitors, who represented the family at the inquest, said: “While the trust has made changes in the last year the coroner did not think they went far enough, and she will be issuing a prevention of future deaths report.

“James and Karolina have sat patiently and listened to the evidence this week and they do have some answers, but nothing can bring Cassian back. Nothing can lighten their grief over what happened and how it happened. “Cassian’s death was avoidable. He was a strong baby who should have gone home with his parents who had tried for years to start their family. James and Karolina want to make sure the trust makes changes so that no other family has to go through this.”

Parents ask if Sheffield hospital's staffing levels led to son's death

Parents ask if Sheffield hospital's staffing levels led to son's death

21 Apr 2022

The NHS has paid out at least £20m over poor care in children’s mental health services, a leaked report has revealed.

The report, seen by The Independent, found the huge sum was paid out by healthcare providers over five years up to March 2020 to deal with clinical negligence claims.

That includes £9m over claims related to self-harm and £3m for claims involving assault by staff on patients, the most common cause for clinical negligence.

The review addresses improvements needed in inpatient and community children’s mental health services and highlights “significant concern” over young people being detained for “emotional disregulation disorders” and self-harm.

Young people with “challenging behaviour” and living in complex circumstances, who are in social crisis rather than a mental health crisis, are the most likely to be “inappropriately” admitted to inpatient units, the report said.

The report into child and adolescent mental health services warns there is too much variation in inpatient services and that it costs the NHS an average of £77,000 every time a child is detained.

The review is part of the NHS’s Getting it Right First Time project, led by Dr Guy Northover, and is based on data from before the pandemic.

Data from NHS Resolution obtained by reviewers found £1m between 2015 and 2020 was paid out in claims relating to suicide attempts, nine of which led to a child’s death.

The report highlighted that serious incident investigations done by providers following a patient’s death “lack involvement of the family” and lacked “robust” recommendations so were “unlikely to impact on future practice.”

Cost of inpatient care

Dr Northover’s report highlighted “significant variation” in the quality of children’s inpatient units and warned that hospitals could not explain why their model of care was different from another’s.

It added: “CYP [children’s and young people’s] inpatient beds are the second most expensive mental health beds and that has driven an approach of reducing the cost per bed day, but less thought has gone into understanding why the cost is high or if this is justified.”

The cost of children’s beds per day ranged from £600 to £1,600, with the cost for an entire inpatient stay ranging from £28,500 to £148,500.

The cost of one inpatient admission is the equivalent of a year’s mental health support for a child in the community.

According to estimates the NHS could save £21m if it were to reduce the average time spent by children in beds from 55 days to 48 days. Data showed that in more than one third of cases children were spending more than 60 days within an inpatient unit.

The report said despite the “imbalance in spend”, for too long admission into inpatient units has been driven by a lack of appropriate community services rather than the belief it is the best treatment.

It was warned that future surges in need for children’s mental health beds could not be met within the current number of beds, however that this would need to be balanced by the need to reduce the NHS’ reliance on inpatient CAMHS care in the longer term.

The report found variation in staffing models and levels across units. According to the data independent sector units had lower rates of staff per 12 beds compared to NHS units.

Inexcusable restraint

In an analysis of restraint used on children’s inpatient units the report warned it was “not excusable” that seclusion and restraint was high in children’s services and more than five times higher compared to adult services.

Other areas of concern highlighted within the report included the number and level of staff used in Section 136 suites, which are rooms within hospitals for children who are taken there by police after being picked up in crisis.

The data gathered found just 53 per cent of Section 136 suites had full or partial clinical staff and said young people will often be left within these rooms for days at a time while waiting for an inpatient bed.

Regarding the treatment of patients with eating disorders within A&E the report noted that previous recommendations from the CQC that paediatric and A&E staff have training for children’s mental health needs is not being implemented within hospitals.

The report added concerns have been raised over the use of “nasogastric tube feeding”, managing children with neurodiverse conditions and the use of restraint in general hospitals.

A spokesperson for the NHS said: “The NHS continues to prioritise children and young people’s mental health, with record investment in community services, introducing mental health teams in schools and growing our workforce by 40 per cent in the last three years alone.

“More children and young people are being treated by the NHS than ever before and there are plans in place so that an additional 345,000 are supported each year by 2023/24. So if you need help or your child needs support, please come forward.”

NHS pays out £20m in clinical negligence claims over children’s mental health care

NHS also spends around £77,000 each time it admits a child to a mental health ward, leaked report warns

9 Apr 2022

Eleanor Botwright - who won an MBE for her community work in 2017 - was left burned and scarred by botched laser therapy after beautician Nara Simonyan spotted an unsightly 'line' on her face during a previous consultation.

The 40-minute laser session in April 2016 left her with weeping skin and scarring to the cheeks and around her mouth.

Mrs Botwright, of Hammersmith, west London, sued Ms Simonyan for negligent treatment and was handed a payout of £12,630 by Judge Heather Baucher following a court hearing.

The beautician was also hit with £40,000 court costs.

The total award includes cover for special creams to help combat the effects of the sun on Mrs Botwright's fair complexion, and to 'camouflage' any lingering traces of scar damage.

Central London County Court heard that Mrs Botwright had the treatment after Ms Simonyan spotted the blemish at a clinic in Acton.

The 71-year-old told Central London County Court: 'She drew attention to a line around my mouth and said that she had just the treatment for it'.

She told the judge that she began feeling 'uncomfortable' soon after the treatment kicked off, with the main affected area being above her lip.

Ms Simonyan assured her that any 'redness' from the lasering would disappear within ten days, but soon afterwards her face started to 'weep' and felt 'very tender,' she said.

She said the treatment had left her with scarring and discoloured skin around her mouth.

A specialist doctor who examined her reported that the lasering caused 'a burn which led to permanent depigmentation'.

Following the treatment, Mrs Botwright sued her beautician and this week won a compensation payout at a court hearing in London, which Ms Simonyan did not attend.

The judge hailed Mrs Botwright as a 'charming witness' who had been completely honest about the effects of the botched treatment.

'Mrs Botwright did not seek to exaggerate or emphasise anything inappropriately,' said the judge.

Judge Baucher noted that photos taken soon after the clinic trip highlighted the damage done to Mrs Botwright's face.

But having examined her close-up in court she was clear that the scarring has now largely faded.

'I don't consider these scars are distinctive,' the judge explained, although adding: 'She may say that she can see it but that's probably because it's her face'.

As well as the compensation payout, Ms Simonyan was also ordered to pick up the £40,000 bill for the legal costs of the case.

Irish-born Mrs Botwright worked as a community leader for over 30 years before retiring in 2019, heading Camden's Castlehaven Community Association as well as raising over £17million for local area causes.

Beautician who scarred pensioner with botched therapy to pay £50,000

A beautician has been hit with a £50,000 court bill after she burned a charity worker's face with a laser in a botched bid to remove a wrinkle.

15 Mar 2022

Dr Narayanasamy Raghuraman was working at the Spire Hull and East Riding Hospital in Anlaby when he injected the woman's right hip with local anaesthetic and steroid injections instead of the left hip.

It remains unclear whether the patient suffered long-term damage as a result of the error.

A tribunal found the doctor's actions showed a 'serious departure from good medical practice and throughout his evidence giving he continued to show elements of dishonesty. 

Further allegations of incompetence, errors and not fully obtaining consent before operations relating to three other patients were also made against him but were not fully proven. He was found to have made a mistake while treating Patient PM at the hospital between 2012 and 2018. 

The hospital carried out an investigation after which the General Medical Council (GMC) was alerted. 

After the procedure, he took various steps to justify his actions and try to cover up his mistake. 

Dr Raghuraman dishonestly amended the consent form and also changed the markings on the site of injection. 

At the Medical Practitioners Tribunal several other allegations about Dr Raghuraman's actions were made but not proven, such as inappropriately advising a patient dubbed 'RE' to proceed with a hip replacement and then performing it when it was not clinically necessary.

He was also accused of advising another - Patient GS - to undergo a hip arthroscopy (an invasive procedure to diagnose any problems) that was potentially clinically harmful and failing to obtain fully informed consent.

It was also reported he inappropriately advised Patient KF to undergo a knee arthroscopy that was not clinically indicated and performed it without obtaining consent.  

Concerns were initially raised with the General Medical Council (GMC) on May 25, 2018 following a local investigation by the Spire Hull and East Riding Hospital.

Mark Monaghan, on behalf of the GMC, told the hearing issues relating to Patient PM involved several distinct aspects of dishonest behaviour clearly amounting to misconduct.

He said: 'This is not only misconduct in itself but also goes to the issues of the doctor's integrity and the public's trust in the profession.'

He also pointed out Dr Raghuraman was suspended from practice for four months in 2010 for misleading his supervisor over the submission of two research papers to journals, and then giving a dishonest account when his behaviour was being investigated. 

Mr Monaghan submitted that Dr Raghuraman's fitness to practise is currently impaired.

Dr Raghuraman told the tribunal his clinical capabilities have never been below standards.

He submitted that while he was a very busy surgeon, his clinical outcomes have been 'nothing short of excellent'.

However, he said: 'I deeply regret my actions towards Patient PM.'

Dr Raghuraman admitted that when the mistake occurred, he lost focus and forgot how to handle the situation. He felt 'snowballed into a lot of things' which led him to behave in a manner that he is ashamed of.

He said: 'I regret that I failed to set things right when given the opportunity immediately after the incident.

'I meant no harm to the patient, and I will live with the guilt of my errors forever.

He admitted it was a human error which could have been avoided and his biggest mistake was subsequently trying to cover this up.

Dr Raghuraman submitted that he has gained tremendous insight about mistakes and how they must be remedied.

He said he offered a heartfelt apology to Patient PM which he believes to be the most important thing and he 'hopes and prays' Patient PM has forgiven him.

He told the tribunal he has undergone intense training courses and has even become a qualified yoga instructor and practises meditation to help deal with stress and pressure.

In the findings, the tribunal noted that Dr Raghuraman's dishonesty had been prolonged, not only to the patient but to his colleagues.

He even continued to insist the MRI scan he ordered was necessary during the hearing when it was clearly not.

The tribunal said: 'We are concerned that Dr Raghuraman had continued with his dishonesty even during his current fitness to practise hearing as he had maintained his view that the MRI scan which he ordered was clinically needed despite the evidence to the contrary.

'Viewing this alongside the other measures taken by Dr Raghuraman to cover up his initial wrongdoing, we determined that the series of dishonest acts amounts to serious misconduct.'

The tribunal also questioned the veracity of Dr Raghuraman's remorsefulness.

It said: 'While Dr Raghuraman in his submissions had expressed that he felt deep shame and contrition, his reflections appeared mainly to centre around the impact of his dishonesty on him and his family.

'Although he regretted the impact on the patient, he did not mention the impact on colleagues, the profession and on the wider public.' 

'The fact we consider Dr Raghuraman had continued to either minimise or deny certain elements of dishonesty during his evidence, and the history of previous dishonesty, we are satisfied that there is a high risk of repetition of his dishonest behaviour.

'We consider that public confidence in the profession would be undermined if a finding of impairment were not made in this case.

'We have therefore determined that Dr Raghuraman's fitness to practise is impaired by reason of misconduct.'

Having concluded that his fitness to practise has been impaired the tribunal decided Dr Raghuraman should be struck off.

It said: 'We note that Dr Raghuraman's conduct represented a serious departure from good medical practice and he had also shown a deliberate disregard for the principles therein.

'We conclude that erasure is the only appropriate sanction to protect patients, promote and maintain public confidence in the medical profession, and to uphold proper professional standards and conduct for members of the profession.'

Dr Raghuraman has 28 days to appeal the decision.

Surgeon fired for injecting patient in wrong hip and trying to hide it

A surgeon who mistakenly injected a patient with local anaesthetic and steroids in the wrong hip and then tried to cover it up has been struck off.

14 Mar 2022

Many businesses have been looking at their insurance policies to see if they are able to make an insurance claim as a result of closure due to the Covid Pandemic. 

Under the clauses commonly found under a heading such as "Notifiable Diseases" policies often define a notifiable disease as an illness suffered by an individual resulting from any infectious or contagious disease but specifically exclude SARS (Severe Acute Respiratory Syndrome), Pneumonia or any mutant variation.

The Association of British Insurers (ABI) have commented on their website:

Most notifiable disease extensions cover specific diseases that will be named in the cover. These are diseases that are well known and understood. If the policy does not allow for all human infectious diseases, then cover is unlikely to apply.

Some notifiable disease extensions are more general and do not specify certain diseases. In these cases, business interruption cover for COVID-19 may apply if COVID-19 is present at the premises and all policy conditions are met.

If you are unsure about what your policy covers your business for, check with the broker you purchased the policy from or your insurer if you purchased it directly.


Many insurers consider the SARS-CoV-2 / COVID-19 virus, a variant of SARS and therefore excluded by the insurance policy. This is where Stewart House is able to help. 

Our experts are able to confirm whether or not SARS-CoV-2 is directly related to SARS or Atypical Pneumonia or a mutant variation.

Covid-19, SARS and Business Interruption Insurance

Business Interruption Insurance, how Stewart House can help

3 Mar 2022

An inquest is underway into the death of a young Yorkshire mother-of-two who died of undiagnosed sepsis following a miscarriage.

Lorette Divers died on November 20, 2020, two days after she was told her child had miscarried in the womb four weeks earlier.

She arrived at hospital by ambulance at 8.30am on November 18 after suffering from pain, vomiting and a high temperature the night before.

The 30-year-old was admitted to Sheffield Teaching Hospital’s Jessop Wing, where she was tragically told her 18-week pregnancy had miscarried a month earlier.

At Lorette’s inquest, which opened on Wednesday at Sheffield Coroner’s Court, coroner Tanyka Rawden heard the young woman was not assessed by a doctor despite her condition.

