Monday, 25 February 2013

Sacked saline inquiry nurse Rebecca Leighton lodges appeal

Rebecca Leighton was in prison for six weeks before charges were dropped

Sacked Stepping Hill Hospital nurse Rebecca Leighton has lodged an appeal against her dismissal.

Ms Leighton was arrested during an inquiry into contaminated saline solution, linked to three patient deaths at the Stockport hospital.

Criminal charges against her were dropped, but she was sacked by the Stockport NHS Foundation Trust after admitting stealing opiate drugs.

The trust confirmed Ms Leighton's appeal will be heard in February.

A trust spokeswoman said she was unable to comment further until the appeal is concluded.

Poisonings investigated

The nurse, from Heaviley, Stockport, lost her job in early December after a Nursing and Midwifery Council (NMC) heard her admit the drugs theft, which she said she carried out to treat her throat infection.

The NMC lifted a ban order preventing Ms Leighton from nursing, which it had imposed while she was being investigated by police.

She spent six weeks in custody until her release in September.

Police are continuing to investigate the deaths of Stepping Hill Hospital patients, Tracey Arden, 44, Arnold Lancaster, 71, and 83-year-old Derek Weaver, who police said were all administered insulin unlawfully.

Greater Manchester Police confirmed it is also examining the poisoning of 19 other patients, after they were first called in to the hospital on 12 July after an experienced nurse reported a higher than normal number of patients on a ward with "unexplained" low blood sugar levels.

Vertical gaze palsy

Contributors

Jason J S Barton MD PhD, author. Dr. Barton of the University of British Columbia in Vancouver has no relevant financial relationships to disclose.

James Goodwin MD, editor. Dr. Goodwin of the University of Illinois at Chicago has no relevant financial relationships to disclose.

Publication dates

Originally released July 19, 2001; last updated February 27, 2012; expires February 27, 2015

Key points

• Vertical gaze palsies are due to damage to pre-motor structures in the midbrain, namely the rostral interstitial nucleus of the medial longitudinal fasciculus and the interstitial nuclear of Cajal.

• Vertical gaze palsies can involve upgaze, downgaze, or both.

• Parkinsonian conditions with vertical gaze palsies are due most often to tauopathies, such as progressive supranuclear palsy and corticobasal degeneration.

• Several genetic defects can cause cerebellar ataxia with vertical gaze palsies, chief of which is Niemann Pick type C disease.

Historical note and nomenclature

The term “gaze palsy” is best restricted to deficits in conjugate eye movements that affect both eyes. Thus, strictly unilateral problems such as palsies of cranial nerves III, IV, or VI are not gaze palsies, even though they do affect gaze. Likewise, impairments in vergence control, such as convergence or divergence insufficiency, are not gaze palsies, as they do not involve conjugate eye movements.

A fundamental distinction is between vertical and horizontal gaze palsies. Most gaze palsies affect 1 direction in 1 plane of eye movement only, reflecting the separation of the prenuclear control systems for vertical and horizontal eye movement. Reduction of eye movements in all planes is best termed “generalized ophthalmoparesis.” These reductions are most commonly myopathic, occurring with mitochondrial disorders (chronic progressive external ophthalmoplegia, Kearns-Sayre syndrome, MELAS) or muscular dystrophies (myotonic dystrophy, oculopharyngeal dystrophy, congenital fibrosis), among others.

The term “gaze palsy” requires further elaboration. There are many different types of conjugate eye movements, including saccades, pursuit, optokinetic, and vestibulo-ocular responses. The anatomic systems that control these diverge and converge at various levels, and it is possible for some lesions to impair some eye movement systems and spare others. Hence, a left saccadic palsy is a selective gaze palsy affecting only leftward saccades but not leftward pursuit or vestibulo-ocular response. A palsy affecting all types of eye movements should be designated as a nonselective gaze palsy. Most vertical gaze palsies are selective in nature.

