Woman, 31, died after being left with unqualified healthcare worker who mixed up blood samples and scribbled medical records on plastic surgical gloves
A 31-year-old mentally ill patient died unnecessarily because of a catalogue of errors by A&E staff, an inquest has concluded.
Michelle Jannetta, from Bletchley, Milton Keynes, died at Milton Keynes Hospital on March 8, 2012, after taking an overdose of painkillers.
While at the hospital she was left in the care of unqualified healthcare assistants, was believed to be faking her illness despite being in a deep coma, and was not given the antidote which could have saved her life, the inquest heard.
Her medical notes were also written on the back of a glove which was subsequently lost, and staff mixed up her blood samples with those from another patient.
The coroner, Tom Osborne, delivered a narrative verdict, which stated that: ‘There was a failure to undertake and report on her regular observations and a failure to recognise her deteriorating condition or the seriousness of her situation that resulted in a lost opportunity to render further effective treatment before she went into respiratory arrest caused by obstruction of her airway, attempts at resuscitation were unsuccessful and she died at 11.18 on 8th March 2012.’
Ms Jannetta, who had a history of mental illness, arrived at the hospital’s A&E department at midnight on March 7, 2012.
Initially, she told staff that she had not taken any drugs. She later told staff she had in fact taken Tramadol.
She was well known to the department’s staff but they failed to administer the antidote which would have counteracted the effects of the painkiller within minutes.
Her family’s lawyer, Carolyn Lowe, a partner in the clinical negligence department of Henmans Freeth LLP, told MailOnline: ‘There is no record of anyone having considered giving her the antidote.
‘The whole attitude of the staff was clouded by the fact that she was a regular attender – she was not treated as the vulnerable patient that she was.’
Ms Jannetta was left in the care of a healthcare assistant, instead of a nurse, and only two sets of formal observations were taken during her 11 hours in the hospital.
One of these sets of results was written on a surgical glove which was then lost.
The second set of observations was taken by a healthcare assistant at 8.30am but she failed to report the seriously abnormal results to her seniors. Ms Lowe said: ‘Either the HCA did not recognise the danger signs or she did, and she failed to pass on the information.
‘If the findings had been passed on, Michelle would have been put on half hourly observations and her rapid deterioration in the following hours would have been spotted.
‘The coroner believes that the observations should have been carried out by a fully qualified nurse because having HCA’s playing this role is a major risk to a patient’s life.’
The inquest also heard that Ms Jannetta had been placed to sleep on her back which resulted in her breathing becoming obstructed and caused her death.
While she was in the hospital staff also mixed her blood gas samples with that of another patient.
She died at 11.20am after she stopped breathing.
Nicola Rose, Ms Jannetta’s sister, said: ‘Michelle may have suffered with mental health issues but to the family she was a fun-loving and caring person who was very much adored by every one of us. ‘Michelle was a very much loved aunt, daughter and sister who we all miss desperately.
‘It has been incredibly difficult to come to terms with her untimely death. We wish she was still here bringing smiles to us all and we’ll never forget her.
‘We can only hope that her tragic death will bring a change to attitudes towards mental health patients who are being treated in a general hospital and make it a safer place for the vulnerable and those struggling with mental illness.’
Ms Lowe added: ‘Michelle’s inquest has highlighted the problems that vulnerable patients with mental health issues can encounter in hospitals and I hope that the Trust will have learnt lessons from this.
‘I can only hope that the family can take some comfort from knowing that as a direct result of Michelle’s death the coroner has written to the Secretary of State for Health asking her to consider changing hospital policy so that observations taken in patients who are seriously ill, like Michelle , are to be carried out by trained nurses.
‘As the coroner said, this should mean that Michelle has not died in vain.’
She told MailOnline: ‘It is clear that due to staff shortages it has become general practice in hospitals for healthcare assistants to take nursing observations.
‘Whilst this may be acceptable in patients that are not seriously ill, for patients that are very ill or have for example taken an overdose, like Michelle, observations should be taken by fully trained nurses who are able to take them and then to interpret them properly.
