Day-old baby left brain damaged after horrendous blunder during treatment for jaundice

A day-old baby suffered permanent brain damage when a blood transfusion for jaundice went disastrously wrong at London’s biggest NHS trust.

An investigation into Barts Health found the two doctors and nurse involved in the procedure took out far more blood than they put in.

This caused the girl, referred to only as Baby F, to suffer a collapse and for her heart to stop. She was left disabled and will need care for the rest of her life.

The incident happened in 2010 but only came to light today as one of many appalling NHS blunders highlighted by the Parliamentary and Health Service Ombudsman as it published details of 160 investigations completed between April and June.

The Ombusdman refused to say which of Barts’ three hospitals with maternity units – the Royal London, Newham and Whipps Cross – the case involved, claiming this would breach the child’s confidentiality.

Parliamentary and Health Service Ombudsman Julie Mellor said: “These investigations highlight the devastating impact failures in public services can have on the lives of individuals and their families.

“A shocking case that stood out was that of a one-day-old baby who suffered permanent brain damage at Barts Health NHS Trust in London because a nurse and two doctors made serious mistakes during a blood transfusion.”

A Barts Health NHS Trust spokesman said: “We have recently completed an investigation into the care received and the circumstances surrounding this incident, and intend to share this and its recommendations with the family shortly.

“As this case is currently the subject of on-going legal proceedings, it would be inappropriate for us to comment further at this time.”

Another of the 15 cases in London involved the death of a man two days after a liver biopsy at Barking, Havering and Redbridge NHS Trust (BHRUT), which runs Queen’s in Romford and King George in Ilford.

The man, who was not named, was admitted via the accident and emergency department and was given a biopsy. But consent for the biopsy – in which a small amount of the organ is removed for testing – was not properly obtained. He was not adequately cared for and monitored afterwards.

The ombudsman’s report said: “It is impossible to judge whether the biopsy was safe to proceed with, because of the missing records. We were unable to say if [his] death could have been avoided, but he was not given the best possible chance of surviving.”

BHRUT acting medical director Magda Smith said: “A comprehensive action plan was drawn up following the patient’s tragic death in 2010 and shared with his family. I hope that they are reassured that processes have now been put in place to protect patients who require a similar procedure.
“We have sincerely apologised to the family for the mistakes that were made.”

A third case saw the Royal Free hospital pay the daughter of a patient £1,500 compensation for failures in the last six weeks of his life.

She accused the hospital of giving her father too little help with eating and drinking and claimed he had unexplained wounds and injuries. The ombudsman said the experience worsened her bereavement.

‘Model’ hospital that survived axe requires improvement, say inspectors

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A hospital held up as an example for others in London to follow was today found by inspectors to require improvement.

Chelsea and Westminster, which fought off the closure of its accident and emergency department last year, was marked down across a number of key departments by the Care Quality Commission.

They said increased demand in its A&E had caused delays in assessment and treatment for patients needing to be seen quickly. The hospital also failed to meet the 18-week NHS target for surgery, with longer waits in general surgery, trauma and orthopaedics, urology and plastic surgery.

However is burns unit – which treated the London schoolgirls Katie Gee and Kirstie Trup who had acid thrown at them in Zanzibar last year – its HIV and sexual health services, and a female genital mutilation (FGM) service were “outstanding”. Critical care and maternity – it handles 6,000 births a year including many complex deliveries – were rated “good”.

Chelsea and Westminster, which has 430 beds, was one of the winners in the shake-up of emergency and maternity care across west London, with its selection last year as one of five major hospitals leading to closures at Charing Cross, Ealing, Hammersmith and Central Middlesex. Staff told inspectors the reconfiguration had contributed to the extra pressure.

At the time, doctors leading the Shaping a Healthier Future reorganisation said Chelsea and Westminster set standards for others to follow. But
staff told CQC inspectors, who visted in July, that the reconfiguration had contributed to the extra pressure on its A&E.

