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Found 172 results
  1. Content Article
    Mr Malone was diagnosed with treatment resistant schizophrenia in 1983 and had been sectioned multiple times. In May 2023 he was diagnosed with adult autism. At a review on 31 May he was considered to be stable. On 15 June a routine clozapine review identified sub-therapeutic levels but this was not notified to his clinicians. Sub-therapeutic levels of clozapine are likely to have contributed to a worsening in his symptoms. Around 24 June he was noted to have suffered a significant deterioration – with symptoms of thought disorder, anxiety, and responding to hallucinations – and following a mental health act assessment on 28 June clinicians wanted to detain him under section 2. No inpatient psychiatric bed was available. Whilst he awaited a bed, he remained in the community with daily visits from the mental health team. Last contact was on 1 July when he accepted his medication and appeared more settled. There was no answer when he was visited on 2 July. His room at supported accommodation was entered on 3 July and he was found deceased. Recently he had expressed no suicidal ideation. Post-mortem examination confirmed the medical cause of death was:  1a Cervical spinal cord injury. 1b Laceration. The conclusion of the inquest was that death was the consequence of suicide.
  2. News Article
    Ministers must intervene over systemic failures which are “too big for hospital or ambulance trusts to fix on their own” and have led to multiple preventable deaths, a senior coroner has warned. In a move usually considered rare for such an official, Cornwall and Isles of Scilly coroner Andrew Cox has written to the Department of Health and Social Care a second time over ongoing delays to ambulance responses and long ambulance handovers in the area. Last year he warned the NHS was “broken” after he ruled ambulance and emergency care delays contributed to the deaths of four people. Now, he has sent a similar report on the same types of failings in the deaths of John Seagrove, Pauline Humphris, and Patricia Steggles at Royal Cornwall Hospital to new health secretary Victoria Atkins. Mr Cox wrote: “I set out in my [prevention of future death report] last year my understanding of the reasons for the difficulties that are continuing in the Cornwall & Isles of Scilly coroner area. I do not believe those reasons will have changed significantly. ”The challenges are systemic in nature. They are too big for a single doctor, nurse or paramedic to fix. They are too big for either the hospital trust or the ambulance trust to fix on their own.” Read full story Source: HSJ, 1 December 2023
  3. Content Article
    Peter had a long history of depression, anxiety, and reported suicide attempts. He had acknowledged his reluctance to always engage fully with the treatment offered. On 3 August 2022 he was referred to the home treatment team for crisis intervention. After poor engagement he was transferred back to the community mental health team. On the 14 October he was detained by police under section 136 mental health act after expressing suicidal ideation. He told a psychiatric liaison service nurse he had no ongoing suicidal ideation and was referred to the community mental health team and his GP. He then contacted services further a number of times. On 10 November 2022 Peter was found deceased in his flat having taken a deliberate overdose of his prescribed medication. At the time of his death he was on the waiting list to be allocated a mental health care co-ordinator and there had been no multi-disciplinary meeting with all teams involved to agree how best to work with Peter. His cause of death was confirmed at post-mortem: 1a Carbamazepine toxicity. The conclusion reached was death was a consequence of suicide.
  4. News Article
    Three patients died after delayed transfers from a private hospital within a nine-month period, coroner’s findings reveal. Three prevention of future deaths reports reviewed by HSJ raised concerns about the deaths of patients whose transfer from Spire’s Norwich facility to the NHS hospital in the same city was delayed. The sites, which are one mile apart, are run by £1bn-turnover private company Spire Healthcare and Norfolk and Norwich University Hospitals Foundation Trust respectively. Read full story Source: HSJ, 15 November 2023 Prevention of Future Deaths reports: Geoffrey Hoad (13 September 2023) Prevention of Future Deaths report: Christina Ruse (3 October 2022) Prevention of Future Deaths report: Barbara Hollis (3 October 2022)
  5. Content Article
    Christina Ruse was admitted to the Spire Hospital on 14 December 2021 and underwent a total left hip replacement. Her condition deteriorated and observations were commenced at five minute intervals. Mrs Ruse was reviewed and on further deterioration in her condition it was decided to transfer her to the High Dependency Unit, Norfolk and Norwich University Hospital. On arrival of the ambulance Mrs Ruse was undergoing a further investigatory procedure. On this being completed Mrs Ruse was taken to the Norfolk and Norwich University Hospital, where her condition continued to deteriorate and she died on 15 December 2021.