‘If that had been done on the night that Michelle was admitted to hospital then she would most likely still be here today.’
Joe Harrison, Chief Executive of of Milton Keynes Hospital NHS Foundation Trust, said: ‘Our thoughts are with Michelle’s family at this difficult time.
‘Michelle sadly passed away in our Accident and Emergency Department in March 2012. We are sorry that Michelle did not consistently receive the high level of care that we expect.
‘Since Michelle’s death, we have conducted an investigation to ensure lessons are learned. We will be continuing to improve our service in regard to emergency patients.
‘The Coroner has issued a Rule 43 to the Secretary of State for Health to express his concerns about the national practice of healthcare assistants (HCAs) taking crucial observations.
‘We have already commissioned the Open University to provide training for 50 of our Healthcare Assistants (HCAs) to build on their skills.’
Ofsted chief: raise class sizes to pay top staff more money
Schools could be required to increase class sizes to give the best teachers higher salaries under a new system of performance-related pay, the head of Ofsted has admitted.
Sir Michael Wilshaw said a major reorganisation of lessons and timetables may be needed in many schools to accommodate a more flexible salary structure.
Schools cannot afford to maintain a “highly-paid staff” while keeping class sizes down, he warned.
Speaking in central London, the chief inspector also criticised poor-performing schools that routinely place all teachers on the highest salary level.
He said it was “nonsense” that large numbers of teachers expect a salary increase even when they “don’t teach effectively” and “take too much time off”.
The comments are likely to fuel the row over the new system of performance-related pay, which will be introduced into English state schools from 2014.
Under the plans, heads are being told they can no longer award higher salaries to teachers based on length of service and must hold annual performance appraisals before setting pay rates.
Last month, the Department for Education published guidance suggesting that heads should reward teachers who improve pupils’ exam results, keep order in the classroom and take part in extra-curricular activities.
The move has been savaged by union leaders who claim the system will create tensions in the staffroom and damage teachers’ morale. The National Union of Teachers and NASUWT are already taking strike action over the changes.
But Sir Michael has strongly supported the plans, insisting inspectors will mark down schools that fail to link salaries to performance.
Schools will be expected to pay teachers from their existing budgets.
However, Sir Michael admitted that schools may need major reorganisation and larger class sizes to pay staff more money. The average primary school in England currently has 27 children per lesson, while numbers are set at 20 in secondary education.
“The good heads know they have got these additional freedoms and will reorganise,” he said. “[As] an ex-head teacher, I always said to the staff, ‘I want a highly-paid staff, I want to reward those of you who are prepared to commit yourself to the school and do a good job in the classroom. To do that, might mean that we have larger classes. You can’t have both. You can’t have small classes – small groups – and a highly-paid staff’.”
He added: “It might mean that head teachers have got to make [that choice]… So negotiation with the staff is going to be important.”
Christine Blower, general secretary of the National Union of Teachers, said: “This is an invidious choice no head teacher or governor would want to make. It gives lie to the idea that changes to teachers’ pay are a free chance for heads and governors to pay ‘good teachers’ more. The simple fact is there is no more money in the pot.”
Currently, teachers outside London can earn a standard salary of up to £31,500 but see their pay rise to £34,200 if they pass the “threshold” into the upper pay scale, which is supposed to mark good performance.
But Sir Michael said that it was “nonsense” that more than 90 per cent of teachers were put through the threshold “on the nod” when the system was first introduced.
He added: “It’s a nonsense that we see failing schools where most people are at the top of the scale, and that’s something that inspectors comment on. It’s a nonsense that promotion through incremental progression should not be related to the quality of the teaching.”
Sir Michael said: “I have met teachers who have been upgraded because they don’t teach effectively, they then go on leave, they take too much time off, but still expect a salary increase.
“Of course performance and pay should be linked to those who deliver in the classroom and those that go the extra mile. And to make that judgement, heads have got to take performance management much more seriously.”
A Department for Education spokesman said: “It is vital that schools can recruit and reward the best teachers. We are reforming pay so schools can attract and retain the best teachers who have the greatest impact on their pupils’ achievements.