In its summary of findings, the report states: “There had been an increase in demand for services, and the capacity in some areas of the trust, such as A&E, experienced difficulties in meeting this additional demand. Staff reported that a contributing factor to this increase was due to the local reconfiguration of services across London.”

Professor Sir Mike Richards, the CQC’s chief inspector of hospitals, said: “When we inspected Chelsea and Westminster Hospital we found that, while staff were caring and compassionate, some of the services we looked at required improvement in some areas.

“Our overall findings highlight the level of variation that can be found within the same organisation. We hope that the trust can quickly build on the good work that we found in most areas to consistently deliver good services across the board.”

Chelsea and Westminster has the highest Caesarean rate in the capital, at 35 per cent of all deliveries. The report said the maternity department’s “leadership and culture needed to improve… to ensure women did not have interventions that might not be needed”.

Staff shortages meant there was reliance on overtime and agency staff, while the acute assessment unit and children’s services “did not always have safe staffing levels”. National medical staffing standards were breached in the A&E department.

The hospital said it had recruited 85 nurses and midwives since July and was spending £10 million on refurbishing and extending its A&E. The work is due to be completed in summer 2016.

It said in a statement: “We have a strong historic A&E performance having been the best performing trust two years in a row. Our A&E performance against the four hour target in October is the best in North West London and so far this year is 96.6%, compared to the national target of 95%.”

Chief executive Tony Bell said: “We are obviously disappointed that we have been rated as requiring improvement and take all of their feedback on board. I believe that the areas in which the CQC have said we must make improvements can be resolved swiftly.”

This is the second CQC report to flag concerns with changes proposed under the Shaping A Healthier Future programme. In August, the CQC warned that maternity services at Northwick Park hospital were under pressure, ahead of the closure next year of Ealing hospital’s maternity unit.

Another report showed the impact on North Middlesex hospital of closing the A&E and maternity department at Chase Farm hospital – an extra 40,000 patients.

Councillor Julian Bell, leader of Ealing council said: “This is the second report in as many months where the chief inspector of hospitals has highlighted concerns about the remaining A&E services in our area. Since the plans to shut A&Es were announced, I have expressed concerns about the ability of the remaining A&E services to cope with extra demand in patient numbers and this second report confirms my fears.

“We are committed to ensuring that our residents have access to the best possible health services available. I will now be writing to the secretary of state for health to reiterate the very real concerns that this council has about the NHS’s plans for accident and emergency services in this area and ask that he assures us that patient safety is not put in jeopardy by further reconfiguration.”

Cyclist discovered brain tumour after being knocked off bike by taxi

Paul and Louise Bartlett 2

A cyclist who ended up in hospital after being run over by a taxi today recalled how it led to the shock discovery of a brain tumour.

Paul Bartlett, 37, (above, with wife Louise), from East Dulwich, underwent a nine-hour operation to remove a tumour “the size of a mushroom” after being admitted unconscious to UCLH following the crash in Soho Square.

Mr Bartlett, who teaches art and design at Kingsford Community School in Beckton, told me: “I feel like the luckiest person in the world to have been hit by a London taxi. I knew nothing about brain tumours until I found out I had one.”

At the time of the crash, in May 2010, he had been working as a coffee shop barista as he prepared to begin his PGCE teacher training.

He recalled: “I woke up in hospital and I didn’t really know what was going on. I went back to sleep and woke up in the morning, and was confronted by a doctor who said: ‘Your helmet saved your life.’”

After recovering from the crash, he was invited onto a research project testing cognitive behaviour. A 15-minute MRI scan revealed the presence of the tumour.

He recalled: “They asked: ‘Have you ever had any trouble with headaches?’ I said no. They said: ‘We would like to refer you to a specialist.’”

Four months later, surgeons at Charing Cross hospital removed the tumour, which was found to be non-cancerous.

Mr Bartlett was among the survivors of brain tumours present at the launch of a new centre of excellence set up by the charity Brain Tumour Research at Queen Mary University of London’s campus in Whitechapel.