  6. Content Article
    Barbara Hollis underwent a total left knee replacement operation on 22 February 2022. The surgery was uneventful with no complications, however after her return to the ward Mrs Hollis became restless and confused. Following a review of her deteriorating condition the decision was made to transfer her to the High Dependency Unit at the Norfolk and Norwich University Hospital. Arrangements were made for the transfer and the ambulance service was called at 19.51 and were told that immediate clinical intervention was needed, but the agreed hospital to hospital transfer pathway was not followed. There was a two hour delay in ambulance attendance, during which time Mrs Hollis continued to deteriorate. Mrs Hollis was subsequently taken to the High Dependency Unit at the Norfolk and Norwich University Hospital where her condition continued to deteriorate and she died in the early hours of the 23 February 2022.
  7. Content Article
    This report makes several recommendations to unlock the preventative potential of Prevention of Future Deaths (PFD) Reports. These reports should be viewed as an opportunity for organisations to improve, share good practice, and ultimately prevent custodial deaths – not as criticism to be avoided at all costs. PFD reports have an integral function in ensuring compliance with the state’s duties under Article 2 of the European Convention of Human Rights (ECHR), the right to life, both locally and nationally. This, as well as their immense importance to bereaved families, must be borne firmly in mind.
  8. Content Article
    In England and Wales, law requires that coroners issue a Prevention of Future Death (PFD) report when they believe that action should be taken to prevent future deaths. Prevention of Future Death reports therefore provide an opportunity to learn and prevent harm. This study in the Journal of Patient Safety and Risk Management thematically analyses PFD reports received by the National Institute for Health and Care Excellence (NICE) along with the organisation's response. The study provides insight into the PFD report practices of a national guidance producing and standard setting body in the UK, as well as supporting system-level understanding of current practices in relation to PFD reports. However, the authors note that there are no means to assess if the Chief Coroner's Office and the wider safety system considered NICE's responses adequate or whether the actions taken were effective. 
  9. Content Article
    Patient harm due to unsafe care is the 14th leading cause of death and disability globally. In this paywalled blog, Dr Georgia Richards from the Preventable Deaths Tracker, looks at patient safety through the lens of avoidable deaths.
  10. Content Article
    Harold Pedley, known as Derek, attended his GP surgery during the late afternoon on 21.12.22 and after spending most of that day feeling unwell with symptoms including abdominal pain and vomiting. He was appropriately referred to the hospital and travelled there with his friend after his GP had discussed his case with doctors. Due to a lack of available beds in the assessment unit, Derek needed to remain in the emergency department. Following his arrival at 20.07 hours, doctors were not notified of his attendance. He remained in the emergency department waiting area for almost two hours during which time due to significant pressures faced by the department he was not assessed or spoken to by a medical professional. At 21.59 hours a triage nurse called for him. By then, Derek had been unresponsive for some time and had died, his death confirmed at 22.26 hours. A subsequent post mortem examination revealed he died from the effects of non-survivable extensive small bowel ischaemia caused by a significantly narrowed mesenteric artery. His death was contributed to by heart disease.
  11. News Article
    A coroner has warned that a private hospital is relying on NHS ambulances to transport patients despite “being fully aware” of the pressures on the ambulance service and resulting delays. The warning came at the end of an inquest into a patient who died after a 14-hour wait for an ambulance to transfer him from the private Spire hospital in Norwich to the NHS-run Norfolk and Norwich university hospital a few minutes’ drive away. The last two years have seen a succession of inquests relating to ambulance delays. But in the latest case Jacqueline Lake, senior coroner for Norfolk, expressed concerns over Spire hospital’s use of NHS ambulances when complications and emergencies mean its patients need NHS care. “Spire Norwich hospital does not deal with multi-disciplinary and emergency treatment at its hospital and transfers patients requiring such treatment to local acute trusts, usually the Norfolk and Norwich university hospital,” Lake wrote in a prevention of future deaths (PFD) report. “Spire Norwich hospital continues to rely on EEAST [East of England Ambulance Service NHS Trust] to transport such patients to the acute hospital, being fully aware of the demands placed on the EEAST generally and the delays which occur as a result.” Research suggests that nearly 600 patients were urgently transferred from private healthcare to NHS emergency care in the year to June 2021 across the UK – around one in a thousand private healthcare patients. But previous analysis by the Centre for Health and the Public Interest (CHPI) thinktank found that some private hospitals were transferring more than one in every 250 of their inpatients to NHS hospitals. ‘“Transferring unwell patients from a private hospital to an NHS hospital is a known patient safety risk which all patients treated in the private sector face – including the increased numbers of NHS patients who are now being treated in private hospitals because of government policy,” said David Rowland, director of the CHPI. “And despite numerous tragedies and despite the fact that politicians and regulators are fully aware of this risk, nothing has been done to address it.” Read full story Source: The Guardian, 23 September 2023
  12. Content Article
     On 3 August 2022, Geoffrey Hoad underwent a total hip replacement at The Spire Hospital. On 5 August 2022, Mr Hoad was diagnosed with a paralytic ileus and some respiratory compromise with gradually deteriorating renal function. On 6 August 2022, Mr Hoad’s transfer to Norfolk and Norwich University Hospital was agreed due to possible bowel obstruction, possible pulmonary infection and deteriorating renal function.   Ambulance service was called at 18:16 hours and again at 23.45. On 7 August 2022, the ambulance service was called again at 07.38 hours. The ambulance was on scene at 08:26 hours.         The medical cause of death was: 1a) Sub Acute Myocardial Infarction 1b)  Coronary Artery Atherosclerosis 2) Hospital Admission for Post Operative lieus.
