1. Mary was referred to the mental health team in November 2019 and was assessed in January 2020, some three weeks later than should have been.
2. There was a delay in Mary receiving psychological therapy. She was still on the waiting list at the time of her death.
3. The evidence was that at the date of inquest, there continued to be a delay in service users receiving psychological therapy. Evidence was heard that balancing capacity and demand, which has increased, remains a challenge. The cases referred are of increasing complexity, as in Mary’s case.
4. Some steps have been taken in an effort to deal with this, such as specific risk assessment training, focusing on intervention treatment plans to aid capacity and throughput, reviewing the skill mix of staff.
5. However, there is the ongoing issue of recruitment and retention of suitably skilled staff by the Trust and the ability to resource this to enable the Trust to function effectively.

This report was sent to NHS Norfolk & Waveney Clinical Commissioning Group, the Secretary of State for Health & Social Care, the Child Death Overview Panel and the Local Safeguarding Board.

• Ms Bruce was cared for in the community by several different District Nurses. This meant that it was not the same nurse who was always seeing the wound. No photographs were taken for reference and the electronic records could not be accessed by the District Nurses while they were in Ms Bruce’s home. This meant that all information that could have been available was not, meaning Ms Bruce’s change in condition was not fully appreciated.
• Leicestershire Partnership Trust has learned from this and District Nurses now have work mobile phones so that they can take photographic evidence of wounds as well as IT technology that means they can access the electronic records while they are with the patient. In addition, they also have a ‘sepsis’ bag containing equipment to record a patient's blood pressure, oxygen saturation levels and temperature.
• Although this lesson has been learned and changes made to prevent future deaths locally, the concern is that the practice that was in place at the time of Ms Bruce’s death may be practice elsewhere.

This report was sent to the Department of Health and Social Care, Leicestershire Partnership NHS Trust and University Hospital of Leicester NHS Trust.

Informed consent and maternal choice regarding mode of delivery

• That this appears to be a recurring theme in obstetric practice. The culture in this area appears to still not fully accept the principles of informed consent set down in case law of the appeal courts (Montgomery) and in NICE guidance (Caesarean Section). It also does not seem to prioritise the wishes of pregnant women or holding full and frank discussions about the risks and benefits and pros and cons of different options.
• He noted that he had concerns that situations might arise, like it appears happened in Rhian’s case, where maternal requests are being made for re-consideration of the mode of delivery owing to feelings of physical weakness, pain or developing ill health.
• Evidence heard at Rhian’s inquest demonstrated that there was very little, if indeed any, recorded (in medical records) discussion held between midwives/obstetricians and Rhian regarding mode of delivery, maternal wishes and risk and benefits of differing management plans.

Infection risk of retained foetus following feticide

• That a significant infection risk (retention of a deceased foetus) is not being given due weight in clinical decisions when a mother is attending for delivery (following feticide).
• There does not appear to be any specific or detailed local, or indeed national, guidance, for obstetricians and midwives which addresses this issue or discusses important considerations such as whether infection can be controlled by antibiotics alone or whether swifter methods of foetal delivery, such as a caesarean section, should be considered, or indeed whether specific microbiology advice needs to be obtained as part of a multi-disciplinary team approach.
• That while cases such as Rhian’s may be rare, consideration could be given as to whether more detailed and specific guidance should be made available to assist clinicians when treating mothers in maternity units following feticide.

This report was sent to Worcestershire Acute Hospitals NHS Trust, Birmingham Women and Children’s Hospital NHS Trust, the Royal College of Obstetricians and Gynaecologists and the Healthcare Safety Investigation Branch.