A £1 million a year fund has been provided for research into what causes brain tumours. They kill more people under 40 – 306 in 2012 – than any other cancer but receive only one per cent of total cancer research funding. Only 18.8 per cent of people survive for five years after being diagnosed with a brain tumour.

Emily Jones, 27, a PhD student and lecturer at Oxford university, said it took a year and five visits to a GP before her cancerous brain tumour was diagnosed.

Doctors thought she was suffering from stress, vertigo or food intolerance. “I couldn’t finish a can of fizzy drink because tipping my head back would make me feel as though I would fall over,” Ms Jones, from Willesden Green, said.

“What frustrates me is that I was allowed to go on so long. A perfectly healthy 24-year-old woman was having persistent vomiting and extreme dizziness for an extended period, and nobody really thought it was that unusual.”

Almost £41 million was spent on breast cancer research in 2012, about 10 times more than on brain tumours. “I just think it’s very, very scary when you see this expenditure gap between certain types of cancer that have been ‘branded’ a particular colour and the survival rates have increased exponentially, and others such as brain cancer that are really underfunded,” Ms Jones said.

Commons speaker John Bercow, patron of Brain Tumour Research, said the “ghastly scourge” of brain tumours deserved more funding, as it was “sharply and embarrassingly lower than that for other cancers”.

Only one London borough offers three full cycles of IVF

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A call has been made for childless couples to be offered greater access to IVF after a survey found only one London borough was meeting NHS guidelines.

The National Institute for Health and Care Excellence (NICE), the clinical body that decides whether the NHS can afford treatments, called on clinical commissioning groups (CCGs) to stop restricting the fertility treatment.

It said IVF, which costs around £3,000 per cycle, was a “core part of NHS services” and said patients should not be subject to a postcode lottery.

Research by the campaign group Fertility Fairness found that Camden was the only one of 32 CCGs in the capital to offer the recommended three cycles, while Islington offers two. All other areas offer only one cycle.

The group downgraded the claims of seven east London CCGs - Barking and Dagenham, City and Hackney, Havering, Newham, Redbridge, Tower Hamlets and Waltham Forest – to offer three cycles. It found they offered only “three embryo transfers in total” – which could include a fresh embryo and two frozen embryos harvested from the same initial procedure.

Susan Seenan, chief executive of Infertility Network UK and co-chair of Fertility Fairness, told me: “It’s unfair that access to IVF depends on where you live, when national guidance says you should get up to three cycles.

“Not that many people need the third, but there are a few that do. The psychological impact of not having that third puts so much pressure on the woman that it can make a big difference.

”From speaking to patients, it’s very apparent that knowing they have only got one cycle or two causes a great deal of stress. It’s wrong for a CCG to say they don’t agree with the guidance. NICE are the body of experts. They have done all the research.

NICE has no power to compel CCGs to follow its guidelines, leaving local GPs who control each area’s NHS budget free to decide whether to prioritise fertility treatment. This forces many women, especially those aged over 40, who face additional restrictions on IVF on the NHS, to spend vast sums at private clinics.

The move by NICE involved it issuing tougher “quality standards” stating that the NHS should provide three full cycles of IVF for women under 40 who have failed to get pregnant after two years of trying. Women aged 40-42 should receive one full cycle if certain criteria are met.

Fewer than one in five CCGs across the country offer three full cycles. Last month, Mid Essex CCG said it would no longer provide any specialist fertility services except in “exceptional clinical cases”.

Normally one or two eggs are implanted at a time. A full cycle of IVF is defined as the use of any additional fertilised eggs that are frozen rather than implanted. No all women produce eggs of good enough quality to be frozen for future use.

Professor Gillian Leng, deputy chief executive and director of health and social care at NICE, said: “Infertility can have a potentially devastating effect on people’s lives. It can cause significant distress, depression and possibly lead to the breakdown of relationships. It is unacceptable that parts of England are choosing to ignore NICE recommendations for treating infertility. This perpetuates a postcode lottery and creates inequalities in healthcare across the country.”

Woman cyclist critically injured in HGV collision dies of her injuries

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A woman cyclist critically injured in a collision with a HGV on Friday has died of her injuries, police said today.