  13. Content Article
    Patient harm due to unsafe healthcare is widespread, potentially devastating, and often preventable. Hoping to eliminate avoidable harms, the World Health Organization (WHO) published the Global Patient Safety Action Plan in July 2021. The UK's National Health Service relies on several measures, including ‘never events’, ‘serious incidents’, ‘patient safety events’ and coroners’ Prevention of Future Deaths reports (PFDs) to monitor healthcare quality and safety. This systematic narrative review of PubMed and medRxiv articles on 19 February 2023 aimed to explore the strengths and limitations of coroners’ PFDs and whether they could be a safety tool to help meet the WHO's Global Patient Safety Action Plan. The authors identified 17 studies that investigated a range of PFDs, including preventable deaths involving medicines and an assessment during the Covid-19 pandemic. The review found that PFDs offered important information that could support hospitals to improve patient safety and prevent deaths. However, inconsistent reporting, low response rates to PFDs, and difficulty in accessing, analysing and monitoring PFDs limited their use and adoption as a patient safety tool for hospitals. The authors concluded that to fulfil the potential of PFDs, a national system is required that develops guidelines, sanctions failed responses and embeds technology to encourage the prevention of future deaths.
  14. News Article
    A London coroner has warned the health secretary that preventable child suicides are likely to increase unless the government provides more funding for mental health services. Nadia Persaud, the east London area coroner, told Steve Barclay that the suicide of Allison Aules, 12, in July 2022 highlighted the risk of similar deaths “unless action is taken”. In a damning prevention of future deaths report addressed to Barclay, NHS England and two royal colleges, Persaud said the “under-resourcing of CAMHS [child and adolescent mental health services] contributed to delays in Allison being assessed by the mental health team”. An inquest into Allison’s death last month found that a series of failures by North East London NHS foundation trust (NELFT) contributed to her death. In her report, Persaud said delays and errors that emerged in the inquest exposed wider concerns about funding and recruitment problems in mental health services. “The failings occurred with a children and adolescent mental health service which was significantly under-resourced. Under-resourcing of CAMHS services is not confined to this local trust but is a matter of national concern,” she said. Read full story Source: The Guardian, 14 September 2023
  15. Content Article
    On 3 August 2022 an investigation was carried out into the death of Allison Vivian Jacome Aules. Allison was 12 years old when she passed away on the 19 July 2022. The investigation concluded at the end of the inquest on the 17 August 2023. The conclusion was that Allison died as a result of suicide, contributed to by neglect.
  16. News Article
    A coroner has strongly criticised a mental health trust for failing to investigate serious incidents promptly. Tees Esk and Wear Valleys Foundation Trust has been told that delays in probing serious incidents may “compromise the quality” of these investigations and hence “their value in preventing deaths”. The warnings, from Jeremy Chipperfield, senior coroner for County Durham and Darlington, come amid an ongoing inquest into the death of TEWV patient Ian Darwin. Mr Darwin died aged 42 in March, and the serious incident review into his death is still ongoing. A recently published prevention of future deaths report relating to Mr Darwin’s death said TEWV’s serious incident death investigations, “at all levels of seriousness, are routinely (if not invariably) significantly delayed and I understand there is no expectation of immediate, or any timetable for eventual rectification”. “In permitting delay of ‘serious incident’ investigations, TEWV may permit lethal hazard to persist for longer than necessary, and compromise the quality of such investigations and hence their value in preventing avoidable deaths.”
  17. Content Article
    On 7 March 2023 the coroner commenced an investigation into the death of Ian Darwin, aged 42. The investigation has not yet concluded and the inquest has not yet been heard. However, during the course of the investigation the inquiries revealed matters giving rise to concern. The coroner concluded that in his opinion there is a risk that future deaths could occur unless action is taken.