• The inquest heard that there were significant delays in patients being seen in secondary care for gynaecological referrals from GPs. The inquest was told that these delays had now increased. In November 2020 the wait time for an appointment was 1 month for an urgent appointment and 4 months for a routine appointment. The wait times now in Tameside for gynaecology were 8 months for a routine appointment and 4 months for urgent appointments. The increase in wait times reflected a national picture the inquest was told and reflected a significant backlog and a rising demand across the NHS.
• The inquest heard that understanding and application of the NICE guidance on heavy premenstrual bleeding in General Practice was a factor in recognising the risk to her health and that the risks around heavy premenstrual bleeding were not well understood in General Practice and in particular where it was necessary to expedite referral to specialist services.
• The quality of the documentation in the referral to secondary care form the GP was poor and the inquest was told that this hampered the triage of her case by secondary care. Standardisation of GPs referrals in relation to detail and guidance regarding key information for referral would assist with effective triage and identification of high risk patients by secondary care.
• There was no evidence available that GP practices had clear systems of follow up in relation to referrals to identify where they had not taken place or identify if the risk had increased and to escalate the referral.

This report was sent to the Secretary of State for Health and Social Care and Tameside Clinical Commissioning Group.

Initial delay in seeing a doctor

Mr Collinson was not seen by a Doctor until eight hours after he arrived at hospital. The reason given for this was that the department was highly pressured on this date, and although a junior doctor had assigned the case to them by "clicking", that doctor had not in fact been able to see Mr Collinson. He did not "unclick" the patient and therefore other doctors who may have had capacity were not aware that Mr Collinson had not been seen.

The coroner expressed concerns that that the current system for allocating patients requires a manual check to see whether a patient has actually been seen once they have been allocated. She noted that if they are not seen, there is currently no way of other clinicians being aware of that, and therefore patients could be left for long periods of time without being assessed.

Flaws in the electronic prescribing system process

The doctor who saw Mr Collinson prescribed a prophylactic dose of Enoxaparin rather than the therapeutic dose which she had intended to prescribe. The reason for this was that the electronic prescribing system involves a drop-down box with confusing tables to select the medication. The doctor was under pressure due to the busy department and accepted that this was human error, having accidently selected the wrong medication.

The coroner stated that the current electronic prescribing system does not require a doctor to perform a secondary check to ensure that they have selected the correct medication. She expressed concerns that it is easy to select the wrong medication, particularly when the department is busy and doctors are under pressure. She suggests that this could lead to further fatal outcomes for patients if they are given incorrect medication. 

This report was sent to University Hospitals Birmingham NHS Foundation Trust.

1. Both calls to the 111 service were significantly non-compliant; the call handlers did not correctly complete the algorithm, they did not take into consideration Hannah’s disabilities and inability to verbalise, they failed to recognise Hannah as a complex case requiring transfer to a more senior member of the 111 service despite Hannah’s parents providing sufficient information for that to be the case.
2. The 111 service does not have a sufficiently robust system to manage members of the public with underlying disabilities in that no accommodation is given for it in the completion of the algorithm.
3. The skill and expertise of the ‘clinical advisor’ was wholly inadequate for her position as she had no contemporaneous or relevant experience in working in an emergency department as a nurse. She was also insufficiently robust in her assessment and understanding of Hannah’s condition when the call handler contacted her for advice.
4. Members of the public who contact the 111 are ill-informed with a real risk they are being misled over the role and capability of the 111 service. There is little clarity or understanding by the public that it is based on following and completing an algorithm by individuals who have no need for any qualification in health care and who will only receive a short training programme after they are employed. Hannah’s parents indicated that if they knew this, they would have opted to ring 999 and the outcome would have been different.
5. The 111 service is not a ‘diagnostic’ service yet the ‘call handlers’ have been renamed ‘health advisors’. This is misleading to the public as it implies professionalism which is untrue given their underlying skills and unsubstantiated given it is their role to complete an algorithm.
6. The NHS pathway for ‘Abdominal Pain’ is insufficiently robust or sufficiently discriminatory to effectively deal with the myriad of potential symptoms associated with this complaint.

This report was sent to NHS England and NHS Improvement, Health Education England, NHS Digital and South East Coast Ambulance Service.

He expresses concerns that when Poppy’s mother came to the hospital she did not have a birth plan and the midwives did not attempt to complete one. As a result of this there was no indication as to her preferences for treatment and care throughout her labour. The Coroner also suggests that the Hospital should carry out an urgent review of the use of Kielland’s forceps and in his view decide that they should no longer be used.