“We expect heads to be able to judge what is best for their pupils.”
Pregnant women should up iodine intake to increase child’s IQ
They probably should. People used to get iodides with their table salt but the war on salt may leave some people deficient. Low iodides can turn babies into cretins. Sea salt naturally has iodides in it and other salt is usually “iodized”
Women who are pregnant or planning to have children should ensure they consume the right amount of iodine or risk their child having a low IQ, according to researchers.
A study of more than 1,000 pregnant women found those who consumed lower amounts of iodine, which is absorbed from food and found in milk, dairy products and fish, were more likely to have children with lower IQs and reading abilities.
Iodine is essential for producing hormones made by the thyroid gland, which has a direct effect on the development of the foetal brain.
The study by researchers at Bristol and Surrey universities found two thirds of the 1,040 pregnant women they tested were iodine deficient. These women were more likely to have children with lower IQs, and it was found the lower the iodine the lower the IQ and reading ability.
Professor Margaret Rayman of the University of Surrey, who led the study, said: “Our results clearly show the importance of adequate iodine status during early pregnancy, and emphasise the risk that iodine deficiency can pose to the developing infant, even in a country classified as only mildly iodine deficient.”
Researchers have said pregnant women should ensure they get enough iodine by eating dairy products and fish, as well as drinking milk. But they warned against kelp supplements, as they can have ‘excessive levels’ of iodine.
The study, which has been published in The Lancet, used samples from the ‘Children of the 90s’ project, a long term health research project involving 14,000 mothers who enrolled while pregnant during 1991 and 1992. The health and development of their children has been followed ever since.
Dr Sarah Bath, a co-author and registered dietician, said: “Pregnant women and those planning a pregnancy should ensure adequate iodine intake; good dietary sources are milk, dairy products and fish. Women who avoid these foods and are seeking alternative iodine sources can consult the iodine fact sheet that we have developed, which is available on the websites of the University of Surrey and the British Dietetic Association.
“Kelp supplements should be avoided as they may have excessive levels of iodine.”
An earlier study based in Tasmania, published in the Journal of Clinical Endocrinology and Metabolism, showed nine year olds who received insufficient iodine in the womb due to a period of deficiency in the population got lower scores on literacy tests.
LOL. Benny Peiser has called the Royal Society’s bluff
London, 22 May: In response to a suggestion by Sir Paul Nurse, the President of the Royal Society, the Global Warming Policy Foundation has invited five climate scientists and Fellows of the Royal Society to discuss the current state of climate science and its wider implications.
In a letter to Lord Lawson, the GWPF chairman, Sir Paul stated that the Royal Society “would be happy to put the GWPF in touch with people who can offer the Foundation informed scientific advice.”
Sir Paul suggested that the GWPF should contact five of their Fellows: Sir Brian Hoskins; Prof John Mitchell; Prof Tim Palmer; Prof John Shepherd and Prof Eric Wolff.
The GWPF has now invited the five climate scientists to a meeting with a team of members of the GWPF’s Academic Advisory Council and independent scientists and has proposed a two-part agenda:
1. The science of global warming, with special reference to (a) the climate sensitivity to carbon dioxide and (b) the extent of natural variability;
2. The conduct and professional standards of those involved in the relevant scientific inquiry and official advisory process.
“I hope the Fellows of the Royal Society will be happy to meet with our team of scientists so that something positive can come out of Sir Paul’s recommendation,” said Dr Benny Peiser, the Director of the GWPF.
Press release from GWPF
Apology over children taken from UKIP foster pair ‘too little, too late’
The council that told a couple it was removing their foster children because they were members of the UK Independence Party has been accused of attempting to cover up its “ridiculous” mistake after it issued a partial apology.
Rotherham borough council sought to draw a line under the controversy today by issuing a statement in which it admitted giving misleading media interviews but said it was in the children’s “best interests” to remove them.
Nigel Farage, the leader of Ukip, said the authority’s apology for its handling of the case “didn’t go far enough”.
“I’m afraid this is a bully-boy council trying to cover up for a ridiculous error and, as ever, it is ordinary decent people who are made to pay the price,” he said.
