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Last year, four premature babies died at Great Ormond Street Hospital after having been transferred from University College London Hospitals Foundation Trust following a treatment intended to stop them developing a lung condition.

Another two infants were transferred to GOSH from UCLH but survived. GOSH medics said they had all received a steroid which might have been linked to perforations they received. UCLH stopped performing the procedure but said there was no evidence that the procedure — sometimes called premiloc, following a large-scale study carried out in France — was linked to the deaths.

The effects of the treatment are now being studied. A member of Imperial’s Neonatal Data Analysis Unit is supervising a PhD student’s work on the matter, which is due to report in the next 12 months.

Care of pre-term babies is very difficult and mortality, sadly, is high. But NHS England, the royal colleges and regulators seem to have very little insight into which units are giving this treatment in England. Neither GOSH nor UCLH would confirm whether there had been any referral to coroners.

Recurring risk

Nearly half of hospital inspections for emergency departments and mental health wards have raised concerns over ligature risks for vulnerable patients, HSJ analysis has found.

Reports into urgent and emergency care services and inpatient mental health wards, carried out by the Care Quality Commission over the past six months, were scrutinised by HSJ for common themes.

Ligature risks were a recurring issue, with concerns about management and potential anchor points mentioned in almost half (44 per cent) of the 25 reports published since November.

This included potential ligature points found in mental health rooms and accident and emergency departments. Many of these concerns were around a lack of safeguards taken or poorly monitored adaptations made to dedicated mental health areas.

Presence of ligature points and lack of assessments for them have been raised in high-profile cases of harm and deaths, including the independent review into Greater Manchester Mental Health Trust.

In the 2022 national confidential inquiry into suicide and safety in mental health, experts wrote that reducing ligature points is important as they are directly linked to an increased likelihood of death. They found 80 per cent of mental health inpatients who died were likely to do so by hanging and strangulation.

Also on

An NHSE finance boss has been appointed chief executive of an acute trust in the North West. And don’t forget to tune in to our Health Check podcast every Friday. This week we discuss what the new regime involves and if it will make any difference to the national £3bn deficit.