In contrast, the terms “partial” or “complete” when applied to gaze palsy indicate whether some motion across midline in the paretic direction is present.

Clinical manifestations

Vertical palsies usually appear selective, affecting primarily saccades. However, though clinical testing often shows sparing of pursuit and vestibulo-ocular range, quantitative testing of eye movements shows that this selectivity is relative and not absolute (Sharpe and Kim 2002). Pursuit gain and vestibulo-ocular reflexes are impaired in many patients, though dissociable. Upgaze palsy is most frequent, combined upgaze and downgaze palsy is next in frequency, and pure downgaze palsy the most unusual (Bogousslavsky et al 1988). Because these are due to lesions of rostral midbrain nuclei, associated signs include pupillary or ocular motor signs of partial nuclear or fascicular third palsies (Castaigne et al 1981; Beversdorff et al 1995), including rarely a wall-eyed bilateral internuclear ophthalmoplegia (Sierra-Hidalgo et al 2010), impaired convergence, and skew deviation (Ranalli and Sharpe 1988; Steinke et al 1992). Somnolence or even a transient fluctuating coma at onset reflects damage to the reticular activating system (Castaigne et al 1981; Bogousslavsky et al 1988; Beversdorff et al 1995). Behavioral disturbances from thalamic damage include hemineglect, amnestic syndromes (Bogousslavsky et al 1988; Beversdorff et al 1995), akinetic mutism, or subcortical demented states with apathy and slowness of thought (Guberman and Stuss 1983).

Upgaze palsy.

This is frequent with unilateral lesions at either the thalamomesencephalic junction (Bogousslavsky et al 1986; 1988), or the posterior commissure, or its nucleus(Buttner-Ennever et al 1982). There are often other signs of the pretectal syndrome. A lesion of the periaqueductal grey matter rarely causes this, perhaps by destroying descending outputs from the riMLF (Thames et al 1984). Rarely, it occurs as a transient effect of right frontoparietal lesions, with bilateral ptosis (Averbuch-Heller et al 1996).

Downgaze palsy. This occurs with bilateral dorsomedial lesions of the rostral intrastitial nucleus of the medial longitudinal fasciculus (Buttner-Ennever et al 1982; Bogousslavsky et al 1988). It is hypothesized that bilateral lesions extending laterally impair upgaze also; therefore, selective downgaze palsy must require a small and specific lesion, accounting for its rarity (Pierrot-Deseilligny et al 1982). Convergence, accommodative responses, and the pupillary near response may all be impaired too (Cogan 1974). The pupillary light response can be affected (Cogan 1974) or preserved (Pierrot-Deseilligny et al 1982). Skew deviation and internuclear ophthalmoplegia can occur (Cogan 1974).

Downgaze is also affected by akinetic movement disorders, most typically progressive supranuclear palsy (Cogan 1974).

Combined up and down gaze palsy. The lesions involve the riMLF or the interstitial nucleus of Cajan, most frequently bilaterally. In the less common unilateral cases the lesion of the ipsilateral riMLF likely also interrupts decussating fibers from the contralateral riMLF. Vertical vestibulo-ocular response frequently appears normal (Buttner-Ennever et al 1982; Page et al 1982; Pierrot-Deseilligny et al 1982; Yamamoto 1989; Bogousslavsky et al 1990), but is sometimes absent (Beversdorff et al 1995) or impaired in 1 direction alone (Guberman and Stuss 1983). Torsional and vertical nystagmus may occur if the interstitial nucleus of Cajal is involved (Ranalli and Sharpe 1988). Bell phenomenon can be absent (Page et al 1982) or inverted (Ranalli and Sharpe 1988).

Pretectal syndrome. This syndrome combines vertical supranuclear palsy, affecting either upgaze alone or both upgaze and downgaze, sparing vestibulo-ocular response range, with a variable number of other signs (Keane 1990). These include light-near pupillary dissociation, with loss of the pupillary light reactions from damage to the pretectum, Collier lid retraction sign, and skew deviation. Horizontal conjugate eye movements are spared but there may be esotropia, exotropia, or convergence insufficiency. An unusual convergence-retraction nystagmus is pathognomonic. Fragmentary pretectal syndrome, with only some of the above features, is common.