William Chapman, a solicitor representing Lorette’s family, including her mum Maxine Nicholson and partner Jahred Smith, urged the coroner to rule there had been medical negligence in her death.

He said: “She did not receive any emergency treatment. She wasn’t seen by a doctor. She did not receive antibiotics. She did not receive surgery.

"Nobody suspected what they ought to have suspected. This was a failure by the state in its obligation to protect life.”

Lorette’s vomiting was reportedly viewed as a result of pain brought on by her miscarriage.

She was noted to have a high temperature, which is typically seen in miscarriages. However, soon after arrival, Lorette tested positive for Covid-19.

Dr Karen Selby, consultant gynaecologist, was asked if it was possible staff on the ward could have focused on this Covid-19 infection as a cause for her high temperature rather than consider sepsis.

Dr Selby said: “I suspect the Covid did distract staff at that point.”

At this stage, Lorette opted to abort her pregnancy by surgery at a later date, but afterwards decided to use medical management and attended the gynaecology ward at Royal Hallamshire on November 20.

Several signs were missed here that Lorette was at this point suffering from sepsis. Blood cultures were taken, but would not have come back for up to 48 hours.

On November 20, Lorette was placed in a room and was seen to be “comfortable and asking to be left alone to rest”.

However, Lorette later collapsed on the ward and the emergency cord was pulled. She was prepared for immediate surgery but sadly she died of heart failure shortly after on November 20.

A post-mortem later revealed Lorette was infected with clostridium perfringens, a common bacteria but one that a consultant gynaecologist noted was “rare, if not unheard of” in cases of sepsis in miscarriage without medical intervention such as Lorette’s.

In a letter read out in court by Lorette’s mother-in-law, her mum Maxine wrote: “From the second Lorette entered this world there was no stopping her.

"She knew exactly who she was – an independent, confident and fiercely loyal young woman who loved her family, especially her two boys. Her main focus in life was to create memories for her children.

Yorkshire mother-of-two died in hospital from undiagnosed sepsis following miscarriage

Lorette Divers inquest: Yorkshire mother-of-two died in hospital from undiagnosed sepsis following miscarriage

25 Feb 2022

Around £60,000 a day is paid out due to medical negligence in Northern Ireland, figures show.

The Department of Health reported that a total of £21.9m was spent last year covering the cost of negligence cases.

This figure includes £6.7m used for legal costs – a third of the total.

Cases concerning obstetrics, including to do with pregnancy, childbirth and the postpartum period, accounted for three fifths of the amount paid out.

Clinical negligence is defined as: “A breach of duty of care by members of the health and social care professions employed by HSC organisations or by others consequent on decisions or judgments made by members of those professions acting in the course of their employment, and which are admitted as negligent by the employer or determined as such through the legal process”

The statistics were collected from Health & Social Care (HSC) Trusts, Agencies and Legacy Health and Social Services (HSS) Boards on all clinical and social care negligence cases in Northern Ireland open during the year ending March 31 2021.

Of the £21.9m paid on all clinical and social care negligence cases in 2020/21, over two thirds (£15.2m) was paid in damages, £4.2m was paid in plaintiff costs and £2.5m in defence costs.

Almost half of all cases open that year related to four specialties – obstetrics (628), accident & emergency (577), neurology (333) and ‘general surgery’ (328).

A total of £152.4 million has been paid to date on the 3,872 clinical and social care negligence cases which were open at any stage during 2020/21.

Over three quarters of that had been paid in damages and £33.2m was paid out in legal costs.

Over three fifths of the amount paid out on clinical and social care negligence cases open at any stage during 2020/21 related to obstetrics (£95.9m), of which, four fifths (£77.3m) had been paid in damages.

During the last five years, the amount paid on clinical and social care negligence cases decreased by £6.7m from the previous figure of £28.5m in 2016 and 2017.

The amount of cases open at any stage throughout 2020/21, however, was 225 more than that in 2016/17.

The length of time the cases remained open increased as well, for an average of 2.9 years.

This was slightly longer than in 2016/17 where cases stayed open for 2.6 years.

According to figures released by the Department of Health for 2019/20, £32.8m was paid out for blunders relating to medical and clinical care.

Of the £32.8m paid out in 2019/20, over two thirds was paid in damages. The remaining amount went towards legal costs.

Northern Ireland clinical negligence cases cost up to £21.9m per year

Negligence cases in NI cost up to £21.9m a year including legal fees, DoH reveals

24 Feb 2022

As a solicitor specialising in spinal injury claims including both personal injury and clinical negligence matters, I have always been baffled by the lack of interim funding available in the latter of these claims. 

Information obtained from NHS Resolution (NHSR) through a freedom of information request shows that of the 6,969 clinical negligence claims that were settled by NHSR in the financial year 2019/20, interim funding was given in only 650 (9.2%) of them.

These figures are staggering. More than 90% of claimants in these cases clearly endured avoidable clinical negligence and most probably suffered its consequences in the form of, for example, ill health, mental health issues, ongoing care needs and work difficulties, with no access to interim funding from the defendants to help alleviate at least some of these issues and aid their recovery while claims are ongoing.

This is in stark contrast with PI cases. Many road traffic collision (RTC) claims, for example, will have interim funding offered or agreed, often shortly after the claim is notified (and possibly even before decision on liability is made). From my experience, these interim payments can be significant (reflecting a claimant’s rehabilitation needs) and insurers are more willing to consider further payments, as required, throughout the life of the legal claim.

It has been the topic of many discussions with case managers who sadly share these sentiments. The ratio of clinical negligence cases versus PI claims where case managers are instructed has been and remains worryingly low. Furthermore, even when there is an opportunity to instruct one, the amount of interim payment is usually very limited and claimants are having to forgo many of their rehabilitation, care or other needs, often with no prospect of being able to secure a further payment to allow them to continue with rehabilitation.

Interim funding is vital for many who have experienced clinical negligence and can be used for things such as specialist inpatient rehabilitation, physical and psychological therapy, reversing procedures that were performed incorrectly and so on.

It has long been accepted that early rehabilitation yields significantly better long-term outcomes for those injured. For example, a 2018 study confirmed that early intense rehabilitation aids recovery and improves outcomes for people with moderate to severe traumatic brain injury.

Mental health is another area to consider. Those who sustain life-changing injuries, such as spinal injuries, are more likely to develop mental health issues. This can create a further barrier to effective rehabilitation and lead to much poorer overall recovery.

Recent research by the Spinal Injuries Association, the University of Reading and the University of Buckingham found that 28% of spinally injured people reported having had suicidal thoughts, compared with just 8% of the rest of the population. Half of the participants reported having mental health struggles. It also highlighted issues with mental health support through the NHS, including long waiting lists, and lack of specialist knowledge and counselling for spinal cord injury sufferers. More than two-thirds of participants did not feel the available support services were suited to their needs.

Claimants pursuing clinical negligence claims often find themselves in the most unenviable situation where they cannot afford specialist treatment privately, have no funds from the defendant and the NHS provision for many aspects of their condition is scarce. Additionally, clinical negligence claims can take years to settle as the process of investigating liability, evaluating present and future needs and negotiating a settlement can be time-consuming.

Take for example individuals who have developed cauda equina syndrome, a life-changing medical condition where all of the nerves in the lower back suddenly become severely compressed. Clinical negligence claims for delayed diagnosis and treatment of this condition have been rising in the past decade or so and yet very few of these clients receive interim funding. While it is generally accepted that rehabilitation plays an important role when recovering from this condition (which can include bladder, bowel and sexual dysfunction as well as mobility issues and neuropathic pain), it can be a real challenge for these patients to obtain a specialised therapeutic input on a multi-disciplinary basis through the NHS due to lack of resources, and also because of the strict eligibility criteria under the NHS spinal cord injury pathway.

The current situation, with ever-increasing NHS waiting lists for surgical treatment and therapeutic intervention, makes it impossible for those injured through clinical negligence to access specialist treatment or therapies at a critical time in their recovery process.

Social care provision is also severely under-resourced and claimants are often left to rely on friends and family, or make do with no care at all. This can put them at risk of further injury (which can mean bigger compensation payouts by NHSR). Stories of clients having no option but to rely on their elderly and often ill parents are sadly not uncommon.

Having access to interim funding for clinical negligence claimants is likely to result in their recovery being optimised and a lesser degree of longer-term dependence on carers, state benefits and so on. It can also free up already stretched NHS services.

Here are some ways in which interim funding can be utilised while at the same time saving money for NHSR:

Access to professional carers/enablers, possibly allowing the injured person to conserve sufficient energy to resume employment.

Access to specialist mental health support and pain-management services to include coping techniques to deal with mental health stressors.

Access to (neuro) physiotherapy and/or hydrotherapy sessions (if one is lucky enough to be referred on the NHS it is likely to be limited to roughly six hydrotherapy sessions). This helps with pain management, increasing the range of movements in joints and overall mobility.

Access to specialised equipment/vehicle leading to greater independence and better prospects of resuming employment.

It is difficult to understand why NHSR’s approach to interim funding is lagging behind.

It has never been more important for NHSR to address this gap and for a more collaborative approach to be adopted. This way those who sustained injuries can maximise their rehabilitation potential in the early stages of recovery and increase long-term independence and quality of life. This issue is particularly timely in light of the recent ministerial comments that legal costs in lower-value clinical negligence claims divert resources from the NHS frontline. A more collaborative approach on interim funding will not only help save NHS costs but also ensure that victims of medical negligence are treated fairly and properly.

NHS must address interim funding gap

NHS must address interim funding gap

11 Feb 2022

The University of California has agreed to pay $243.6m to settle claims that a former gynaecologist sexually abused hundreds of women, some of them cancer patients.

More than 200 women said they were victims of Dr James Heaps over his 35-year career and each will get $1.2m, lawyers said.

It is claimed that UCLA ignored decades of complaints and deliberately concealed the abuse.

The women have accused him of touching them sexually without gloves, simulating intercourse with a probe and making sexually inappropriate remarks.

Kara Cagle, one of the alleged victims, said she was assaulted by Heaps while she was being treated for a rare form of breast cancer.

"I could never have imagined that someone would have taken such despicable advantage of me during that time. It was so traumatic that I left in tears," she said.

The doctor was also criminally charged last year with 21 sexual offences involving seven women, to which he has pleaded not guilty.

"The conduct alleged to have been committed by Heaps is reprehensible and contrary to the university's values," said a UCLA statement.

"We express our gratitude to the brave individuals who came forward, and hope this settlement is one step toward providing healing and closure for the plaintiffs involved."

The lawsuit is the latest in a series of huge payouts by universities in similar cases.

The University of Michigan last month announced a $490m settlement with 1,000 people who said they were sexually assaulted by a sports doctor over a career of nearly 40 years.

The alleged abuser, Dr Robert Anderson, died in 2008.

An $852m settlement was also agreed last March by the University of Southern California after more than 700 women said they were also abused by a campus gynaecologist, Dr George Tyndall.

American university to pay out $243m over gynaecologist sexual assault claims

University to pay out $243m over claims gynaecologist sexually assaulted hundreds of women

9 Feb 2022

A mother whose newborn daughter died following failings in care is campaigning to improve maternity safety after an inquest concluded neglect contributed to the death.

Charlotte Middleton died 40 minutes following her birth after Hinchingbrooke Hospital staff failed to act upon warnings which meant she was born two hours after she should have been, a coroner ruled.

Her mother Laura, 40, was diagnosed with gestational diabetes – she had the condition during two previous pregnancies – and her blood sugar levels should have been monitored. She and then husband Chris had discussions with midwives and doctors and opted for an elective caesarean section at 37 weeks.

Upon admission to hospital on July 17, 2019, Charlotte’s heart rate was monitored using a cardiotocography (CTG) machine. Next morning, Charlotte’s heart rate was found to have slowed and Laura was taken to theatre for delivery. Charlotte was born at 9.54am and died shortly afterwards.

Laura instructed medical negligence experts at Irwin Mitchell to investigate her care under the North West Anglia NHS Foundation Trust and to support her family through the inquest process.

Now the family and legal team are calling for lessons to be learned. The trust admitted to “failings in ante-natal care” which “at least materially contributed” to Charlotte’s death.

An inquest at Cambridgeshire and Peterborough Coroners’ Court concluded Charlotte died as a result of complication of maternal diabetes in pregnancy and neglect contributed to her death.

Coroner Lorna Skinner QC found staff did not act upon Laura’s blood sugar level readings and an abnormal CTG reading that should have seen Charlotte delivered by 7.40am. Had she been delivered by then, she would have survived, the coroner ruled.

The trust has since introduced a scheme called ‘Charlotte training’ to help prevent further neonatal deaths.

Irwin Mitchell’s Guy Forster, who represented Laura, said after the inquest: “We thank the coroner for such a thorough investigation and acknowledging the part serious failures in care had in causing Charlotte’s death. The tragic but inescapable truth is Charlotte’s death was entirely avoidable.

“We welcome the hospital trust’s acknowledgement that Laura should have received better care in a variety of respects, the changes they have made and their pledge to improve maternity safety through training named after Charlotte.”

The coroner raised concerns about a lack of out-of-hours specialist diabetologist provision at Hinchingbrooke and a lack of staff training. She recorded a narrative conclusion.

Laura said after the hearing: “We were all really looking forward to having Charlotte in our lives, and Isabelle and Harry couldn’t wait to have a little sister.

“During my time in the hospital before Charlotte was born, I wasn’t told of any problems. To hear she had died was awful. When Chris arrived, I couldn’t bear to tell him. The senior midwife broke the news to him and brought Charlotte in. She put her into Chris’ arms and I watched his heart break. That will stay with me forever.

“Walking out of the hospital without our baby devastated us. Losing Charlotte is something we’ll never get over and we’ll never be the same. While we can’t change what’s happened, we’re determined to campaign to improve care for others.

“Now the inquest is over we can move forward more positively knowing that Charlotte’s death wasn’t in vain.”