Her death brings to 10 the total of riders killed in London’s streets this year. It was near the same location at Ludgate Circus where a former Spanish soldier, Victor Manuel Ben Rodriguez, 32, was killed by HGV cycling to an interview in April this year.

City of London police today launched an appeal for witnesses as the 26-year-old’s death was confirmed. The crash happened on Friday morning. She has not yet been named.

Paramedics and a specialist trauma team from London’s air ambulance had fought to keep her alive after she went into cardiac arrest.

A statement from the City Police said: “Officers were called at approximately 11.30am on Friday, 17 October to reports of a collision between a lorry and a cyclist on Ludgate Hill close to the junction with Farringdon Street.

“This morning she died at Royal London Hospital with her family at her bedside. The family have asked for privacy at this time. Detectives from City of London Police are investigating.

“The driver of the lorry stopped at the scene. He has not been arrested at this time. Officers are appealing for witnesses to contact them on 0207 601 2222.”

The location has been earmarked to become part of a segregated cycle superhighway linking King’s Cross and Elephant and Castle.

Help offered to young victims of gang violence at London’s busiest major trauma unit

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Children as young as 11 are part of an “exponential rise” in victims of gang violence requiring life-saving treatment, London’s busiest major trauma centre has revealed.

About a quarter of the 2,500 cases handled by the specialist unit at St Mary’s hospital are patients aged 11 to 25. Last year it saw almost as many young victims of stabbings, shootings and beatings with a blunt weapon (170) as those injured in road collisions (200).

The figures were revealed as St Mary’s today set out plans to “embed” youth workers in its trauma unit for three years to help young people escape from gangs.

A pilot project at King’s College hospital found that victims of gang culture are most likely to be swayed during the “teachable moment” when their presence in hospital brings home the risks they face.

John Poyton, chief executive of Redthread youth charity, which runs the schemes, said: “The moment young people are injured, they suddenly realise they’re not immortal. They realise they’re vulnerable.

“It’s the one time when the kids are able to remove that mask of bravado, and they’re much more honest with themselves. A young person can be laid on a bed scared witless. It’s a window of opportunity.”

Last year the major trauma centre – one of four in London – was treating an average of 11 serious stabbings and one shooting each month.

St Mary’s has seen the total number of cases handed at its major trauma centre increase from 1,932 between April 2011/March 2012 to 2,242 the following year to 2,610 between April 2013/March 2014.

Medics reported an increase in “humiliation wounds”. Dr Asif Rahman, a consultant in paediatric emergency medicine, said: “At the Notting Hill Carnival, we had a lot coming in with buttock wounds.”
“Hundreds” of patients were victims of gang-related sexual violence and exploitation. Dr Rahman said: “We are seeing more and more attendances to A&E of people who are victims of violent crime. It’s a big problem. We see lots of people in their pre-teens who are involved in violence. Some of our patients, at 11 years old, have been involved in some form of gang violence.”

The largest proportion of the hospital’s gang cases were from Brent – 28 per cent – followed by 19 per cent from Kensington and Chelsea and 15 per cent from Ealing.

The £648,000 project is funded by Imperial College Healthcare Charity and the Home Office. Crime prevention minister Norman Baker told me: “I would like to see this become standard practice across the NHS because I think it works.

“The idea you can get to somebody at a moment when they are prepared to listen to you, and stop them being involved in potentially damaging behaviour to themselves, has got to be good.

“The evidence is this sort of work is far more effective than the traditional method of the police trying to hand out fines or prosecute.”

Boris: memory of celebratory cigar forced me to reject ban on smoking in parks

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Boris Johnson has revealed why he refused to implement a smoking ban in London parks and squares – because it would stop people enjoying a celebratory cigar.

The Mayor told how he decided to reject the call from his own health commission to outlaw smoking in Trafalgar Square, Parliament Square and the Royal Parks to reduce the 8,400 premature deaths of Londoners from tobacco each year.