Vertical one-and-a-half and other syndromes. Rarely a patient may have a vertical impairment that spares only a single direction in 1 eye. Supranuclear bilateral downgaze paresis affecting all movements combined with monocular elevator palsy occurs with bilateral midbrain infarction (Deleu et al 1989). The opposite, supranuclear bilateral upgaze paresis with monocular depressor palsy, has also been described with unilateral midbrain infarctions (Bogousslavsky and Regli 1984; Miyashita et al 1987; Gulyas et al 2006). A unique case of ipsilateral monocular elevator paresis and contralateral monocular depressor paresis, combined with mild bilateral ptosis, has been reported (Wiest et al 1996). Finally, a patient with supranuclear vertical palsy combined with complete ophthalmoplegia of 1 eye has been described, with the ophthalmoplegia attributed to a combination of oculomotor nerve palsy and pseudoabducens palsy (Thurtell et al 2009).

Vertical congenital ocular motor apraxia is rare (Ro et al 1989; Brown and Willshaw 2003) and has been related to perinatal hypoxia (Hughes et al 1985) or bilateral mesencephalic-diencephalic lesions (Ebner et al 1990).

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Aqueductal Stenosis

General Information

Aqueductal stenosis is one of the known causes of hydrocephalus and the most common cause of congenital (present at birth) hydrocephalus. It can also be acquired during childhood or adulthood. In some cases, this is due to a brain tumor compression (such as a pineal tumor) surrounding the aqueduct of Sylvius.

Symptoms

Symptoms are related to hydrocephalus. Hydrocephalic patients with aqueductal stenosis are more likely to have difficulty looking up (“upward gaze palsy”).

Diagnosis

The diagnosis of aqueductal stenosis is best made by magnetic resonance imaging (MRI), particularly using a special constructive interference in steady state (CISS), or fast imaging employing steady-state acquisition (FIESTA) sequence. CISS imaging is not available at all imaging Centers.

Treatment

Endoscopic third ventriculostomy.
- This technique is generally favored.
- More than 200 endoscopic third ventriculostomies have been performed in adults at UCLA.
Shunt placement.
Endoscopic aqueductoplasty and stent placement.

The Neuro-ICU cares for patients with all types of neurosurgical and neurological injuries, including stroke, brain hemorrhage, trauma and tumors. We work in close cooperation with your surgeon or medical doctor with whom you have had initial contact. Together with the surgeon or medical doctor, the NeuroICU attending physician and team members direct your family member's care while in the ICU. The NeuroICU team consists of the bedside nurses, nurse practioners, physicians in specialty training (Fellows) and attending physicians. UCLA Neuro ICU Family Guide

Friday, 22 February 2013

Hospital food 'sourced from animals reared in poor conditions'

Many of the eggs used by hospitals came from chickens kept in cages

Meat and eggs used in hospital food in England do not meet the animal welfare standards expected by consumers, a survey suggests.

The RSPCA and Campaign for Better Hospital Food study found most chicken, eggs and pork served came from animals reared in basic welfare conditions.

They said this was at odds with the food products people are now buying for themselves.

And they urged the government to take action.

The questionnaire, which was sent to every hospital trust in England, found that 71% of eggs used in hospital cooking are from hens kept in cages.

It also found that around 80% of chicken and pork served in hospitals is from animals reared in conditions that do not meet RSPCA welfare standards.

'Strange'

Yet the RSPCA and Campaign for Better Hospital Food said this contrasts with trends in supermarkets where consumers are increasingly taking account of animal welfare.

They pointed out that more than half of eggs produced in the UK are now cage-free and several supermarkets including Sainsbury's, Waitrose, M&S and the Co-operative have banned cage eggs altogether.