The council was widely criticised from all sides of the political spectrum after its social workers removed three siblings of ethnic minority descent from the experienced foster parents last November, saying that the parents’ membership of Ukip meant they supported “racist” immigration policies.
In interviews at the time, Joyce Thacker, the council’s director of children’s services, said the quality of the couple’s care was “not an issue”.
She added: “These children are from EU migrant backgrounds and Ukip has made very clear statements on ending multiculturalism. I have to think about how sensitive I am being to those children.”
The Telegraph, which first reported the story, understands that the husband and wife have not received any apology from Rotherham council and have not had any other foster placements since the siblings were taken away.
The wife said last year that she felt “bereft” to lose the children, adding: “We felt like we were criminals.”
In its statement, the council said it gave the impression in media interviews that the decision to remove the siblings was made solely because the couple were Ukip members.
It insisted that a “detailed” internal review had concluded that it was in the best interests of the children to take them from their foster parents.
The council said legal reasons relating to the welfare of the children prevented it from releasing further details, but it pledged to learn “important lessons” about the way it makes decisions, communicates and shares information.
It added: “The council can confirm that membership of Ukip would not prevent any individual from being considered as a foster carer in Rotherham and could not be a reason for removing foster children from a placement.”
The foster parents declined to comment on the council’s statement, saying they were considering taking legal action against the authority over the way they had been treated and did not want to prejudice any future court hearings.
A friend of the couple said the council’s apology was “too little, too late” and questioned why social services had handled the case so aggressively.
John Gilding, the leader of the Conservative group on Rotherham borough council, said he would be asking questions about precisely what action the local authority had taken to learn lessons and suggested that the response should have led to a resignation.
“For the furore it caused, I would think somebody should have been answerable, but I don’t think that will happen,” he said.
British justice boss to crack down on criminals freed early from jail
Justice secretary Chris Grayling has plans to crack down on criminals who are freed from jail halfway through their sentence.
Mr Grayling said he wanted to get tougher on Britain’s sentencing rules that let inmates walk free from prison early, and said he hoped to provide the public with “reassurance” over the coming months.
His comments follow the release of ex-Cabinet minister Chris Huhne and his former wife Vicky Pryce, who served only two months of an eight-month sentence.
Other offenders who did not serve their full sentence include Karen Matthews, who was released from prison last year after serving half of an eight-year sentence for kidnapping her nine-year-old daughter in Dewsbury, West Yorkshire, sparking a huge manhunt in the area.
Philip Davies, a backbench Tory MP who has campaigned for longer jail terms, said an “overwhelming majority” of the public wanted offenders to serve the terms they were given.
Mr Grayling responded by saying he had “sympathy” with this view and hoped to be able to provide further “reassurance” in coming months, the Daily Mail reported.
The Conservatives have previously said it felt that “many people feel that sentencing in Britain is dishonest and misleading”.
Sources have revealed that Mr Grayling has ordered a review on changing the current sentencing regime, which was introduced by Tony Blair a decade ago, and allows everyone apart from the most serious criminals to go free after serving half their sentence.
Mr Huhne and Ms Pryce, who were jailed for perverting the course of justice by swapping speeding points, benefited from further time being cut from their sentences in exchange for wearing tags.
Mr Grayling’s plans will initially focus on the most serious violent and sexual offenders, where they will have to earn the right to be released, instead of being automatically freed regardless of their behaviour while in jail.
Continuing their education or carrying out work behind bars and showing a willingness to earn the skills to go straight are among possible ways inmates could earn their right to be released.
The plan, which is likely to require additional prison places, will initially be limited to the more serious offenders because of budget constraints.
But Mr Grayling wants to move to a sentencing regime which is easier to understand and will rebuild public trust, with one option being to introduce a system where the courts can specify minimum and maximum sentences.
Under the new system, prisoners will only be able to leave jail after their minimum sentence is served by having earned their release.
Mr Grayling revealed his stance in questions at Westminster yesterday when Mr Davies asked him: “Chris Huhne and his former wife were released from prison recently after serving just two months of an eight-month sentence.