“In considering whether I could support a ban on smoking in large expanses of public space, I had to think back to my own way of life,” he told a City Hall meeting of the capital’s health chiefs.

“About two decades ago, my wife had a baby – my wife and I had a baby, for the avoidance of doubt. It came that point in the whole rhythm of things when everybody except me was asleep.

“I was in such a mood of absolute elation that I did what I don’t normally do. I wondered out into a park in Islington. It was in the middle of winter but I laid on the grass and I had a cigar.

“I don’t want to be in a city where somebody can stand over me and say, I’m so sorry, you have got to pay £115 for the privilege of doing something that is absolutely no harm to anybody else except me.”

Lord Darzi, the cancer surgeon who led the health commission, insisted that London would eventually follow New York and ban smoking in public parks.

He told me: “I have no doubt in my lifetime this will happen.”

The former Labour health minister headed a group of 28 of the most powerful figures in the London NHS in putting a series of proposals to the Mayor to improve public health. They focused on the preventable deaths linked to smoking and obesity.

Mr Johnson backed the call for a ban on fast-food takeaways being able to open near schools but instantly dismissed the call for the smoking ban and on proposals to introduce minimum pricing for alcohol.

Lord Darzi denied he was angry with the Mayor. “I’m not, actually,” he said. “I think we started a fantastic debate and a fantastic dialogue. [The Mayor’s view] doesn’t surprise me. He has his own views. I respect them. I think this is an issue that Londoners will keep talking about.”

Asked whether he had wasted a year of his life, Lord Darzi said: “I don’t think so. If you are doing things for the right reasons… ultimately there is a political reaction to this, and there is the clinical view.”

London borough with 3rd highest birthrate facing closure of maternity unit

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Facing closure: Ealing hospital's maternity unit

Facing closure: Ealing hospital’s maternity unit

Plans to axe the only maternity unit in the London borough with the third highest birthrate were today described as “madness”.

GPs were this afternoon deciding whether to end births at Ealing hospital from next March in the latest stage of a move to provide maternity services at six “super hospitals” in north and west London.

Ealing clinical commissioning group, which controls the budget for maternity services, is considering whether to endorse the Shaping a Healthier Future masterplan for the NHS in north west London and close Ealing’s maternity department.

This would almost certainly be followed within three months with the removal of the hospital’s paediatric services and emergency and in-patient gynaecology. Ealing’s A&E is also due to be downgraded at a later date.

Ealing council leader Julian Bell said: “We oppose it vehemently. Closure will mean expectant mothers travelling further to give birth and this can only increase the risks and dangers to both mother and child.

“It is madness to leave Ealing without a maternity unit when we have one of the highest increases in birthrate in London. The Prime Minister denied that this closure would happen, highlighting the recent £2m investment in Ealing’s maternity unit. We will fight it every inch of the way.”

Dr Onkar Sahota, Labour chairman of the London Assembly health committee, said: “After the debacle of the A&E closures in North West London and the London Ambulance Service at breaking point this is not the time to be closing services. All this will do is to place further pressure on hospitals which are already ‘running hot’ and struggling to cope.”

A report being presented by Shaping a Healthier Future medical director Mike Anderson says the shortage of consultant cover at Ealing – specialists are on duty just 60 hours a week – means expectant mothers do not receive the same quality of care as at neighbouring hospitals.

This means there is an “increasing risk that services will become unsafe” and that allowing the unit to continue operating as normal is a “significant and increasing risk to the public”.

Of the 2,884 births at Ealing in 2012/13, 504 were by emergency Caesarean while 329 required the use of medical instruments such as forceps or ventouse suction cup.

In March, the Care Quality Commission watchdog found that maternity staff at Ealing were not always following guidelines on counting needles and swabs, placing women at risk after delivery. In February 2013, a “never event” – a medical blunder so serious it should never have happened – was recorded when a swab was left inside a mother.

In August, the CQC reported difficulties at Northwick Park’s maternity department – one of the hospitals that would see a rise in births if Ealing’s unit were axed.