Dr Kanchan Rege, chief medical officer and deputy CEO at North West Anglia NHS Foundation Trust, which runs Peterborough City, Hinchingbrooke and Stamford Hospitals, said: “Following a thorough investigation, the trust has ensured lessons have been learned in this tragic case and further training has also been put into place in order to prevent this from happening again.

“The safety of the women in our care during pregnancy has always been paramount and ensuring the healthy delivery of a baby is something we strive for in every birth. We have been in touch with the family throughout and offer our sincerest condolences and continued support, should they require it.”

Failings in care contributed to baby Charlotte’s death at Hinchingbrooke Hospital

Failings in care contributed to baby Charlotte’s death at Hinchingbrooke Hospital

6 Feb 2022

An NHS doctor killed his partner’s father and almost caused the deaths of her and her mother by giving them a poison that is popular among murderers, a London court has ruled.

He poisoned the trio with thallium then tried to cover his tracks, did not deploy his medical knowledge to help his partner and lied about what happened, the judge found.

The ruling has been handed down by Mr Justice Williams in the family court at the end of a case between the doctor and his now former partner over the arrangements for the care of their child. The case is highly unusual legally because the medic has been found to have committed the killing in a civil court, on the balance of probabilities of the evidence, rather than in a criminal court, in which a jury has to be sure beyond all reasonable doubt.

“It is truly horrifying that any doctor who has signed the Hippocratic oath would be responsible for killing someone else and attempting to kill other people,” said Simon Bruce, a senior family law specialist solicitor who was part of the woman’s legal team.”

While most cases that come before the family court involve injuries, harassment and domestic abuse, Bruce added, “the killing of the child’s grandfather, and the attempted killing of the mother and grandmother, are off the scale of unusualness”.

The Guardian is unable to disclose the doctor’s name because in the judgment the judge ordered that his identity, the mother of his child and their son had to remain anonymous.

However, Williams said in his judgment that the poisoner was a Bulgarian-born doctor who had moved to the UK in the late 2000s. The medic had a relationship with the woman, a bookkeeper and fellow Bulgarian who had been granted British citizenship, and their child was born in 2010.

The court found that he added thallium to a pot of coffee when he, his then partner, their then one-year-old child and her parents were on holiday in Bulgaria in September 2012. His partner and her parents drank from the pot while the doctor had instant coffee instead. The child’s grandfather died two days later. The two women became seriously ill but survived. The doctor and his partner separated soon afterwards.

The Bulgarian police have made inquiries into the poisoning and interviewed the medic, and the Metropolitan police have also been notified. But he has not been charged with any criminal offence.

“The circumstances around my father’s death and the thought of how he had suffered from the effects of the poison in his last hours will haunt me forever. No one could possible imagine the excruciating pain my mother and I felt as a result of the poisoning in the first six weeks after we had been poisoned,” the woman told the Guardian.

“Every day I suffer tremendously bearing the thought that I brought a murderer to my parents’ house and that my dad died as a direct result of this. What I have been through is a nightmare.”

The doctor began legal action in 2018 in an attempt to gain access to his son after he and his partner separated. She argued that he should not have contact because he had poisoned her parents and herself.

The Centers for Disease Control and Prevention in the US say that thallium, a heavy metal, “is tasteless and odourless and has been used by murderers as a difficult to detect poison”.

After a five-day hearing last year, Williams ruled in favour of the mother. He found that on the balance of probabilities her claim that he had poisoned her and her parents was correct.

During the hearing the doctor’s former partner told how he insisted they leave Bulgaria for Britain when the debilitating effects of the poisoning were starting to appear. She said that once back in the UK, he did little to help her get medical help, despite her hair falling out and her suffering sudden weight loss. It was later determined that the woman, her mother and her father had all been poisoned.

In what the judge said was a ruse to evade detection for what he had done, the doctor told fellow medics seeking to identify the source of her sickness that she may be suffering from Guillain-Barré syndrome, a rare and serious nerve condition.

In his judgment Williams several times noted that the doctor had told lies in the different accounts he had given of events surrounding the poisoning. His evidence during the hearing was “rather fractured” and at time “felt like a construct” and he was “insincere” when answering questions, the judge noted. “Overall, I found him to be a quite unsatisfactory witness,” he added.

He also noted: “The father as a qualified medical doctor would have had the intellectual capacity to determine the amounts of thallium that would be required to deliver a sufficient dose to kill an individual without delivering such a significant dose as to make it obvious to the consumer of the drink that it had been contaminated.”

“At a time when the mother was frantic and had come to believe that she was poisoned, his failure to do anything of substance on the medical front is almost inexplicable save by prior knowledge of the causes,” he added.

The doctor is not currently working. The Guardian sought his response to the court judgment. A statement issued by Delphine Philip Law, his solicitors, said: “He vehemently denies the mother’s allegations that he poisoned her or her parents. He stated that the court took inadequate account of the fact that there was no direct evidence to collaborate [his former partner’s] allegations.”

NHS Doctor killed family members with poison

NHS doctor killed his partner’s father with poison, civil court finds

31 Jan 2022

An NHS trust paid £103m in compensation in the past 10 years following failings in its maternity department.

A Freedom of Information request revealed the pay-outs made by the Mid and South Essex NHS Trust.

The Trust also had the highest number of successful clinical negligence claims of any NHS provider, according to recent data.

A Trust spokesman said the maternity payments related to cases which could have happened over a 20-year period.

The obstetric figures, obtained by Channel 4 News, revealed pay-outs and costs totalling £103,097,198 between 2010-11 and 2020-21.

Clinical negligence claims during this period related to 36 mother or baby deaths, 31 babies with brain damage, 24 with cerebral palsy and 27 stillbirths.

Overall there were almost 300 obstetric claims against the Trust and its three predecessor organisations over the 10-year period.

Last year the Care Quality Commission (CQC) said there were still concerns about staffing levels within the Trust's maternity units at Basildon, Southend and Broomfield hospitals.

The Trust also had the highest number of successful clinical negligence claims of any NHS provider, according to recent data covering all of its departments.

According to data published in December by NHS Resolution, which handles negligence cases on behalf of the health service, the Trust recorded 179 successful claims against it in 2020-21 relating to all its departments.

These resulted in damages valued at £107.7m, the highest in the NHS.

The Trust was created in April 2020 by the merger of the three trusts of Mid Essex, Southend and Basildon, and most of the cases originated before that merger.

Its combined maternity units make it the third biggest in the country, dealing with 12,500 births a year.

Safety incidents

Basildon Hospital's maternity unit had previously been rated inadequate due to problems with leadership and staffing.

However, this had improved by the time of the most recent inspection with the service upgraded to a "requires improvement" rating.

There had also been an increase in "safety incidents", where patient safety was compromised, with 397 reported from May to July 2021, according to the CQC.

But staff were praised for the way they had managed these incidents, with learning being shared across the wider service.

At the time of the publication of the inspection report last September, the Trust said it had just recruited an additional 40 midwives.

In November 2020, the BBC reported that the Trust had been handed an urgent safety deadline by the CQC and had conditions imposed on its registration over the failings at Basildon.

This followed the death of Gabriela Pintilie in February 2019 while giving birth to her daughter and "a high volume" of whistle-blowers who had approached the regulator.

An inquest into her death concluded there had been "delays, confusion and a lack of leadership" after Ms Pintilie, 36, lost six litres of blood.

'Staggering'

Mrs Pintilie's husband Ionel had taken legal action against his Trust and his solicitor Stephanie Prior said that problems persisted.

Responding to the number of successful claims in 2020-21, she said: "I think it's staggering.

"These pay-outs have been made because claims have been successful whether they've been fully litigated or whether they've been settled out of court, but the fact of the matter is that the NHS trust is not learning from its mistakes, and rectifying issues and problems that have caused these claims to be made in the first place."

NHS Resolution guidance says the list of compensation pay-outs made by trusts should not be treated as a league table owing to "different levels of risk because of the variations in the nature and complexity of the procedures they perform".

However, Mid and South Essex's figures are still the worst when compared with similar-sized institutions performing the same acute hospital functions.

A spokesman for the Trust said: "Since our merger, we are one of the largest trusts in England and the figure is for all clinical claims across all of our sites settled in 2020-21.

"The incidents giving rise to these claims could have happened up to two decades before.

"Over the last few years we have made improvements to our maternity services, including recruiting 40 newly-qualified midwives, a consultant midwife, practice development midwives and maternity care assistants and securing almost £2m in funding for the further recruitment and development of staff.

"We are pleased that the CQC's latest inspection recognised the work that has taken place and improved our rating."

Maternity failings cost Essex NHS Trust £103m in the past 10 years

Essex NHS trust pays out £103m over maternity failings

19 Jan 2022

Most lawyers understand intuitively that there are upper limb surgeons and lower limb surgeons and can direct their enquiries for expert reports with no difficulty. However, ophthalmology is somewhat different. Not only do they use technical terms that some medical colleagues don’t always fully understand, they have sub-specialities and special interests that to them are commonplace but perhaps not to the rest of the world.

Ophthalmic subspecialities:

1.	Oculoplastics
     a.	Lids, lacrimal apparatus, often orbits and aesthetic lid surgery

2.	Cornea and external eye disease
     a.	Dry eye, conjunctivitis, corneal infections and disease, corneal transplants

3.	Strabismus
     a.	Squints in adults and children
     b.	Often some overlap with neuro-ophthalmology

4.	Glaucoma
     a.	There are multiple types of glaucoma!

5.	Cataract & refractive surgery
     a.	Often some overlap with cornea

6.	Medical retina
     a.	Diabetic eye disease and macular degeneration

7.	Surgical retina
     a.	Retinal detachments

8.	Neuro-ophthalmology
     a.	Optic nerve disease and watershed eye/brain disease

9.	Paediatric ophthalmology

10.	Trauma

So with 10 possible options, how can a lawyer know they are getting the best report for their case? Eye doctors tend to be very busy with their clinical practice and finding an Expert is likely to be challenging. 

Stewart House has a panel of experts covering all subspecialties in Ophthalmology. All our experts, such as Professor Charles Claoué and his team are all in active clinical practice and have undertaken extensive medicolegal training. Professor Claoué and his associates are well recognised by Solicitors, Barristers and peers in the medicolegal arena for their expertise.

A common area where negligence is explored by an individual is in relation to Laser eye surgery. Patients often undergo Laser eye surgery but after a period of time, find their eyesight has deteriorated again. Unfortunately there are no guarantees that Laser eye surgery will permanently fix visual problems. In this instance, a claim for negligence wouldn’t usually be successful.

On the other hand, if following Laser eye surgery, a patient starts to suffer with an astigmatism, limited night vision, dry eyes or permanent damage to eyesight, there could be a claim for clinical negligence.

Our experts are well placed to provide screening and full reports on any area of Ophthalmology.

Ophthalmology

Ophthalmic expert witnesses

18 Jan 2022

The NHS is going ahead with plans to redeploy or dismiss healthcare workers in England who are not fully vaccinated against COVID-19, which could lead to some staff being shown the door without redundancy pay.

The British Medical Association (BMA) described it as a "very worrying" move, and said the overall strategy risked making staff shortages worse.

The regulations mean that frontline staff, whether in the NHS or independent health sector, must have had at least two vaccine doses no later than April 1, or face the possibility of their contracts being terminated.

The deadline means they must have had a first dose by February 3 to be eligible for a second dose by the deadline.

A letter to health service employers from NHS England & Improvement, sent last Friday, has confirmed implementation of the rules that could lead to some staff having their contracts terminated by the end of March.

Staff Warning in Formal Meetings

An accompanying 24-page document,  Vaccination as a Condition of Deployment (VCOD) for Healthcare Workers , sets out how employees should be encouraged to get vaccinated, and the steps for managing cases of individuals who do not comply.

From February 4, staff who have not had a first vaccine dose, unless exempt, will be invited to a formal meeting with a manager and told the potential consequence may be dismissal "on the grounds of contravention of a statutory restriction".

Exemptions from the VCOD regulations include those who:

Are under the age of 18

Are medically exempt, such as those with severe allergies to vaccines, and certain medical conditions

Have participated in a clinical trial for a COVID-19 vaccine

Are pregnant and have a temporary exemption, which will be valid until they are 16 weeks post birth

Having acquired natural immunity through previous SARS-CoV- infection is not listed as an exemption in the regulations.

Redeployment Option

Managers should consider temporary or permanent redeployment of an unvaccinated member of staff whenever possible, according to the guidance. However, individuals would not be eligible for pay protection of their basic salary or additional earnings if their new role is in a lower band or grade to their previous position.

Alternative options, including "possible adjustments to their current role" and "restrictions to duties", should be explored.

During formal meetings, an individual can be accompanied by a trade union representative or a staff representative.

NHS vaccination strategy could make staff shortages worse

NHS strategy to terminate staff without vaccinations risks making staff shortages worse

18 Jan 2022

The creators of the whiplash portal are actively exploring why so few litigants in person appear to be using the service.

Official Injury Claim went live last May having been designed for use by both represented claimants and those without a lawyer. But early indications are that unrepresented people are unlikely to use the portal, with 90% of claims coming from people who instructed a solicitor.

Minutes from last month’s OIC advisory group meeting, chaired by the Ministry of Justice and attended by solicitor, insurer and medical agency representatives, were published on Friday and revealed that research has been commissioned into unrepresented claimants exiting the service.

Stakeholders also want to establish whether unrepresented claimants may be receiving additional advice ‘in the background’ and if this might be having an impact on settlement figures.

The group remarked on the continued absence of claims management companies in the process (in the first quarter of the OIC operating, just 101 claims out of 41,000 were made through CMCs).

One area being researched is unrepresented claimants’ level of awareness of the service and their journey through the process. The assumption was that individuals with potential whiplash claims would be directed to the portal by their insurer, but the numbers would suggest that many are not taking this advice – or alternatively that many are being put off running their own claim and seeking out solicitors instead. The Civil Liability Act prevents the recovery of legal costs for any claim valued less than £5,000, so any successful claimant using a solicitor would have those costs deducted from damages.