This report was sent to Milton Keynes University Hospital NHS Foundation Trust, the Royal College of Obstetricians and Gynaecologists, the Care Quality Commission and the General Medical Council.

Following this incident consideration should have been given to a formal risk assessment to include consideration of her level of observation. The details of the incident should have been fully disclosed to the MDT meeting on 6 June and consideration given to increasing the level of observation. The incident should also have been discussed and disclosed to all members of staff caring for her. On 10 June 2019 Brooke Martin was found secretly fiddling with a bedsheet on two occasions by two different members of staff.. The bedsheet should have been removed and examined, that would have shown that a section of the sheet had been torn off. This would and should have resulted in a full risk assessment and search of her room, that would have resulted in an increase in her level of observations to 1:1 observations. Brooke Martin, if constantly observed or other safety measures put in place would not have been able to tie the ligature that caused her death and would not therefore have died on 11t June 2019.

Coroner's concerns

During the course of the evidence it was explained to the coroner that it had not been possible to access the notes and records from an out of area hospital because not all the health providers were using “System One”. It is a major concern that the various systems used throughout the NHS are not compatible with each other and it is not always possible for each healthcare provider to access the notes and records of the patient.

This situation should be reviewed to see how access across the NHS can be gained to patient records when required. The coroner was told by one senior clinician that when a patient is referred to his specialist mental health unit it is often the case, that is 9 times out of 10, he does not receive all the information of the patient’s history. This would not be the case if he had direct access to the records.

It was noted that the introduction of a filter at the site of the connection increased the potential for the joint to come apart. The Coroner asks whether a more robust docking system could be installed which is less vulnerable to working loose or being inadvertently pulled apart. The report notes that in the case of Mary Land, although the inquest was unable to conclude whether this malfunction contributed to her death, it remains a possibility, and has the potential to contribute to harm in future.

This report was sent to Philips Respironics, the Secretary of State for Health and Social Care and the Mid Yorkshire Hospitals NHS Trust.

Mrs Wiltshire's toileting care plan indicated that she was to be assisted with her toileting needs and she had access to a call bell. However, there were lengthy delays in responding to the call bell and on the night of 22 January 2021 she tried to relive herself without assistance which caused her to fall. She died in hospital on 19 February 2021 from pneumonia caused by the fall and by Covid 19 that she acquired in hospital.

Coroner's concerns:

1. The matron who gave evidence was not aware of obtaining data on response times from the call bell system and had not introduced any other system to monitor response times.
2. Staffing levels were inadequate due to higher dependency of patients with Covid. I heard that one patient had to soil herself in her hand as no one was available to assist her with her toileting needs. Mrs Wiltshire phoned home on occasion to ask her family to call the ward because they were not responding to her call bell. The family could hear other patients on the ward crying out for help.
3. Although Mrs Wiltshire was at risk of falls, no risk assessments were completed on any of the three wards in which she stayed. This suggests a systemic problem across the hospital that requires remedial action. 

His family were asked to take fresh clothes to the Southgate Ward, which they did so in a plastic carrier bag. It had not been communicated to them that this was a ‘restricted item’ on the ward. Joshua was subsequently transferred to Northgate Ward, also within Wedgewood House, on the 15 August 2019. On the 9 September 2019, Josh was found in his room, having died as a result of asphyxia, by deliberately placing a plastic bag over his head and use of a bed sheet around his neck.

The Coroner in his investigation raised concerns regarding the communication of what are restricted and contraband items to the family and friends of patients before they visit the mental health ward. It was noted that while there are signs in the ward detailing items that are contraband, there are also restricted items that can differ from patient to patient, depending on their risk assessment.

He raised specific concerns that:

• No clear system or procedure was in place for family and friends to be notified of any particular items that have been deemed restricted items for their loved one to have in their possession.
• In the absence of this, current inpatients may still inadvertently take a restricted item onto the ward.