“Start Quote

We want the NHS to serve food for patients that's not only tasty and nutritious, but also sourced ethically”

Department of Health spokesman

In a separate survey of more than 1,000 adults, seven out of 10 people agreed that the welfare of animals should not be compromised in order to produce cheap hospital food.

The two organisations have called on the government to introduce mandatory minimum standards for hospital food in England, to ensure that all eggs are cage-free and all chicken and pork meets RSPCA welfare standards.

David Bowles, head of public affairs at the RSPCA, said: "It is strange that just when you are at your weakest, you are served food that may not be to your taste and can be from animals kept under intensive conditions.

"Even hospitals serving food made from free range eggs in their coffee shops and cafeterias are still delivering food made with cage eggs to patients."

A Department of Health spokesperson said: "We want the NHS to serve food for patients that's not only tasty and nutritious, but also sourced ethically.

"Patients deserve the highest standards, and they have the right to expect food that is high quality and healthy.

"Individual hospitals decide where they buy their food from, but we are encouraging them to adopt the government's buying standards for food.

"They provide clear criteria that encourage environmental sustainability."

Wednesday, 20 February 2013

Jeremy Hunt

Jeremy Hunt warns NHS trusts over 'defensive culture'

Gary Walker broke an NHS gagging clause when he spoke to the BBC

Health Secretary Jeremy Hunt has warned NHS bosses against allowing a culture that is "legalistic and defensive" in dealing with staff who raise concerns over patient care.

In a letter to all English NHS trusts, Mr Hunt highlighted fears that "gagging" clauses were being used to "frustrate" such whistleblowing.

A climate of "openness and transparency" is essential, he said.

It comes after one former NHS trust boss broke a gag to talk to the BBC.

Gary Walker, former chief executive of United Lincolnshire Hospitals Trust (ULHT), said he had been forced out of his job and gagged from speaking out about his concerns over patient safety.

'Positive move'

Analysis

Andrew HoskenBBC Today programme

The row over secret gagging clauses has focused attention on the man at the top of the English NHS, Sir David Nicholson.

His position was already being questioned in the wake of a highly critical report on the Mid Staffordshire Hospitals scandal, where hundreds of patients may have died from neglect and abuse.

However Sir David escaped personal censure from inquiry chairman, Robert Francis QC.

Following the report, another 14 NHS trusts have been placed under investigation.

What makes the gagging row potentially so toxic for Sir David is one of those trusts, the United Lincolnshire Hospitals Trust, has been trying to enforce Gary Walker's gagging clauses with the threat of legal action.

Since Mr Walker broke cover, more people are asking whether Sir David and other senior NHS civil servants can bring about the cultural change and openness Jeremy Hunt and many others consider essential.

In his letter, Mr Hunt called for the NHS to "recognise and celebrate" staff who had "the courage and professional integrity to raise concerns over care".

The health secretary insisted that "fostering a culture of openness and transparency" was essential in creating a climate "where it is easy for staff, present and former, to come forward with any concerns they have relating to patient safety".

Mr Hunt also warned NHS bosses against the "institutional self-defence that prevents honest acknowledgement of failure".

"I would ask you to pay very serious heed to the warning from Mid Staffordshire that a culture which is legalistic and defensive in responding to reasonable challenges and concerns can all too easily permit the persistence of poor and unacceptable care," he said.

Mr Walker, who was sacked in 2010 for gross professional misconduct for allegedly swearing in a meeting, told the BBC he had no choice but to sign an agreement linked to a confidentiality clause in April 2011.

He said he was gagged by the NHS from speaking out about his dismissal and his concerns over the quality of care at the trust.

After breaking the order, lawyers for the trust then warned him he would have to repay £500,000.

Speaking to BBC Radio 4's Today programme on Saturday, Mr Walker applauded Mr Hunt for "clearly taking a personal interest" in his case and the issue of gagging orders.