The minutes record that the advisory group’s discussion ‘included the importance of capturing how the claimant found their way to the service, to enable a better understanding of its visibility and whether/how this can be improved’.

Although designed with both unrepresented and represented claimants in mind, the clear intention of the portal was to encourage more people to handle their own claims and reduce costs.

The government says ‘substantial work’ was undertaken to ensure that the service was fair, accessible and efficient for all users, and has been ‘carefully designed with the claimant firmly at its heart’. The service includes a dedicated phone support centre who do not wish to handle their case online.

Litigants in person not using the portal

Whiplash portal bosses want to know why LiPs aren’t using it

17 Jan 2022

Liability for secondary victims in clinical negligence claims is likely to be considered by the Supreme Court, after the Court of Appeal ruled that ‘no claim can be brought in respect of psychiatric injury caused by a separate horrific event removed in time from the original negligence’.

Sir Geoffrey Vos, the master of the rolls, said that the elements required to establish legal proximity in secondary victim cases ‘apply as much to clinical negligence cases as they do to accident cases’.

‘For a secondary victim to be sufficiently proximate to claim for psychiatric injury against the defendant whose clinical negligence caused the primary victim injury, the horrific event cannot be a separate event removed in time from the negligence,’ Vos ruled.

Both Vos and Lord Justice Underhill indicated that the ‘important issues’ raised in three linked appeals should be considered by the Supreme Court, which would be asked to disapprove a previous Court of Appeal ruling on liability for secondary victims.

In Paul and others v The Royal Wolverhampton NHS Trust and others, the court was asked to determine the circumstances in which a defendant to a clinical negligence claim can be held liable for psychiatric injury caused to a close relative of the primary victim of that negligence.

The three cases all concerned claims where the defendant was alleged to have failed to diagnose the primary victim’s life-threatening condition and their subsequent traumatic death was said to have caused psychiatric injury to their close relatives.

The five elements required to establish legal proximity in secondary victim cases – set out in 1991 by the House of Lords in Alcock v South Yorkshire Police, a claim for psychiatric injury caused to friends and relations of those killed and injured in the Hillsborough disaster – apply as much to clinical negligence cases as they do to accident cases, Vos said.

The Court of Appeal’s 2013 decision in Crystal Taylor v A. Novo (UK) Ltd ‘is binding authority for the proposition that no claim can be brought in respect of psychiatric injury caused by a separate horrific event removed in time from the original negligence, accident or a first horrific event’, he added.

Vos accepted that ‘there is no logical reason for these rules’, adding: ‘If I were starting with a clean sheet, I can quite see why secondary victims in these cases ought to be seen to be sufficiently proximate to the defendants to be allowed to recover damages for their psychiatric injury.’

However, he concluded that ‘it is for the Supreme Court to decide whether to depart from the law’ as stated by Lord Dyson in Novo.

Secondary victims cases to be considered by Supreme Court

Landmark ‘secondary victims’ cases heading for Supreme Court

14 Jan 2022

Making claims against the NHS can be “a difficult, and in some cases inhumane, experience”, with the worst cases seeing staff trying to “proactively cover up” errors and even fabricating medical records, a report has found.

However, in other cases they were “very upfront about what had gone wrong” and consultants recommended taking legal action, according to research for the Association of Personal Injury Lawyers (APIL).

The research was carried out by insight agency Opinium in advance of yesterday’s meeting of the House of Commons health and social care select committee, which is holding an inquiry on NHS litigation reform.

Researchers carried out detailed interviews with 15 victims of medical negligence for the report, The Value of Compensation. Those interviewed came from a mixture of backgrounds in terms of age, gender and ethnicity.

The report said the approach taken by the NHS to medical negligence differed “hugely” for different patients.

“Some of those interviewed received an apology from medical staff for the negligence but many got a much less empathetic approach and agreed that the NHS could have shown more compassion.

“Some felt that the NHS failed to acknowledge them as people throughout the compensation process, others felt victimised for challenging treatment decisions and for pursuing their compensation claim.”

There were also “very different experiences” in terms of transparency.

“A few said that the NHS had been very upfront about what had gone wrong and about the learnings that had emerged from the case, with consultants even recommending that the patient take legal action.

“However, most had a much less open experience. In the worst cases, NHS staff had tried to proactively cover up the errors that had been made and some reported that medical staff had lied about the events and even fabricated medical records.

“Those having to deal with a negative backlash of claiming and proving the credibility of their case felt betrayed by the NHS and found the process especially stressful.”

Researchers said the claims process was often “lengthy and drawn out”, becoming an “all-absorbing activity for some as they engaged in time-consuming research” about their condition or that of their child.

“Some speak of accepting the first offer presented to them as a means of bringing the experience to a close. All in all, these factors compound to make it a difficult, and in some cases inhumane, experience.”

The report highlighted how emotional and financial health, as well as physical, could be seriously affected by medical negligence.

“When rapid recovery isn’t possible, people can fall into a spiral of decline. Financially, they face mounting debt; psychologically the pain and suffering can result in poor mental health, including depression.

“In the cases with the most serious consequences, the negligent act can become embedded in the patient’s sense of self-identity and self-worth.

“It’s not possible for people to return to the life they previously enjoyed when they have lost relatives unexpectedly or when the negligence has caused acute impairment.”

Compensation helped victims recoup expenses, alleviated financial pressure and provided access to private medical treatment, which could be a “key factor” in recovery.

On an emotional level, compensation could provide “recognition of the injustice experienced” by victims and families.

It could also provide a “sense of security”, particularly where children were involved, and was not about “shaming” the NHS.

“Many patients mention their admiration and respect for the NHS and the work that they do, and some mention not feeling particularly happy at having to take action against them.”

APIL committee member Guy Forster, who gave evidence at the committee, said: “There is a fixation on the financial cost of clinical negligence, rather than on the human cost and the reasons why injured patients have to make a claim for compensation at all.

“There are a lot of voices and opinions in any debate which concerns the NHS and patient safety, but they are almost never the voices and opinions of the patients.”

During the evidence session – which also heard about how medical negligence cases were handled in other countries, such as no-fault systems – committee chair Jeremy Hunt, the former health secretary, asked Mr Forster whether the legal profession opposed major reform out of “self-interest”.

Mr Forster rejected this, pointing out that three-quarters of those who received compensation did so without needing to issue proceedings.

He acknowledged though that some cases went to court that should not do and said the causes needed to be examined, such as whether it was a lack of resources at NHS Resolution to ensure an early investigation or “not getting the family around the table with the clinician early on”.

He also agreed with the importance of mediation, with another witness, Lauren McGuirl, director of commercial services at the Centre for Effective Dispute Resolution, agreeing with Mr Hunt’s suggestion that it should be compulsory before claimants could start litigation, even if just to get the parties engaged.

Mr Hunt, the former health secretary, highlighted the value of examining other jurisdictions’ approach, such as Sweden’s no-fault system, which he said had a much lower compensation spend as a proportion of healthcare costs and much better safety rates.

Mr Forster predicted that the administrative costs of such as system in England and Wales would be huge.

Medical negligence claimants face "inhumane experience"

Medical negligence claims process can be "inhumane experience"

12 Jan 2022

A “financially motivated” consultant, who inappropriately treated cancer patients with a machine he co-owned has been struck off the medical register.

The decision follows an earlier ruling by the Medical Practitioners Tribunal Service (MPTS) which found consultant urologist Paul Miller acted dishonestly by not disclosing a financial interest.

Mr Miller, who was a practicing consultant at East Surrey Hospital in Redhill, had referred five NHS patients and treated three private patients at the Spire Gatwick Park Hospital in Horley.

The tribunal heard that patients were referred for high intensity focused ultrasound (Hifu) treatment at the private hospital, which rented the machine which was owned by Mr Miller’s company.

The tribunal concluded Mr Miller’s recommendation and treatment was inappropriate, either because standard treatments of radical radiotherapy or radical prostatectomy offered better prospects of a cure, or because their cancers were not of the kind for which Hifu was considered appropriate.

The General Medical Council’s Catherine Cundy, told the hearing Mr Miller had “taken no steps to demonstrate that he has reflected on or reconsidered his actions or the failings”.

Ms Cundy added that Mr Miller had “painted a picture of himself as a man thwarted and frustrated by the failure, as he saw it, of the Surrey and Sussex Healthcare Trust to get behind the emerging technology of Hifu”, but the reality was different.

Dishonest consultant struck off

Surrey consultant struck off medical register over dishonesty

21 Dec 2021

Alder Hey Children’s NHS Foundation Trust agreed to pay £27m after a young boy suffered life-changing injuries in 2009 because it failed to diagnose that he was suffering from the HSV virus when he was admitted at the age of 17 months with a seizure.

He sustained catastrophic brain injuries, leading to profound impairments, and intractable epilepsy.

Proceedings were commenced in October 2018 and the trust admitted breach of duty. Subject to one contested point – that the boy would have suffered mild residual cognitive deficit and epilepsy in any event – it also admitted causation of loss and damage.

The questions of quantum, including the contested point, were listed for a 10-day trial due to start on 1 November 2021. However, the case settled two working days before and the agreement has now been approved by Mr Justice Fordham.

His barrister, Bill Braithwaite QC of Exchange Chambers, said: “While it is a relief for the family that this claim settled, it is unacceptable that they were kept waiting and worrying until only two days before their claim was due to start in court.

“There was ample opportunity for NHS Resolution, which is supposed to be keen on resolving claims, to grasp the nettle and admit that Alder Hey’s repeated negligence had caused catastrophic injury to an innocent baby and his family.

“The pressure on parents of children with severe brain injury, particularly as the child get older, larger and more difficult to manage, is immense, and in this case it went on for years.”

An NHS Resolution spokesman said: “At NHS Resolution, our aim is to reach the right decision as quickly as we can. We never intend to cause any harmed patient or their families’ distress or anxiety through the claims process.

“This is a tragic case where the family have provided substantial support to their child. The case was complex and required substantial expert evidence to assess the child’s ongoing needs and for the parties to reach agreement on the settlement.

“We hope the settlement provides the family with certainty for the future.”

NHS Resolution criticised for settlement delay

A leading QC has criticised NHS Resolution for “unacceptable” delays in settling one of the largest ever settlements in a clinical negligence case.

16 Nov 2021

Data from NHS Digital, which manages the register, implies that around 8500 women across England and Scotland have not been added to the register after they were fitted with an implant last year.

The register was recommended as a result of the breast implant scandal which saw some women fitted with faulty implants.

It records the details of every person who has breast implant surgery in case of a product recall or another safety concern.

But the latest figures suggest that many are being missed off the register and NHS Digital has asked women undergoing such treatment to ensure their surgeon has registered their details.

The figures show that operations on 10,500 people were recorded in 2020.

But officials have estimated this represents around 55% of the total number of cases.

This means that approximately 8485 people were not added.

PIP Scandal

The Breast and Cosmetic Implant Registry was launched in October 2016.

PIP (Poly Implant Prostheses) implants were withdrawn from the UK market in 2010 after it was found they had been filled with non-medical grade silicone intended for use in mattresses.

Estimates suggest that as many as 47,000 women in the UK have been fitted with the implants but the exact figure is not known.

A UK Government-ordered report in June 2012 found the implants were made from an unauthorised silicone filler and ruptured at twice the rate of other implants.

It was recommended that a national registry be created so that faulty implants could be efficiently tracked if products turn out to be faulty.

Since it was set up, around 60,000 breast implant patients have been added to the register.

Lee Martin, NHS breast surgeon and chairman of the Breast and Cosmetic Implant Registry steering group, said: "It is pleasing to see that the number of submissions to the registry has increased steadily over the past 5 years and now includes information from almost 60,000 patients.

"We want all patients, past and present, to be aware that the registry exists and ensure they are included by speaking to their surgeons.

"As a surgeon, I know first-hand the importance of patient information being included on the registry, it's crucial in providing good patient care and provides patients with assurance that they will be followed up with if there are issues with their breast implants in the future."

This article contains information from PA Media.

Thousands missed from breast implant registry

Thousands of women are being missed off the breast implant registry, new figures suggest.

10 Nov 2021

Hospitals are not learning from their mistakes in part because of time-consuming clinical negligence litigation, former health secretary Jeremy Hunt MP has claimed.

Hunt, now the chair of the House of Commons health and social care committee, said England and Wales should follow the likes of Sweden by taking negligence out of the equation altogether and paying compensation much sooner after the harm has been caused.

Speaking during a webinar hosted by national firm Irwin Mitchell last week, Hunt said the current adversarial system potentially causes serious harm to hundreds of babies every year because necessary changes are taking years to be implemented.

Hunt said: ‘[In Sweden] When a child is born severely disabled they are able to access compensation without having to get a court to agree there was clinical negligence… You get that compensation as long as the clinicians agree there was a mistake made [but] they don’t have to accept there was clinical negligence.’

Hunt said families were understandably desperate to get compensation because of the huge financial burden of bringing up a severely disabled child, but they are told the only way to get that compensation is by proving clinical negligence, which necessitates lawyers’ involvement. ‘For the most difficult cases it can take easily five years – that is five years when people are fighting in the courts rather than using the knowledge from that.’

Hunt’s committee has already urged the government to end the adversarial system. There continues to be speculation that the government is preparing to reform the sector.

While ministers consider legislating to encourage more cooperation and fewer cases coming to court, it would appear that the lawyers involved in clinical negligence cases are already collaborating more since the pandemic and the introduction of a new protocol for handling cases.

Jasmine Armstrong, partner with defendant firm Weightmans, told the webinar there had been a ‘culture shift’ with both parties sharing a common goal to secure earlier resolution. She added that one way of extending this could be for claimant and defendant lawyers to consider jointly instructing one expert.