The Coroner’s report was sent to the Minister for Patient Safety, Suicide Prevention and Mental Health and the Chief Executive of Norfolk and Suffolk NHS Foundation Trust.

The Coroner raises concerns that:

• The Philips central monitoring station used by the hospital detected the two periods of ventricular standstill but its alarm notification self-terminated when the heart rhythm had corrected.
• Following the Trust’s investigation, they had a discussion with the manufacturers of the equipment to establish whether the alarms can be configured in such a way that the alarm does not self-terminate when certain abnormal heart rhythms correct themselves but it does not appear a software update or alterative system has been developed to remedy this issue.
• Given Phillips is one of the largest providers of cardiac monitoring equipment to the NHS, the Coroner highlighted that there is a risk of future deaths occurring relating to the use of this type of Philips monitoring station without further changes.

This report was sent to Philips Electronics UK Ltd, University Hospitals Birmingham NHS Foundation Trust, NHS England and the family of the patient in this case.

The Trust had put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. The Coroner stated concerns about this as an alternative to being invited to attend an MDT, noting that:

• There is the potential that information will not be recorded accurately or will not be understood in written form.
• This doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views.

The Coroner stated that in their view there is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.

The report states this issue is not confined to Nightingale hospitals, but relates equally to all intensive care settings. It was sent to the Royal College of Anaesthetists and Faculty of Intensive Care Medicine for action and response.

The Report notes that while the Trust concerned in this case, Liverpool Heart and Chest Hospital, have amended their own policy, it is not clear that the external agency that carries out these scans have done so. This report was also sent to the Care Quality Commission.

Follow the link below to read the coroner’s report regarding Mary’s death in full.

Children-particularly small infants do not present like adults when they are very unwell. Nor can they articulate their symptoms in a way that lends itself to prescribed pathway questions and answers and they are not in front of the staff handling the calls who therefore rely on parents for information. Whilst since this event there have been steps to provide training of staff at 111 and Out of Hours services and NHS Digital have reworked the pathways to deal with multiplicity of symptoms there are still concerns re what further steps may be taken regrading cases involving children and infants.

Evidence given at the Inquest was that about 20% of calls to both services relate to sick children. There should therefore be robust systems in place to prevent sick children going without potentially lifesaving treatment. Steps should include:

1. Mandatory annual training for all staff on recognising and interpreting signs and symptoms for all staff taking calls needs to be put in place.
2. A suitably qualified paediatric specialist clinician should be available to discuss or review such cases at all times.
3. The default position and precautionary advice should be- if in doubt call an ambulance.

In 2020, The Healthcare Safety Investigation Branch published an investigation into delayed recognition of acute aortic dissection, which also made safety recommendations.

Follow the link below to read the coroner's report regarding Paul's death in full. 

1. The product description used by Enteral was insufficient to enable the end user to clearly identify that the tube marketed as a carefeed size 14FR feeding and drainage tube would not operate as a 14Fr tube due to the restricting en-fit connector.
2. Enteral sales marketing staff were not trained to recognise the new restriction in the bore of the tube and were consequently unable to advise the end user of the change.
3. The Hospital Trust did not fully evaluate the size 14FR tube prior to replacing all previous drainage tubes (Ryles) with the carefeed 14Fr feeding and drainage tube. Feedback was generally difficult to obtain.
4. Nursing staff did not consider alternative action when the NG tubes were not adequately draining. There was no general recognition of the need to aspirate the tube.
5. There is no compulsory training of clinicians required to undertake root cause analysis.
6. Despite reports to the MHRA and issue of amended instructions for use and a field safety notice the product continues to be promoted as suitable to feeding and drainage. Please see link to the Nursing times.
7. This was a joint inquest into the death of two patients who died in quick succession as a result of the Enteral 14F nasosgastric tube being used for decompression in an emergency situation. Four similar (non-fatal) incidents followed. It was not clear to the hospital that the Enteral connector reduced the bore of the size 14Fr tube. The inquest was aware that other Hospital Trusts had also needed to change the tubes. I am concerned that the product labelling problem identified during these inquests may not be limited to the University Hospital North Midlands but is in fact a much wider problem that merits wider industry investigation and changes.