“In surveys that I have conducted, an overwhelming majority of my constituents believe that prisoners should serve their sentences in full. Aside from locking them up for longer, will the Secretary of State say how long he thinks people should serve in prison before they are released?”
Mr Grayling replied: “On this matter, I have a lot of sympathy with what [Mr Davies] says. I am looking closely at this area. I hope to be able to provide further reassurances to him in due course.”
Steve White, deputy chairman of the Police Federation, said prison sentences should do ‘what they say on the tin’.
He said: “It is hugely confusing for the public who read that Chris Huhne is sentenced to eight months and then see him walk out weeks later. The same applies to someone convicted of murder and sentenced to life, something most people think is unequivocal.
“If it does not mean that the courts should say so. They should be open and honest. The idea that you get up to 50 per cent off for good behaviour, which in effect is lack of bad behaviour, is nonsense.”
Men can’t be expected to turn a blind eye to beauty
The last time I was back in Britain and stuck in the bowels of the Central Line on a Tube train limping painfully towards Oxford Circus, I found myself observing a group of teenage girls in prohibitively short skirts. “Look at him,” shrilled the loudest, prettiest member of the pack, pointing out a silver-haired gent peering over the top of his Metro. “He keeps staring at my legs.” The man turned a violent shade of puce and raised his newspaper still higher, in an attempt to block out all the body parts he shouldn’t be looking at.
I felt for him. The girl had very nice legs. The girl knew she had very nice legs, and had chosen to showcase them in a belt of fabric that would draw admiring glances from every male member of that carriage – and a few females besides. Yet she found it demeaning – or “disgusting”, to quote her friend’s empathetic murmur – to be reduced to an object of beauty. Women, she believed, in her indignant, third-wave feminist little head, are more than the sum total of their gloriously appealing body parts. So she happened to be beautiful. So what?
So what, indeed. But women seem to have got themselves into a tangle over beauty. If the media is any reflection (and it is), anyone would think that the majority of women now spend an inordinate percentage of their time worrying about their looks – and the rest of it actively trying to enhance them. Historians will tell you that this has always been the case, only modern women have tools at their disposal that even the corseted and bewigged Madame de Pompadour would have blanched at.
We can dye our skins, suck the fat from our bottoms and thighs, stretch and plump out our faces. We can subject our bodies to intensive fitness regimes, embark on scientifically tested diets and then flaunt parts of ourselves that have for centuries remained hidden in a provocative array of new fabrics and styles. But should any man (or woman) notice or – God forbid – point out the results of our efforts, we immediately rise up in revolt.
Take Laura Fernee, a 33-year-old science graduate from Notting Hill who poutingly decried her own beauty in yesterday’s papers as the reason she was unable to hold down a job. “I’m not lazy and I’m no bimbo,” she mourned. “The truth is my good looks have caused massive problems for me when it comes to employment.” Female colleagues were jealous and male colleagues “were only interested in me for how I looked. I wanted them to recognise my achievements and my professionalism, but all they saw was my face and body.”
Fernee is not alone in her self-made beauty inferno. Just the other day, a scrupulously turned-out, highly attractive friend remarked that a casual comment her boss had made about her dress had left her feeling “patronised”. Last month, President Obama was forced to publicly apologise for calling the California attorney general “good-looking”. Never mind that he had formerly praised Kamala Harris for being “brilliant” and “dedicated” – it was the “good-looking” that stuck in feminists’ throats.
I feel for modern men, just as I felt for the man on the Tube that day. They’re supposed to remain blind to the legions of women strutting through life and the workplace in thigh-highs and low-cut tops. And, of course, it’s our prerogative to do that. But in this digital age, the days of un-self-aware beauties (the most arresting kind of all) are sadly behind us. If you’re lucky enough to have that extra asset (which is all beauty is), use it cautiously – not as a weapon with which to beat the opposite sex. Better still, ignore it.
If Fernee is so disabled by her looks, she’ll be relieved to discover that nothing makes a woman ugly quite so fast as talking about her own beauty.