‘There is a strong cohort of experts that we tend to instruct and they are well regarded and could be used for joint instruction whether dealing with liability or quantum,’ said Armstrong. ‘There is an opportunity to share evidence early. If one party has a really robust independent expert report or a really strong witness statement there would be an advantage to disclosing it early.’

Reforming clinical negligence claims could prevent infant deaths

Hospitals are not learning from their mistakes, in part, because of time-consuming clinical negligence litigation.

9 Nov 2021

ncertainty today surrounded another significant presence in the claims sector amid reports of a second collapse in the space of a week.

Employees of Pure Legal, based in Liverpool, have posted on Twitter and LinkedIn that the firm has gone into administration and that they are seeking work. The announcement was said to be made to staff on Tuesday lunchtime, with redundancies across the board.

The firm itself, which employs 200 people, has yet to make any public statement and there has been no confirmation from Companies House that administrators have been appointed.

But a recorded message on the Pure Legal phone number tells clients that their files are being transferred to another firm, and that the business is being managed for now by Recovery First, which specialises in transferring claims from firms that can no longer handle them.

Tina Flanagan, group HR manager at the firm, posted on LinkedIn that Pure had been forced into administration and staff all made redundant. She added: ‘It was just awful to see so many people’s lives turned upside down. It was an absolute pleasure to work for such amazing people and the board worked night and day to save the business and for that I thank you all.’

It is understood that Novitas Loans, a provider of loans for legal proceedings, petitioned Pure Legal for bankruptcy last month.

A spokesperson for the company told the Gazette: ‘Novitas’ primary aim is to act in the best interests of our customers who have claims being managed by Pure Legal Limited. Our priority is to ensure that our customers are receiving the highest quality of service and care. We cannot comment further on ongoing legal proceedings.’

Pure Legal is an alternative business structure that is part of the Pure Business Group. It is unclear what effect – if any – the closure of the law firm would have on the wider group. The company is owned by Phil Hodgkinson, a former director at Slater and Gordon and Compass Costs. He is also chairman of Huddersfield Town Football Club.

The most recent annual accounts for Pure Legal Limited, covering the year to 30 March, show that while turnover increase 24% to £18.1m, profit before tax fell by 24% to £3.6m. Creditors were owed £37m within one year, compared with £24m a year earlier, and the company had outstanding loans and overdrafts valued at £21m.

Pure Business Group sold York-based Pryers Solicitors earlier this year, resulting in the transfer of 70 lawyers and support staff. Pure Legal, which was once mostly reliant on personal injury claims, had moved away from that work and handled negligent wall insulation claims, mortgage mis-selling, housing disrepair and data breaches.

A week ago, it was confirmed that Liverpool firm Hampson Hughes had gone into administration, with Recovery First enagaged in finding alternative providers for ongoing work.

Second claimant Law firm goes bust in two weeks

Staff say goodbye as another claims firm reported to have gone bust

3 Nov 2021

Sandra Campbell, admitted in 1998, misappropriated £164,264 from Client A – which remains unpaid – and then misled the Solicitors Regulation Authority and a High Court judge about her purported attempts to transfer the funds, the Solicitors Disciplinary Tribunal found today.

Campbell, whose Mayfair firm Campbell & Co Solicitors was closed by the Solicitors Regulation Authority in February, also misappropriated the entirety of Client B’s £17,000 settlement of a medical negligence claim, a sum which has since been paid out of the Compensation Fund.

She did not attend the hearing and was not represented. 

Michael Collis, for the SRA, told the tribunal that Campbell ‘misled both clients as to the fact that those sums were going to be paid and then misled both the SRA and, so far as Client A is concerned, the [High] Court’.

He said Campbell was instructed by Client A in April 2020 in relation to the sale of a property, which was completed that August. £540,000 was transferred into the client account, £6,736 of which represented the firm’s fees and disbursements. Campbell paid Client A’s 'son and duly-appointed agent, Mr A' around £369,000 over the course of September 2020, which left ‘an outstanding balance to Client A of £164,264’, Collis said. However, ‘by 30 September 2020, the date of the last payment, there was only £4,678.52 left in the client account’. 

After Client A applied for a freezing injunction last October, Campbell ‘wrote directly to the court’ claiming that ‘the reason that [the sums] had not been paid was because of practical difficulties in instructing the bank’, the tribunal heard.

Collis said, however, that only £5.16 remained in the client account at that time and Campbell ‘must have known’ that there were insufficient funds to pay the sums owed to Client A.

Client B was ‘traumatised by the medical negligence that gave rise to the personal injury award in the first place’, Collis said, and the misappropriation of her settlement had caused her ‘ongoing stress and anxiety’.

All the allegations against Campbell were found proven and she was struck off the roll 'effective today'.

Chair Edward Nally said: 'The tribunal were very offended by this case and the respondent's behaviour. We feel that the harm that has been occasioned by the conduct we have found proved was extreme.

'The treatment of two lay clients was extraordinarily bad and we believe that, coupled with misleading and deception on the part of the respondent towards the clients themselves, the regulator and the court, was frankly quite extraordinary.'

Campbell was also ordered to pay £25,114.40 in costs, although the tribunal heard that the SRA would likely be in a 'line of creditors seeking to recover funds from the respondent' as a bankruptcy order was made against her in March.

Solicitor struck off for misappropriating £164,264 and lied to the SRA

A solicitor who misappropriated more than £150,000 from the sale of a client’s property and then lied to the regulator and the High Court about her ability to repay the funds was today struck off the roll.

10 Oct 2021

In a judgment handed down on 1 October 2021, Hill Dickinson LLP secured a third-party costs order against Dr Mercier, who had acted as an expert witness for the Claimant. He is now required to pay £50,543.85, representing the costs that were incurred as a consequence of his advice. 

Synopsis
Dr Mercier, a general dental practitioner, accepted instructions to act for the Claimant in a case concerning treatment provided by a maxillofacial surgeon; specifically an extraction performed under general anaesthetic. 

At trial, Dr Mercier conceded that he did not have any experience of performing an extraction under general anaesthetic over the last 20 years, had no experience of consenting a patient for extraction under general anaesthetic and that he was not as well placed as the Defendant’s expert witness (a consultant maxillofacial surgeon) to comment on the case. The Claimant discontinued her claim during the trial, following Dr Mercier’s evidence.

In her judgment, Ms Recorder Hudson concluded that “but for Dr Mercier’s report, this claim would not have been brought”. She felt that he had shown a flagrant disregard for his duties to the Court and that he did so from the outset in preparing a report on a subject matter in which he had no expertise. She rejected submissions on his behalf that the Defendant Trust could in any way be criticised for having failed to take action itself to bring the point to the attention of Dr Mercier, his legal advisers, or the Court before trial. 

Relevance
This judgment is the second significant third-party costs order made against an expert in clinical negligence litigation. It ought to serve as a further warning to experts that they must report strictly within their own area of expertise, both in terms of specialty and also having regard to their contemporaneous practice. 

It also highlights that the duty of an expert cannot be delegated either to their instructing solicitor, or to the representatives of the other party in the litigation. 

Mr Giles Colin of 1COR was instructed for the NHS Trust.

Claimant expert has costs order against him

[Robinson -v- (1) An NHS Trust and (2) Dr Mercier]

6 Oct 2021

MANCHESTER—World-renowned oncologist Justin Stebbing has been found guilty of providing inappropriate treatment to terminally-ill cancer patients, some who were just days from death.

A long-running medical tribunal, which began in January 2020, handed down its verdict today after he was accused of failing to provide good clinical care to 12 patients.

Prof Stebbing, who'd already admitted 30 of the 36 charges, was found guilty on three charges with three others not fully proved.

The decision will cause serious damage to his reputation and send shockwaves through the UK oncology community and the wider medical world.

International Reputation

Prof Stebbing - nicknamed 'God' because of his pioneering work - is a cancer medicine and oncology professor at Imperial College London and has a private practice in Harley Street.

A MPTS (Medical Practitioners Tribunal Service) tribunal heard of his "international reputation" for innovative cancer treatment, which has led to wealthy patients from around the globe turning to him in the hope of extending their lives.

They've included New Zealand multi-millionaire Sir Douglas Myers and the actor Lynda Bellingham.

But the charges, most of which he initially denied, included inappropriately treating patients given their advanced cancer or poor prognosis, overstating life expectancy and benefits of chemotherapy, and continuing to treat patients who failed to respond or were close to death.

Other charges concerned his failure to gain informed consent by not discussing the risks and benefits of treatment with patients and failing to maintain proper records.

Complainants in the case included Leaders in Oncology Care (LOC), a specialist cancer treatment centre which is part of private healthcare provider HCA Healthcare UK, BUPA and AXA PPP (now AXA Health) insurers, although Prof Stebbing faced no accusations that his actions were financially-motivated.

Oncologist guilty of inappropriate treatment

Leading Oncologist Guilty of Providing Inappropriate Treatment: MPTS

5 Oct 2021

Research by the Institute for Public Policy Research estimated 19,500 people who should have been diagnosed had not been, because of missed referrals.

If hospitals could achieve a 5% increase in the number of treatments over pre-pandemic levels, it would take until 2033 to clear the backlog.

But if 15% more could be completed, backlogs could be cleared by next year.

Too late

Increasing activity levels would require more cash for new equipment and more staff, however.

And all this is dependent on those who have not come forward for checks seeking help.

Between March 2020 and February 2021, the number of referrals to see a specialist dropped by nearly 370,000 on the year before, a fall of 15%.

Behind these figures are thousands of people for whom it will now be too late to cure their cancer, the report, with the CF health consultancy, warns.

And it estimates the proportion of cancers diagnosed while they are still highly curable - classed as stage one and two - has fallen from 44% before to pandemic to 41%.

'Poses risks'

IPPR research fellow Dr Parth Patel said: "The pandemic has severely disrupted cancer services in England, undoing years of progress in improving cancer survival rates.

"Now, the health service faces an enormous backlog of care, that threatens to disrupt services for well over a decade.

"We know every delay poses risks to patients' chances of survival.

"Clearing the cancer care backlog before the next general election looks unlikely with the way the NHS is currently resourced, staffed and organised."

Decade to clear cancer backlog

It could take more than a decade to clear the cancer-treatment backlog in England, a report suggests.

23 Sept 2021

Alison Mutch, senior coroner for Greater Manchester South, said important information missed in telephone appointments may have been acted on if they were seen in person. Ms Mutch has asked Health Secretary Sajid Javid and NHS England to take action to tackle risks associated with remote appointments, a Health Service Journal investigation found.

One woman, Fadhia Seguleh, who had phone call appointments with her GP about her anxiety and depression, killed herself in her own home on Feb 25. The coroner said the lack of access to her doctor in person made it harder to assess her needs.

The deaths of three other people, who died from a fatal blood clot in the lung, undiagnosed Covid and a drug overdose, were also the subject of Ms Mutch's concerns. A fifth patient, an elderly man with severe underlying health conditions, died after breaking a bone that was not spotted by hospital doctors and his GP in a phone call consultation.

It comes amid previous concerns that moving away from in-person appointments can lead to missed diagnoses.

One of the deaths involved Maurice Leech, who died on April 30 last year in Thorncliffe Grange Nursing Home in Manchester after A&E doctors and his GP during a virtual appointment failed to realise he had broken his femur during a virtual appointment.

He was admitted to hospital after an accidental fall and medics did not given the correct x-ray. In another case, Steven Allen died on Oct 26 in his Stockport home after taking a fatal level of prescribed medicine. He had a history of drug addiction and was prescribed medicines including strong painkiller oxycodone through a consultation with his GP that happened via a phone call as a result of Covid.

The other deaths of concern to Ms Mutch involved Stanislaw Zielinski, who died on June 2 from cardiac arrest and a blocked blood vessel in his lung, after he had been hospitalised after falling out of his window.

Mr Zielinski, who was suffering from insomnia and anxiety, told his GP of his mental state one year earlier, but his appointments were limited to phone calls because of the pandemic. Brian Mottram, meanwhile, died in Tameside on Nov 16 from undiagnosed Covid after feeling unwell for a week. Two days before he was found unresponsive, Mr Mottram had a phone appointment with his GP.

Ms Mutch sent five reports to health authorities - including local trusts, Health Secretary Sajid Javid and NHS England - asking them to take action, according to the Health Service Journal.

Earlier this month The Telegraph revealed almost 1,000 GP practices have been ordered to improve patient access, amid growing concern about the number of patients struggling to see a family doctor.

Remote GP calls may have contributed to five deaths says Manchester Coroner

Remote GP appointments may have been a contributing factor in the deaths of five people who did not see their doctor face to face, a coroner has concluded.

9 Sept 2021

Prof Sikora, who's been giving evidence for the Defence, was forced to consult lawyers when the tribunal was dramatically halted on Friday after he said he'd obtained summaries relating to three patients by "ways and means" from undisclosed sources.

It led Sharon Beattie QC, for the GMC, to raise concerns about the truthfulness of his testimony and his involvement as a witness and the tribunal today heard that he could "put himself at risk of investigation" if he continued to give evidence.

That was due to "inconsistencies" in documents he'd since provided to the tribunal, but Prof Sikora told panel chair Hassan Khan that he was satisfied with the legal advice he'd received and wanted to continue.

Inappropriate Treatment

Prof Stebbing, a cancer medicine and oncology professor at Imperial College London with a private practice in Harley Street, is appearing before a Medical Practitioners Tribunal Service (MPTS) fitness to practice hearing and is accused of failing to provide good clinical care to 12 patients between March 2014 and March 2017.

He faces 36 charges - 21 of which he's admitted - which include allegations that he inappropriately treated patients given their advanced cancer or poor prognosis, overstated life expectancy and the benefits of chemotherapy, and continued to treat patients when it was futile and they had just weeks to live.

Prof Sikora told the tribunal that his original account of how he'd obtained the patient records was incorrect and he'd "completely forgotten" about the involvement of lawyers who'd provided him with documents.