Read the report relating to Peter Hussey

Read the report relating to Stephen Oakes

1. Mr Day was not informed that there was any risk of death from the surgery he elected to have, even though there is a risk of air embolus, and therefore death, from this procedure. The Consent Form he signed did not make any reference to a risk of death.

2. There was no check carried out for air embolus after the operation.

3. There was confusion between medical staff as to whether or not Mr Day was to be kept in for an over-night stay in hospital. As it turned out, he was not advised to stay in hospital over-night.

3 Mr Day was allowed to leave 3 hours after the operation had concluded. This meant that when he was taken to the Royal London Hospital on the evening of the 15th December, 2020 clinical staff in hospital did not have immediate access to any medical notes concerning his earlier procedure.

The Assistant Coroner listed his concerns and recommendations as follows:

(a) Any patient who elects to have an endoresection operation of an choroidal melanoma faces a risk (however small) of air embolism and therefore death. This must be made clear to all patients undergoing such a procedure.

(b) There ought to be some check/investigation post operation to determine (or to try and determine as best possible) whether air may have entered the blood stream during the operative procedure.

(c) Patients undergoing this operation (which normally lasts between 2-3 hours) should be advised to stay in hospital as an in-patient for at least 24 hours, which would enable careful and extended monitoring of their condition and a swift and informed transfer, if necessary, to an acute care unit of a hospital in the event of a deterioration in their condition. 

The Coroner also noted that although Brandon-Robert's mother was admitted to hospital the day before his death with an infection and a high risk of developing sepsis, he was not also medically assessed. Again, there is no guidance nationally for babies to be medically assessed when a mother is admitted to hospital. UHD have now put in place a local policy titled which provides guidance to be applied when a women presents at the hospital within 28 days following the birth. This advises that when a mother is admitted to a UHD Hospital, the baby should be medically reviewed either in hospital, or at home by the midwifery team, to ensure the medical wellbeing of the baby.

In the report, the Coroner summarises her concerns as per below:

1. I am concerned that due to the lack of national guidance regarding close monitoring of mothers and babies following discharge after birth, and the fact that there is no national guidance for a medical assessment of a baby when the mother is admitted to hospital with potential sepsis, there could be a death in the future.
2. I would therefore request there is a review of the guidance in place for post-natal care following the discharge from hospital in the immediate time following the birth, namely 10 days and a review of the national guidance in place when a mother is admitted to hospital within 28 days of birth, especially when diagnosed with infection and at high risk of developing sepsis.

Follow the link below for the full report and responses to date. 

Whilst the Trust providing care for Jamie Lee Poole, has now remedied this, and routinely test posttransplant patients’ for magnesium levels, this is not the case in other areas. The evidence heard was that, whether these levels were tested routinely and regularly, was very much dependant on trust area. In one area, patients may be tested routinely for this in others they would not. 

Response from the Royal Sussex County Hospital

• Inadequate training of doctors and other medical professionals re eating disorders.
• Lack of formally commissioned service level agreement for the provision of robust and effective monitoring of moderate to high risk anorexia nervosa patients by primary or secondary care providers.
• Lack of robust and reliable data regarding the prevalence of eating disorders.
• The impact of the COVID 19 pandemic.

In total 710 reports were examined, with 3469 concerns being raised. Thirty-six reports expressed concern about having to issue repeat PFDs to the same organisation for the same or similar concerns. Thematic analysis reliability was high (κ 0.89 unweighted) with five emerging primary themes: deficit in skill or knowledge, missed, delayed or uncoordinated care, communication and cultural issues, systems issues and lack of resources. A codebook of 53 subthemes were identified.

The study concludes that PFD reports offer valuable insight. Aggregation and continued analysis of these reports could offer more informed patient safety, workforce development and organisational policy. Improved data quality would allow for possible automation of analysis and faster feedback into practice.