Dr Mohini Parmar, Ealing GP and Ealing CCG chairwoman, said: “Ealing hospital maternity unit is currently a safe place for women to give birth. The standards for maternity units are changing and we know that in future Ealing may struggle to meet those standards. This could lead to an unplanned closure which is not fair on women or staff.

“These plans are about improving care for women across north west London. We can do this by increasing consultant cover and investing in six maternity units in NW London, rather than the current seven.”

‘Dangers of cannabis have increased but don’t pretend it’s as addictive as heroin’

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A cannabis expert today warned of the growing dangers of the drug but attacked misleading reports that it was as addictive as heroin.

Professor Wayne Hall said he was increasingly concerned at the increased potency of the drug and its use by children in their teens rather than something first tried by university students.

He said cannabis remained less addictive than alcohol, nicoteen, heroin and cocaine and said it was “not helpful” to have it compared to Class-A drugs in media reports today.

“The intention was not to suggest that cannabis was as harmful or as risky as heroin,” he told the Standard. “It was to make the point there are risks with the use of the drug.

“It’s a drug of dependence like alcohol, nicotine and heroin but not as high a risk.”

His paper, which analysed worldwide research into drug addictions since 1993, said that driving while under the influence of cannabis doubled the risk of a car crash while its use during pregnancy reduced the birth weight of the baby.

Prof Hall, of King’s College London, said the risk of regular users developing schizophrenia in adulthod had increased over the last 20 years from one per cent to two to three per cent.

He said: “As a broad generalisation, the earlier you introduce the use of any drug, the greater the risk. There is probably a bigger risk It’s a combination of a more potent product and earlier initiation that has produced that increase.”

He quotes US research from the early 1990s that the life-time risk of developing dependence on substances ranges from nine per cent for cannabis to 15 per cent for alcohol, 23 per cent for heroin and 32 per cent for nicotine.

He writes that the “evidence for a cannabis withdrawal syndrome has strengthened since 1993” and “it is now difficult that cannabis dependence does not require medical attention”.

He added: “The adverse health and social consequences of cannabis use reported by cannabis users who seek treatment for dependence appear to be less severe than those reported by alcohol and opioid-dependent people.”

St Mary’s hospital has UK’s best major trauma unit, says NHS review

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A London hospital’s major trauma centre has been rated as the best in the country.

The unit at St Mary’s hospital, in Paddington, was judged by NHS England to be the best of 25 centres treating critical injuries typically caused by road collisions, falls, freak accidents and shootings and stabbings.

Inspectors said the unit provided a “high quality” service to patients and was at the centre of an “outstanding” trauma network of hospitals across north-west London.

The unit, which has a trauma theatre and staff on standby 24/7, was praised for its innovation and high patient satisfaction rates. The quality of its care meant St Mary’s had an extra two survivors for every 100 patients treated compared to the UK average.

See here for a story from last year about St Mary’s work to treat victims of gun and knife crime.

Plans are now at an early stage to provide a helicopter landing pad at St Mary’s to speed the transfer of life-threatening cases. This would sit on the roof of a new building that it is hoped will be completed by 2020.

Dr Tracey Batten, chief executive of Imperial College NHS trust, said: “We are delighted that we have been ranked as the number one trauma unit in the country.

“It’s a terrific recognition of the hard work of the staff. But more importantly for patients, it means we have two or three more patients surviving per hundred that we see. We are obviously getting great clinical outcomes.”

The Royal London, in Whitechapel, was praised for a “high standard of care”, “outstanding leadership” of the trauma hospital network in north-east London and work to reduce the threat of knife crime and injury to cyclists.

London’s other two major trauma units, at King’s College hospital, in Denmark Hill, and St George’s hospital, in Tooting, also received positive ratings.

King’s was commended for its “excellent” work on gangs and violence but marked down for the need to take spinal cord injury patients two hours’ drive away to Stoke Mandeville hospital in Aylesbury.

See below for a link to a PDF giving details of all the trauma unit inspections: National Peer Review Trauma National Report July 2014

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