The summaries he'd referred to actually related to four patients - not three - and had been written by himself, he said.

He accepted this was a "completely different" version of events, which had happened more than 4 years ago, and blamed a "lapse of memory".

UPDATE 08.09.21

MANCHESTER—Leading oncologist Professor Justin Stebbing may have sent inappropriate messages to a vulnerable patient out of "kindness" and to "jolly her along" knowing her prognosis was poor, a medical tribunal heard.

Prof Stebbing, who's appearing before a Medical Practitioners Tribunal Service (MPTS) fitness-to-practice hearing, has admitted failing to maintain an appropriate degree of professional distance with the woman, known as Patient E.

The 47-year-old woman, who'd been diagnosed with rare ampullary cancer that spread to her liver, was treated by Prof Stebbing between November 2016 and July 2016.

The tribunal previously heard how they exchanged "flirtatious" messages, and he referred to her as LMT - or 'Little Miss Trouble'.

Many of messages were accompanied with kisses, "love to LMT" or "good LMT". 

Not Wise
Cancer expert Professor Karol Sikora, who's appearing as a Defence witness and is honorary professor of professional practice at The University of Buckingham, was questioned about the messages by Sharon Beattie, QC for the GMC.

He agreed with Ms. Beattie when she said he "would haul them over the coals" if any of his foundation level doctors engaged in similar behavior.

Prof Sikora said Patient E was "vulnerable" but also "manipulative" and commenting on the messages, he said:

"In a sense this was kindness, to keep it going towards the end."

"It's not wise to do it, I'll be the first to admit," he continued.

"But I've done it myself, now and again. Patients are all individual, if that's her way of expressing her feelings, as long as it doesn't go to anything else.

"As long as it doesn't involve a relationship a few emails with a few kisses on them probably doesn't do anyone any harm in the modern world."

Ms. Beattie said he didn't seem to accept that the messages were inappropriate.

Prof Sikora replied that he did agree they were inappropriate but Prof Stebbing had been dealing with a dying and "very demanding" patient and he'd been "jollying her along".

Ms. Beattie accused Professor Sikora of avoiding any criticism on Prof Stebbing's actions in a report to the tribunal but he claimed it was a "technical issue" that wasn't his area of expertise.

Patient D
Prof Stebbing, a cancer medicine and oncology professor at Imperial College London with a private practice in Harley Street, is accused of failing to provide good clinical care to 12 patients between March 2014 and March 2017.

He faces 36 charges - 21 of which he's admitted - which include allegations that he inappropriately treated patients given their advanced cancer or poor prognosis, overstated life expectancy and the benefits of chemotherapy and continued to treat patients when it was futile and they had just weeks to live.

Earlier, the tribunal heard about another patient who was treated by Prof Stebbing, a 44-year-old woman known only as Patient D who'd been diagnosed with breast cancer which then spread to her liver and bones.

Although she'd had previous NHS treatment, by April 2016 her condition had deteriorated and medics at The Christie hospital in Manchester decided it would be inappropriate to carry on treatment.

Prof Stebbing then attempted to obtain private funding from the Grand Masonic Lodge so he could prescribe chemotherapy but his request was turned down.

Nevertheless, he went ahead with the treatment, with her father then having to pay the £3000 bill, but she died 2 days later.

Prof Stebbing is accused of failing to obtain informed consent for the chemotherapy and "inadequately" communicating to Patient D and her family the funding position for treatment.

Ms. Beattie said there had been a clear "failure of communication" by Prof Stebbing who knew "there was a problem" with funding as a letter he sent to the Grand Masonic Lodge 3 days before the chemotherapy indicated it hadn't been authorised.

Prof Sikora said the Grand Masonic Lodge may have contacted the patient directly and the job of the doctor was to "make sure the patient understands where you're progressing to".

He said if he'd written the letter he would have "imagined in the circumstances that there was a good chance of funding being provided in the circumstances."

This prompted an intervention from MPTS panel chair Hassan Khan who said it was clear there was no funding in place prior to treatment and Prof Stebbing "surely" should have informed the patient that was the case.

"That would be wise," said Prof Sikora.

"You would expect the oncologist [to do it] or even a junior member of staff or secretary to phone up and say they haven't got approval."

Risks and Benefits
Ms. Beattie said Prof Stebbing's letter had claimed medics at The Christie "seemed to be taking an enormously long time" to make a decision on treatment, which wasn't correct, and he'd failed to check with the hospital.

Prof Stebbing is also accused of failing to discuss the risks and benefits of not having chemotherapy with the patient and failing to appropriately communicate the rationale for treatment and her likely prognosis.

Ms. Beattie said these discussions "could not be underestimated" in Patient D's case given she'd had extensive previous treatment, the progression of her cancer and her "bleak" prognosis.

She said the patient had the option of a "comfortable and dignified departure" and that should have been "spelled out" to her.

 But Prof Sikora argued that the patient had wanted to continue active treatment and there was a chance she could have got better and Ms. Beattie was using a "retrospectocope" to look at the patient's outcome.

Ms. Beattie said when doctors were faced with patients "who didn't want to hear the news" they had a responsibility to do so.

"If you remove hope, you do it at your own peril," Prof Sikora replied.

But he admitted a conversation should take place before a joint decision was taken whether to go ahead with treatment.

Ms. Beattie said there was a "slim or negligible" benefit from the chemotherapy prescribed by Prof Stebbing.

But Prof Sikora claimed there had been a "significant" chance of response to treatment - around 30% in his estimation - although Ms. Beattie described his opinion as a "gut instinct" because it wasn't based on any medical evidence.

The hearing is continuing.

Expert Witness gives "misleading" evidence in an Oncologists tribunal

MANCHESTER—Cancer expert Professor Karol Sikora has blamed "confusion" and his poor memory for providing "misleading" information to the medical tribunal involving leading oncologist Professor Justin Stebbing.

6 Sept 2021

JOHN Hector Bolam was running out of options in the summer of 1954. He had been suffering from depression for more than a decade and now voluntarily admitted himself to the Friern Psychiatric Hospital in London. What happened to him there would have consequences for medical practice both in the UK and around the world, and would define the law on negligence for decades to come.

Bolam was born in County Durham at the very start of the 20th century. Unfortunately, this meant that he belonged to the generation that found itself of age to fight in both World Wars.

During the Second World War, he had been commissioned in the Royal Engineers, but because of his depression was invalided out of service in 1942. His mental health did not improve, and in 1954 he attempted suicide and was admitted for the first time to Friern Hospital. He is reported to have made a good recovery with rest, was discharged and returned to work as a car salesman in London. However, only six weeks later he relapsed and found himself again in need of in-patient care at Friern. On this admission, he was examined by a consultant psychiatrist attached to the hospital and a course of electro-convulsive therapy (ECT) was recommended.

Treatment risks
Mr Bolam was asked to sign a consent form for the procedure, which he duly did, and his first treatment was uneventful. However, during his second treatment, which was administered by a senior registrar in the hospital, Bolam suffered serious injuries. ECT is designed to induce a seizure in the hope that this will provide relief from major psychiatric illness. During the procedure, Mr Bolam was supine with a pillow placed under his back and his chin supported, and a gag in his mouth. Otherwise, he was unrestrained, although a male nurse stood on each side in case he should fall from the couch. Importantly, no anaesthesia or muscle relaxants were administered prior to his treatment. This form of ECT is known as unmodified and even in the 1950s was falling out of favour.

During this second course of ECT, Mr Bolam sustained severe physical injuries as a result of the induced seizure. He dislocated both hip joints with bilateral fractures of the pelvis, which were caused by the head of the femur on each side being driven through the acetabula of the pelvis.

As a result of his injuries, Mr Bolam took legal action and sued the hospital management for damages. He claimed that the hospital had been negligent in allowing the doctor to perform ECT without first administering a muscle relaxant or providing appropriate restraints. He further contended that the doctor had failed to warn him of the risk of fractures during the procedure, which although small was well-recognised, especially as there had been six other cases of unilateral fracture following ECT in the same hospital.

The court case
The case came to court in February 1957 and was heard by Mr Justice McNair. A variety of medical opinion was sought by both sides and what was revealed in court were marked differences in practice. Bolam called a distinguished psychiatrist who remarked that the decision not to provide manual restraint was “foolhardy” and stated that it was his practice always to warn patients of the hazards of ECT. Other expert witnesses offered contrary views and several concurred that it was unnecessary to inform patients of the risk of fracture and agreed that Bolam’s doctor had acted appropriately.

One consultant psychiatrist said: “I have to use my judgment. Giving the full details may drive a patient away. I would not say that a practitioner fell below the proper standard of medical practice when failing to point out all the risks involved.”

Some argued that the use of muscle relaxants and any form of general anaesthesia (so-called modified ECT) rather than being desirable was in fact potentially dangerous and maybe even fatal.

Not the man on the Clapham omnibus
In the course of his summing up to the jury, Mr Justice McNair, made the following remarks on the standard of proof in a negligence suit:

“How do you test whether this act or failure is negligent? In an ordinary case it is generally said that you judge that by the action of the man in the street. He is the ordinary man. In one case it has been said that you judge it by the conduct of the man on the top of a Clapham omnibus. He is the ordinary man. But where you get a situation which involves the use of some special skill or competence, then the test whether there has been negligence or not is not the test of the man on the top of a Clapham omnibus, because he has not got this special skill. The test is the standard of the ordinary skilled man exercising and professing to have that special skill.”

He went on to enunciate the principle, which is at the heart of what is now called the Bolam Test:

“A doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art. ... Putting it the other way round, a doctor is not negligent if he is acting in accordance with such a practice, merely because there is a body of opinion that takes a contrary view.”

Applying this principle, the jury, while expressing their sympathy for Mr Bolam, found for the defendants.

Criticisms of the Bolam Test
This principle underpinning the definition of clinical negligence would be used for the next 50 years and would be upheld by the House of Lords in several important test cases. However, it was not the only case to address this issue. Two years earlier in Scotland, Hunter v Hanley set down broadly similar though not identical principles. These judgements have not been without criticism and have required modification by the courts over the years. When applying the Bolam Test, as originally set down, an act of alleged clinical negligence had to be compared with what was done in standard practice, rather than what perhaps should have been done. Thus, strictly applying the Bolam Test, if bad practice was the norm, no negligence could be proved.

Some felt that this approach stacked the odds against any patient who claimed clinical negligence. In 1997, a House of Lords ruling on another case (Bolitho v. City and Hackney Health Authority) applied the Bolam Test but sought to clarify it by offering a modification. Where there are conflicting bodies of expert medical opinion, if the actions proposed by a body of responsible doctors is not demonstrably reasonable and cannot withstand logical analysis in the court, it will not necessarily constitute a defence. In other words, you cannot defend against negligence on the basis of a practice just because it is current – it also has to be reasonable or logical.

The biggest rejection of the Bolam Test came with the Supreme Court ruling in Montgomery v Lanarkshire Health Board (2015) in relation to consent. That ruling considered a clinician’s duty of care to warn of ‘material risks’. The test of materiality was defined as whether “a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it”.

Accordingly, rather than considering which risks a doctor should discuss with a patient exclusively from the doctor’s perspective, the ruling brought the law in line with contemporary guidance from the General Medical Council and refocused this aspect of consenting discussions firmly on the patient.

Hopeless condition
In that courtroom in 1957, medico-legal history was made, but one man, the unfortunate patient at the centre of it all, hobbled out despondent. The judge, who had described Mr Bolam as being in a “hopeless condition” in the witness box, where he “told the tragic story of [his] sufferings and his experience” could offer him no damages. What he did offer him, however, was a form of immortality. Mr Bolam has now been dead for several decades, but the principle that bears his name, and which deprived him of any compensation for his injuries, lives on.

How a Clapham omnibus and a man called John changed the world of clinical negligence

"A responsible body of medical men"

2 Sept 2021

Recurrent failings in the way X-rays and scans are reported on and followed-up across NHS services are highlighted in the report by The Parliamentary and Health Service Ombudsman (PHSO). It identified several cases in which signs of cancer in X-rays and scans were not reported, leading to delayed diagnoses and poorer outcomes for patients.

Another common issue was inefficient handovers between departments and services. The report documents recurrent themes of varied or poor escalation procedures and communication between hospital teams. Investigations also found that trusts did not learn from previous errors related to imaging, which meant they repeated mistakes.

Ombudsman Rob Behrens concludes that failings related to imaging are found across the NHS, in both primary and secondary care services, and not solely in imaging departments. He calls on the government to commit to a system-wide programme of improvements for more effective and timely management of X-rays and scans.

The report – Unlocking Solutions in Imaging – calls for NHS England and Improvement (NHSEI) and the Department of Health and Social Care to prioritise digital imaging system improvements as a key patient safety concern and ensure there is national guidance on radiology reporting roles and procedures. Individual NHS providers should ensure that radiology staff have allocated time for reflective learning, hospital radiology leads regularly collate and share learnings and intelligence of imaging issues, and that the RCR ensures its guidance on the reporting of unexpected significant findings is clear and continually updated.

Ombudsman Behrens, said: "Now, as the NHS recovers from the devastating impact of the pandemic, we have a vital opportunity to learn from the failings and embed system-wide changes to improve imaging in the health service.

"The evidence-led recommendations I have set out should be implemented swiftly, with collaboration across government and the health sector to strengthen the NHS’s recovery."

RCR President Dr Jeanette Dickson commented: "The Ombudsman’s call for NHS digital shortcomings to be addressed as an urgent patient safety matter is both bold and pivotal. The Covid-19 response has demonstrated the NHS can make rapid digital improvements, such as rolling out remote and networked scan reporting. Innovations in imaging IT must continue as the health service recovers, and trusts must be centrally supported to allocate the staff time and capital investment needed to upgrade IT and alert systems.