"I think that's a very positive move."

"I don't think it's simply about the Lincolnshire Trust," he added, calling for Mr Hunt to investigate the "chain of command" that led to the gagging, which he said included the Department of Health, the East Midlands Strategic Health Authority (SHA) and the Lincolnshire Trust.

"I don't think Mr Hunt can investigate his own department so I think he should be looking for someone exceptionally independent from all of this."

'Suppressed and bullied'

BBC Radio 4 Today programme reporter Andy Hosken said Mr Hunt's letter could spell the end of the National Health Service gag if the NHS trusts' chairmen to whom he wrote actually followed the advice and guidance contained within the letter.

Our correspondent said the letter was certainly a warning shot across the bows of the trusts. It appeared the use of these gagging clauses was widespread in the NHS, he added.

Meanwhile, Dr Phil Hammond, chief medical correspondent at Private Eye magazine joined calls for NHS chief executive Sir David Nicholson to stand down.

He told BBC News: "We need to change the culture, we have to change the people at the top. David Nicholson has to go and that's the one constructive thing that Jeremy Hunt could do.

"Unless you have accountability at the top, you won't get it at the bottom."

Health Minister Lord Howe: "It is the right and the duty of any NHS employee to raise concerns"

A spokesman for the East Midlands SHA said it had always acted "appropriately and properly" in the "interest of patients".

And ULHT has said the allegations that they had tried to stifle debate about patient safety issues were "incorrect".

ULHT is one of 14 trusts in England currently being investigated for high death rates, in the wake of the Stafford hospital scandal, where hundreds are believed to have died after receiving poor care.

It emerged on Friday that police and prosecutors are now studying a damning report into failures at Stafford to see whether any criminal charges should be brought against staff.

Friday, 15 February 2013

carers

More than one in 10 providing unpaid care

The number of unpaid carers in England and Wales has reached 5.8 million - a rise of 600,000 since 2001, the Office for National Statistics (ONS) has said.

Figures from 2011 show that the largest increase was in unpaid carers working for 50 or more hours a week.

Wales had a higher percentage of people providing unpaid care compared with any English region.

In England, the highest percentages of unpaid carers were in the North West, North East and West Midlands.

The ONS study into unpaid care in England and Wales, 2011 found that more than 12% of the population in Wales provided some level of care in 2011.

The rise in those providing over 50 hours a week of unpaid care means that across England and Wales there are now 1.4 million people providing round-the-clock care - an increase of 270,000 people since 2001 (25%).

“Start Quote

Too often the costs and pressures of caring for older or disabled loved ones can force families to give up work.”

Helena HerklotsCarers UK

Across local authorities in England and Wales, the number of carers increased in 320 authorities and fell in just six.

In Birmingham, the number of unpaid carers increased by more than 9,000 between 2001 and 2011.

Across English regions and Wales, the provision of between one and 19 hours was the most common level of care provided.

London was the area with the lowest percentage of unpaid carers at 8.4%.

The study said London's lower level of care provision was likely to be influenced by its younger age structure, the transient nature of its population and differences in household composition.

Family pressure

The provision of unpaid care is an important statistic, the ONS says, because unpaid carers make a vital contribution to the supply of care but their role can also affect their employment opportunities as well as their social and leisure activities.

Unpaid care means care provided to family members, friends, neighbours or others who are disabled, elderly or have long-term health problems. It does not include people providing general childcare.

Heléna Herklots, chief executive of Carers UK said: "Family life is changing as a result of our ageing population and the fact that people are living longer with disability and long-term ill-health.

"Too often the costs and pressures of caring for older or disabled loved ones can force families to give up work to care and lead to debt, poor health and isolation.

"In addition, as more families need help to care, social care support and disability benefits are being cut. This risks putting even more pressure on families, many of whom are already struggling to cope."

mengele plus

Monday, 25 February 2013

Sacked saline inquiry nurse Rebecca Leighton lodges appeal