"Hospital imaging teams are under more pressure than ever, battling through Covid backlogs on top of spiralling demand for radiology scans and procedures, and it is crucial that any system and local-level efficiencies that can happen, do. Staff desperately need breathing space to implement systems change, but this will only take us so far.

"Latest RCR staffing data shows the NHS needs at least another 2,000 radiologists to meet demand and ensure safe practice. Recent training uplifts for more radiologists are welcome, but must go further to meet future demand. In the short-term Government, the NHS and trusts must work together to actively support and retain radiology teams, or risk an exodus of exhausted imaging staff."

NHS radiology systems require urgent improvement

A REPORT calling for Government and hospital trusts to prioritise improvements to NHS radiology IT systems and alerts processes has been welcomed by the Royal College of Radiologists (RCR).

1 Sept 2021

NHS England has instructed GPs to cancel all tests except those that are ‘clinically urgent’ until mid-September, while warning the shortage of blood test tubes is due to worsen over the coming weeks.

Earlier this month, GPs were told to suspend non-essential blood tests amid a worsening shortage of test tubes sparked by soaring demand and ‘UK border challenges’.

But in a letter sent to GPs today, NHS England clarified its guidance on reducing test tube demand, saying that practices must stop all blood tests until 17 September unless ‘clinically urgent’.

Tests that can go ahead include those required for two-week wait referrals, those that are ‘extremely overdue and/or essential for safe prescribing’ or condition monitoring, those that could prevent a hospital admission or onward referral, or those for suspected sepsis or ‘conditions with a risk of death or disability’, it added.

According to NHS England, supply is ‘forecasted to become even more constrained over the coming weeks’ and while the shortage is ‘anticipated’ to improve ‘from the middle of September’, ‘overall supply is likely to remain challenging for a significant period’. 

It followed warnings from GPs that the ongoing shortage could lead to further abuse from patients as well as potential financial losses and negative CQC ratings.

In today’s letter, NHS England said it has made regulators including the CQC ‘aware’ of the guidance.

It also said it had ‘confirmed’ with NHS Resolution that any clinical negligence claims arising from it ‘will be captured in the usual way by the respective state indemnity schemes’.

Meanwhile, it added that it is seeking ‘alternative products’ to ‘alleviate the constraints’ but that there is ‘also significant pressure on a number of similar products’ and that it will ‘take time’ to import and deliver them in bulk.

It added: ‘Organisations are asked not to switch to alternative products unless doing so in coordination with the Pathology Incident Director and NHS Supply Chain.’

Practices should prepare to provide ‘mutual aid’, while those that have followed the guidance but are still likely to run out of blood test tubes within 48 hours should notify their NHS England regional team and their Pathology Incident Director, it said.

The BMA said doctors have been left in an ‘incredibly difficult position’ and called on NHS England to communicate with patients about the scale of the shortage.

NHS England also told GPs that there are ‘no current plans’ to income-protect affected QOF indicators and that practices should reschedule QOF checks.

This comes as Pulse revealed this week that the BMA is lobbying NHS England for QOF income protection to ensure GP practices are not financially impacted by the shortage.

The letter said: ‘There are a small number of QOF indicators that require a blood test to be undertaken. We appreciate that this temporary position is frustrating for patients and services alike. 

‘It may mean practices rescheduling certain QOF indicator checks for later in the year when supply has improved. Given QOF is an annualised process, there are no current plans to change QOF payment arrangements for these indicators though we will keep this under review.’

Deputy BMA council chair Dr David Wrigley said: ‘Doctors have been left in an incredibly difficult situation, with no choice but to inform their patients that they cannot carry out certain blood tests for the time being and that appointments they may have for a test could be cancelled. 

‘Patients need to have clear information about the scale of the problem, the impact it may have on them and what’s being done to keep them safe. That needs to come from NHS England and very soon.’

He added that NHS England must also clarify ‘as a matter of urgency’ what will happen if GP practices or hospitals run out of stock.

Dr Wrigley said: ‘It’s not unreasonable to question that there must have been a time when NHS England and the Government knew that blood tube supplies were running low, and therefore, to now ask, “Why has nothing been done to mitigate that?”

‘Fundamentally, if shortages are due to a manufacturer not fulfilling its obligations, then it’s clear that much better resilience in the supply chain is needed.’

Previously, GPs were asked to temporarily stop vitamin D testing, as well as screening for pre-diabetes and blood disorders such as dyslipidaemia (raised cholesterol levels), along with allergy testing and routine infertility testing.

GPs to stop all non urgent blood tests until mid September

NHS England has instructed GPs to cancel all tests except those that are ‘clinically urgent’

25 Aug 2021

The trust managing Nottingham's hospitals has been warned by independent inspectors.

Care Quality Commission (CQC) inspectors carried out a review of Nottingham University Hospitals NHS Trust, which runs both the Queen's Medical Centre and City Hospital, and its leadership in July this year.

It says a warning notice has been served meaning the trust is required to it to "take action to improve corporate and clinical governance and oversight of risk".

The inspection comes as yet another blow to the trust, which also runs Ropewalk House, following the tragic deaths of babies at the trust's maternity unit.

In the last decade there have been 201 negligence claims in relation to maternity care, and more than £91m has been paid out in damages in costs to some of the families involved.

Independent investigators will now be looking into a number of serious incidents which happened in the maternity unit.

A CQC follow-up visit in May this year found that although improvements have been made, there was still more work to do.

Regarding the fresh concerns a spokesperson said: “We carried out an inspection of the trust’s leadership in July 2021. Following that inspection, the trust was issued with a warning notice requiring it to take action to improve corporate and clinical governance and oversight of risk, and to ensure a more positive, open and supportive culture across the organisation. We will report on the full findings from the inspection as soon as we are able to.”

Such warnings are issued when care falls below what is legally required, however it is still unclear if the warning notice relates to “continuing failure to comply with a legal requirement”.

If it does, the CQC may take further action.

Responding to the report, Rupert Egginton, deputy chief executive and chief financial officer at NUH, said: “We accept the CQC’s comments.

"Work is already underway to learn from the findings and make improvements so that the organisation is led as effectively as possible and we continue to provide world class care for our patients.”

The warning notice comes after NUH’s maternity services were rated inadequate in 2020 – and

NHS England and the Clinical Commissioning Group (CCG), which provides local healthcare services, also confirmed last month that a review dating back to 2016 will examine baby deaths at the trust.

Dozens of midwives are set to be recruited by QMC and City Hospital in the next few months.

Nottingham Hospitals Must Improve Says Inspectors

CQC inspectors issue a warning to Nottingham University Hospitals NHS Trust following the tragic deaths of babies at the Trust's maternity unit

20 Aug 2021

New practices introduced to help the clinical negligence process during lockdown are set to stay for the time being, claimant and defendant lawyers have indicated.

A protocol agreed last summer by the Society of Clinical Injury Lawyers and NHS Resolution sought to help the conduct of litigation during the pandemic. Changes included more flexibility on limitation periods, greater use of email to serve and receive documents and online examinations of clients for medical expert reports.

Most of the restrictions imposed in England and Wales have now been lifted but the protocol looks set to remain for now.

A spokesperson for NHS Resolution said the organisation wanted to keep cases from escalating into unnecessary litigation and minimise legal costs, and the protocol had been successful in achieving these goals.

‘We hope to build on the increased co-operation that we have seen during the pandemic to deliver better outcomes for everyone involved in these claims,' he said. 

‘This will include discussing what has worked well with the protocol agreed with the legal market so that resolving cases out of court becomes the norm for healthcare claims.’

During the pandemic, settlement meetings and mediation have taken place remotely wherever possible, while interim payments of damages and costs have been made to encourage more cooperation in the progress of claims. Parties have also considered whether costs budgeting needs to take place initially or can be requested to be adjourned in order to save court and other resources.

The protocol was due to be in place indefinitely and subject to review and possible refinement every eight weeks.

SCIL told the Gazette: ‘Whilst we are out of lockdown the effects of the pandemic are still being felt. For example, records take longer and clinical staff are very busy which delays obtaining statements and reports.

‘So the Covid protocol is here to stay for now and I expect that the best parts of it will remain even after the pandemic ends.’

Last week the Association of Consumer Organisations, which represents claimant firms, and the Association of British Insurers agreed to end their lockdown agreement but said that some of the new practices would remain in place informally.

Clinical Negligence Cooperation set to stay

New practices introduced to help the clinical negligence process during lockdown are set to stay for the time being, claimant and defendant lawyers have indicated.

19 Aug 2021

A motion, to be proposed by the North West Regional Council, demands that NHS England ‘cease and desist from negative briefings’ about GP practices.

It comes as Pulse revealed last week that a ‘constructive’ meeting between the BMA and NHS England’s new chief executive has failed to bring GPs back to negotiations, following an ongoing row over suggestions that practices were closed.

The motion reads: ‘This meeting recognises that primary care did not shut during the pandemic, but appropriately changed working practices to protect both patients and staff, continuing to see patients face-to-face where this was necessary, and calls on the BMA to demand NHSE cease and desist from negative briefings suggesting otherwise.’

Next month’s BMA conference will also debate various motions relating to workplace pressures, including one put forward by LMCs that said the pandemic will cause ‘changes to what is available from the NHS which may result in rationing of care’.

The same motion also called on the BMA’s GP Committee to ensure that ‘clinical time can be focused on delivering clinical care, not on meeting burdensome targets or indicators that do not directly promote safe, quality patient care’.

The first motion to be debated, put forward by the main agenda committee, said general practices should be ‘empowered’ to direct their own return to ‘business as usual’.

Another motion calls on the Government to be ‘transparent about the efficacy of the NHS 111 First and other equivalent phone-first services’.

NHS England has said it is conducting an evaluation of the 111 First scheme, but it remains unclear when results are expected to be published.

And another LMC motion demanded that the GPC seeks ‘full immunity for all doctors from clinical negligence claims during the Covid-19 pandemic’ amid indemnity provider concerns that goodwill to clinicians will be ‘lost under a deluge of litigations and demands’.

Other motions for debate include calls for:

The GMC’s right of appeal against MPTS decisions to be removed urgently
A ‘major review’ of regulation processes because they ‘discriminate against BAME doctors’
An urgent indemnity solution for GPs in Northern Ireland, ahead of the upcoming discount rate decision which means it could no longer be ‘viable’ to work there
Motions in full

NORTH WEST REGIONAL COUNCIL: That this meeting recognises that Primary Care did not shut during the pandemic, but appropriately changed working practices to protect both patients and staff, continuing to see patients face to face where this was necessary, and calls on the BMA to demand NHSE cease and desist from negative briefings suggesting otherwise.

CONFERENCE OF LMCS: That this meeting believes that honesty with the UK public is needed about the scale of the backlog in usual NHS care as a result of Covid19, and the time it will take for this to revert to normal standards, and:- 

i) believes that there will be some changes to what is available from the NHS which may result in rationing of care; 

ii) requires GPC to enable and empower individual general practices to dictate the pace of return to ‘business as usual’ for all non-essential services; 

iii) demands that governments provide clear public communication about which treatments and services are not available on the NHS and where to seek help otherwise; 

iv) calls on governments to provide additional funding to enable access to, and support from, mental wellbeing services for the general practice workforce; 

v) calls on GPC to continue to ensure that clinical time can be focused on delivering clinical care, not on meeting burdensome targets or indicators that do not directly promote safe, quality patient care.

THE AGENDA COMMITTEE (TO BE PROPOSED BY CARDIFF AND VALE OF GLAMORGAN DIVISION): That this meeting believes that honesty with the UK public is required with respect to the recovery from the pandemic and:- 

i) endorses the Royal College of Emergency Medicine’s plan for the recovery of Unscheduled, Urgent, Emergency and Acute care; 

ii) insists that general practices should be empowered and enabled to manage their return to “business as usual”; 

iii) believes that substantial new additional financial investment is required to increase and support the necessary workforce, equipment, facilities and support services to achieve recovery of physical, mental health and public health services; 

iv) believes that the private sector should be part of recovery plans for elective care; 

v) believes that all unnecessary bureaucracy and targets distracting from patient care should be suspended until the recovery is complete

CARDIFF AND VALE OF GLAMORGAN DIVISION: That this meeting endorses the Royal College of Emergency Medicine’s plan for a Summer to Recover from the pandemic, specifically for the Governments of all 4 nations of the UK to:- 

i) embed Unscheduled Care firmly into recovery plans and allocate sufficient funding to support the whole Urgent and Emergency Care system; 

ii) expand capacity and restore acute hospital beds; 

iii) be transparent about the efficacy of the NHS 111 First and other equivalent phonefirst services; 

iv) commit to using the 12-hour data from time of arrival for all Emergency Departments to drive plans for winter; and 

v) require their NHS Trusts and Boards to: 

ensure there is adequate alternative care for patients with urgent problems who may be better cared for elsewhere 
use 12-hour data from time of arrival to proactively address crowding and corridor care 
work actively with local health systems to ensure that service provision matches local population need.
CONFERENCE OF LMCS: That this meeting notes the concerns expressed by indemnity providers that the goodwill shown to clinicians in the pandemic will be lost under a deluge of litigations and demands the GPC seeks:- 

i) full immunity for all doctors from clinical negligence claims during the Covid-19 pandemic; 

ii) a Repeal of S2(4) of the Law Reform (Personal Injuries) Act 1948; 

iii) the establishment of an independent body to define the NHS health and social care package which can give an appropriate standard of care for all patients irrespective of the cause of the patient’s care requirements; 

iv) to limit compensation claims to the costs of additional care required; 

v) that we move to a New Zealand no fault compensation scheme.

NORTH WEST REGIONAL COUNCIL: That this meeting urges the BMA to impress on the Government that the proposals on regulation of healthcare professionals must ensure that the GMC’s right of appeal against MPTS decisions is removed.

CONFERENCE OF LMCS: That this meeting believes that the professional regulatory processes discriminate against BAME doctors and demands a major review of the system.

CONFERENCE OF LMCS: That this meeting is seeking assurance that an indemnity solution is found for GPs in Northern Ireland and agreed with NI Department of Health in the near future. This is urgent as the upcoming decision on the discount rate could increase indemnity subscriptions to a level where it would not be viable to work as a GP in NI.

BMA Set To Debate NHS England Negative Briefings

The BMA’s annual representatives’ meeting (ARM) is set to debate NHS England’s ‘negative briefings’ suggesting GP practices were ‘shut’ during the pandemic.

16 Aug 2021

Almost 7,000 people are waiting for lifesaving transplants in the UK - the highest number in six years, estimates by NHS Blood and Transplant show.

The analysis, from April 2020 to March 2021, found some key services closed during the first peak of the pandemic.

But many were rapidly reinstated and overall 80% of NHS transplant work did take place, researchers say.

The figures show 3,391 people were given transplants over the year, with more than 1,180 donating organs.

The report found:

474 patients died while waiting for organs compared with 377 the year before (not all deaths were related to being on the list)
The majority of patients were waiting for kidney transplants
There were 3,391 transplants performed in 2020-2021 compared with 4,820 the previous year - a fall of 30%
According to the report, at the peak of the first wave there were concerns about caring safely for people receiving transplants, as resources were diverted to other parts of the NHS.

Careful judgements had to be made around the risks and benefits of patients undergoing major surgery, as people awaiting transplants can have compromised immune systems, leaving them vulnerable to infections.

As a result, some patients were taken off the transplant list.

Researchers say many transplant centres are still tackling the backlog of referrals and putting people back on waiting lists.

Months before the first coronavirus wave struck the UK in March 2020, Ted Dodd was told he needed a new kidney and was put on a transplant waiting list.

As he watched NHS services become more and more stretched, the 26-year-old ambulance worker from Ely in Cambridgeshire feared he would never get "the call" he needed.

"As someone waiting for an organ, you're already vulnerable so the idea of going into a hospital is terrifying - especially when you know the hospitals are full of covid patients," he says.

In May 2020, doctors told Ted a donor had been found.

"Up until the operation I had been struggling to climb the stairs at home without stopping to take a breath, I was very, very poorly," he explains. "But about two months after the operation, I went for a walk for eight miles with a friend and I didn't even notice it.

"I will never be able to thank the donor and their family enough. The only way I can thank them is by living my life the best that I can. I will stay healthy, eat well and exercise.

"I also like to think that in some way the job that I do, gives back in a small part."

Prof John Forsythe, at NHS Blood and Transplant, acknowledged it had been a worrying time for families, but said patients and families should be reassured that recovery was well under way.

He added: " With a great team effort across clinical teams, deceased organ donation and transplant activity continued for the most urgent patients during the first wave of Covid-19 and returned to pre-Covid levels quite rapidly, with July and August being record summer months for donation and transplantation.

"Each one of us in the wider clinical team of donation and transplant, across the UK, are immensely proud of the work to keep organ donation and transplants happening in the most challenging circumstances.

"But our commitment is nothing compared with donors and their families - the gift of life has been donated in the midst of a tragedy made even more difficult by Covid restrictions."

The report shows the number of families giving the go-ahead for organ donation has risen gradually over the last six years.

There has been a change in the organ donation law since May 2020 in England and March 2021 in Scotland, which means it is now assumed people want to be donors after death unless they register otherwise. There is a similar process in Wales.

Experts emphasise people have a choice, and families will still be consulted if organ donation becomes a possibility.

Lifesaving Transplant List Contains Almost 7,000 People

Almost 7,000 waiting for lifesaving transplants

15 Jul 2021

A House of Commons committee report into maternity safety recommends reforms.

Following the conclusions today of the House of Commons Health and Social Care Select Committee’s report into maternity safety in England, the Medical Defence Union (MDU) welcomed proposals to reform the way compensation costs are calculated. MDU’s Dr Michael Devlin, head of professional standards and liaison, said:

“Today’s report must be a wake-up call not only to improve the safety of maternity services, but also to foster a just and learning culture in which incidents are thoroughly investigated and lessons learned and shared. All of those involved in the delivery of healthcare have a role to play in this.

“We are particularly pleased to see the Committee recommend the Department of Health and Social Care removes ‘the need to compensate on the basis of private healthcare provision where appropriate NHS care is available; and that compensation is standardised against the national average wage’. This means repealing Section 2(4) of the 1948 Law Reform Act. The MDU has long advocated for these reforms which would help to restore much needed balance to the system of clinical claims litigation.

“The scale of claims costs facing the NHS is truly astonishing. In 2019-20, NHS Resolution paid out £2.3bn in compensation for maternity claims alone, representing 40 percent of all clinical claims payments and just under 70% of the estimated annual cost of harm in NHS hospitals in England. While clinical negligence claims are not an indicator of poor medical standards, there is a need, as identified in the report, for litigation reform.

“Every example of negligence takes its toll on the patients and families involved, but the compensation being paid out puts enormous pressure on NHS funding, especially at a time when the NHS needs to recover from the pandemic.

“The government must now bring forward proposals for how it will get control of these unsustainable costs.”

Litigation Reform Proposed by MPs Backed by MDU

MDU backs MPs’ call for litigation reform

7 Jul 2021

Dozens of babies have died or been left brain-damaged after errors during childbirth at one of Britain’s biggest hospitals – while managers failed to properly investigate concerns and altered reports to take blame away from the maternity unit.

An investigation by The Independent and Channel 4 News has uncovered repeated examples of poor care over the past decade at Nottingham University Hospitals NHS Trust, with parents forced to fight to find out the truth about what happened to their child.

Families say that if lessons had been learnt, further tragedies at the hospital could have been prevented. Naomi Lewin, whose baby Freddie died after a harrowing labour, told The Independent: “They don’t listen to families. It’s ignorance. If they don’t learn from it, it’s going to be a repeat cycle over and over and over again.”

During a panicked delivery, Freddie’s throat was cut during an attempt to free him and his leg was so bruised it had become blackened. He died soon after birth with no post-mortem examination despite the traumatic injuries. In another case, a baby died hours after being discharged from hospital despite the mother’s concerns that he had never cried or fed since birth.

Nottingham, which has one of the largest NHS budgets in the UK, is currently facing at least a dozen clinical negligence claims by bereaved families and it can be revealed today that the trust has already paid out more than £91m in damages and legal costs since 2010, including 46 cases of babies left with permanent brain damage and 19 stillbirths as well as 15 deaths.

The trust chief executive today apologised to families and said improvements were being made.

Documents seen by The Independent show that, in some instances, key medical notes were missing or never made, while others were completely inaccurate. The NHS trust failed to properly investigate some deaths for months and, in instances when it did, details were wrong or reviews were watered down by senior management to lessen the criticism.

A draft report into the death of baby Harriet Hawkins in 2016 was changed from concluding that her death had been “directly contributed to” by errors to saying her death “might have been avoided”.

The Nottinghamshire coroner was also told some deaths were “expected” when it later emerged they had been caused by serious neglect. As recently as 2020, the death of a mother after giving birth was labelled as a “low harm” incident.

The avoidable deaths and injuries combined with fears of a lack of action have drawn parallels with maternity units at Shrewsbury and East Kent hospitals, both of which are the subject of independent inquiries. Since revealing the scale of the Shrewsbury maternity scandal,The Independent has campaigned for safer maternity care across the NHS.

Now a whistleblower has told The Independent that a “Teflon team” of managers allowed staffing shortages to build up to dangerous levels, while pleas from midwives were ignored and incidents “swept under the carpet”.

Sue Brydon, who worked as a senior clinical midwife at the trust from the 1980s until her retirement at the end of 2019, said her confidence in the management nosedived to the point she instigated a letter to the trust board in 2018, signed by midwives and doctors, warning of fears for patient safety due to staff shortages.

The letter, which became public last year during an inquest into the death of baby Wynter Andrews, raised “grave concerns” for patients and staff and said the senior leadership at the trust had not listened to fears that staffing levels risked “potential disaster”.

At that stage there were 35 vacant full-time midwife posts. In December last year, when the CQC declared the maternity unit’s care “inadequate”, this had risen to 73.

Speaking publicly for the first time, Ms Brydon said she was “absolutely raging” towards managers when she left the trust: “We used to call them the Teflon team. You couldn’t get through to them. The Teflon team refused to do anything.”

When incidents occurred, it rested on individual doctors and midwives to flag the cases which she said were then screened and discussed at risk meetings where decisions would be made if an investigation was needed.

“Quite a lot of the time when I was on that [committee], there were things that were clearly awful, that should have been triggering statements from staff, that were just swept under the carpet for whatever reason; it was someone’s friend etc. That didn’t happen very often. But it did happen.”

After the 2018 letter to the trust board, she said nothing was done: “We were supposed to have a series of meetings; we had one meeting. All we got was the head of midwifery saying that there wasn’t really a problem.”

The trust claims a series of “workshops” were held with staff following the letter to the board, although staffing levels worsened between 2018 and 2020.

Ms Brydon remains in contact with staff working at the trust now and said people were scared. She said: “There’s a real culture of fear that still exists because everybody feels their registration is on the line if they put their head above the parapet and say anything. My impression is that it is safe, but only because of the extra effort put in by the staff.”

Baby Thomas Seddon was stillborn in May 2017 after a midwife employed by the trust failed to refer his mum Sarah, an NHS pharmacist, straight to hospital after concerns he had stopped moving in the womb. Sarah should have had a full check-up and heart monitoring but this was not done. The midwife later told an investigation by the trust that Sarah had refused a blood pressure and urine check and was advised to go to hospital, which Sarah said was not correct.

The trust did not involve Sarah in this investigation and the paperwork had multiple inaccuracies. A second investigation after Sarah’s complaint resulted in a written apology acknowledging the trust had breached the duty of candour around transparency with families. The midwife involved received an official caution from the Nursing and Midwifery Council.

Data obtained by The Independent shows 201 clinical negligence claims against the trust’s maternity services since 2010, with almost half lodged in the last four years.

Of the 84 closed cases, the NHS paid out £79.3m in compensation, and a further £12.3m in legal costs. The true value of the negligence claims is likely to be significantly higher as data may exclude future payments to support the lives of disabled children.

In the 201 claims, there were 15 deaths, 19 stillbirths, 46 cases of brain damage and 18 cases of cerebral palsy. A total of 25 cases were caused by delays in treatment, another 15 by a failure to respond to an abnormal foetal heart rate and 13 attributed to complications not being recognised.

There were also 12 delays or failures to diagnose conditions, 10 cases of inadequate nursing care, and a total of 16 cases involving staff who failed to monitor the second stage of labour when women were actively giving birth. This latter category alone cost the NHS £16m.

An analysis of hospital patient data for maternity, comparing Nottingham Hospitals to more than 20 other similar major hospitals, showed the trust had a consistently above-average rate of spontaneous, or natural birth, compared with other trusts for every year since 2010.

Its rate of instrumental births switched from being above average until 2013 to below average every year since – similarly since 2010 the trust has had fewer emergency caesarean sections every year than the average.

This data could suggest that women are being left longer to achieve a natural birth at Nottingham than other larger hospitals, potentially increasing risks for those who get into difficulty.

Shrewsbury and Telford Hospital NHS Trust had the highest natural birth rate in England during five out of the eight years between 2010 and 2018 and was among the top three in the remaining years.

East Kent Hospitals University NHS Foundation Trust was fined a record £761,000 earlier this month over failings in the care of baby Harry Richford.

One Nottingham trust manager who asked to remain anonymous said: “The signs were there, along with not just poor-quality investigations and things that just remained unanswered, but some inappropriate behaviours in maternity as well.

“I think the board didn’t piece together a number of things soon enough to realise the scale of the problem.”

Last year, the Care Quality Commission identified a failure of staff to “interpret, classify and escalate” concerning heart rate traces for babies. The watchdog said there had been incidents where staff failed to monitor heart rates or had misinterpreted the readings, leading to cases where babies suffered harm or death as a direct result.

From July to September last year there were 488 incidents in maternity at the trust, with three classed as severe harm, six as moderate harm and 477 as low or no harm. The CQC said it found a number of incidents had been “inappropriately graded” where, for example, babies or women who needed intensive care were labelled as “low harm”. In one case the death of a mother was labelled “low harm”.

In its latest inspection, published in May, the CQC said the trust had made progress but more improvements were necessary. The service remains rated as inadequate.

The regulator has said it has concerns about maternity safety units across the country, telling The Independent 41 per cent are rated as inadequate or requiring improvement on safety.

Natalie Cosgrove, an associate at Switalski’s Solicitors, which is representing more than a dozen families in legal claims against the trust, said the problems had created a “collective grief” for families every time they see another family suffering.

She added: “We have had many families contact us. There is an embedded cultural problem within maternity services at Nottingham and despite the fact staff members have raised concerns, there doesn’t seem to be any substantial changes to those cultural issues.

“When families have raised genuine concerns and suggestions for improvement these have been rebuffed. The trust is failing to learn from its mistakes and at some point, someone external has to take control so more families don’t follow the same patterns.”

The trust told The Independent it had a major program to improve maternity services which included a focus on culture, learning and better governance. Work includes better training for midwives on monitoring women and babies and assessing their risk as well as ongoing recruitment of midwives and obestetricians.

In 2019 it carried out a review of its duty of candour process and launched extra training for staff.

The chief executive of Nottingham University Hospitals NHS Trust, Tracy Taylor, said: “We apologise from the bottom of our hearts to the families who have not received the high level of care they need and deserve, we recognise the effects have been devastating.

“Improving maternity services is a top priority and we are making significant changes including hiring and training more midwives and introducing digital maternity records. We will continue to listen to women and families, whether they have received excellent care or where care has fallen short; it is their experiences that will help us to learn and improve our services.”

High Rate of Baby Deaths After Errors at Nottingham Hospital

Dozens of baby deaths after errors at one of UK’s largest hospitals

29 Jun 2021