  18. News Article
    Dozens of young autistic people have died after serious failings in their care despite repeated warnings from coroners, BBC News has found. Their investigation found issues that were flagged a decade ago are still being warned about now. Two bereaved mothers said lessons had not been learned by their local health authority after the deaths of their teenage sons, two years apart. The coroner who oversaw both cases, noted a repeated failure in care. After the first death, the coroner criticised NHS Kent and Medway for "inadequate support" and said a similar incident may happen if this continued. Two years later, the second autistic teenager died under the care of the same authority. The same coroner found that had the victim received the recommended level of care, he might have got the therapy he needed. In the first piece of research of its kind, the BBC combed through more than 4,000 Prevention of Future Death (PFD) notices delivered in England and Wales over the past 10 years. Read full story Source: BBC News, 7 September 2023
  19. Content Article
    On the 20 February 2019 an investigation commenced into the death of Bethan Naomi Harris who was born on the 16 November 2018 at the St George's University Hospitals NHS Foundation Trust. Bethan Naomi Harris died at Shooting Star Hospice on the 26 November 2018. Her mother's pregnancy had been uneventful. After admission to labour ward labour progressed very quickly indeed and Bethan sustained severe brain injury during delivery. Despite best efforts by the neonatal team she succumbed to her injuries. The Investigation concluded at the end of the Inquest on the 19 November 2019. The conclusion of the inquest was that the medical cause of Bethan's death was (1a) hypoxic ischaemic encephalopathy.
  20. Content Article
    This policy sets out a framework describing how the Trust and its staff will respond to and learn from deaths that occur under their care.It will provide guidance for all staff involved in the mortality review process ensuring clarity on roles, responsibilities and expectations. Reviewing mortality can help make improvements to the quality of care received by patients at the Trust by identifying care related issues. This enables the identification of learning themes and provides evidence of a high standard of care. Mortality is a fundamental component of clinical effectiveness, one of the three dimensions of quality described by Lord Darzi in High Quality Care for all (2008). The Trusts aims are to: Have continuous improvement of our Hospital Standardised Mortality Ratios (HSMR) and the Trusts Standardised Hospital-Level Mortality Index (SHMI) Achieve a year-on-year reduction in avoidable mortality  Improve learning from mortality reviews Ensure robust and timely governance processes regarding mortality outcomes and reviews Provide assurance of mortality processes in the Trust.
  21. Content Article
    Coroners, who hold inquests to determine the causes of unnatural deaths in England and Wales, having recognised factors that could cause other deaths, are legally obliged to signal concerns by sending ‘Reports to Prevent Future Deaths’ (PFDs) to interested persons. This systematic review in Pharmaceutical Medicine aimed to establish whether Coroners’ concerns about medications are widely recognised. The authors found that PFDs related to medicines are not widely referred to in medical journals or UK national newspapers. By contrast, the Australian and New Zealand National Coronial Information System has contributed cases to 206 publications cited in PubMed, of which 139 are related to medicines. The research suggests that information from English and Welsh Coroners’ PFDs is under-recognised, even though it should inform public health. The results of inquiries by Coroners and medical examiners worldwide into potentially preventable deaths involving medicines should be used to strengthen the safety of medicines.
  22. News Article
    Ministers are backing a potentially “dangerous” new model allowing police to reduce their response to mental health incidents after failing to formally assess the risk of harm or death. Officials are monitoring any “adverse incomes” from the National Partnership Agreement, which will see police forces stop attending health calls unless there is a safety risk or a crime being committed. Policing minister Chris Philp said a pilot by Humberside Police gave him confidence in national roll-out, which aims to “make sure that people suffering mental health crisis get a health response and not a police response”. Mental health charities and experts have warned the plans could be “dangerous”, and a coroner raised the alarm following a woman’s suicide after police failed to respond to her disappearance. A report published last month said action was needed to prevent future deaths, warning that the new model could “allow each agency to regard such a situation as the other’s responsibility, whilst nobody is on the ground attempting to retrieve a seriously ill patient”. Read full story Source: The Independent, 26 July 2023
  23. Content Article
    At the time of her death, Heather Findlay, aged 28 years, was in the care of the East London Foundation Trust (ELFT), detained under section 2 of the Mental Health Act at Mile End Hospital. At approximately 3pm on 11 June 2020, she was on s17 escorted leave, standing with a healthcare assistant (HCA) at the front gates of the hospital having a cigarette, when she turned to the HCA, said “I’m sorry I have to do this to you” and ran away. ELFT contacted the Metropolitan Police Service (MPS) at 3.17pm, but by 3.58pm, Ms Findlay had been found by a member of the public in a nearby park. At inquest, the jury came to a conclusion of death by suicide and giving a medical cause of death of: 1a hypoxic ischaemic encephalopathy 1b sodium nitrate toxicity.
  24. News Article
    Relatives of a teenage rape survivor who died after failures by mental health services are joining other families to demand a new body to enforce coroners’ recommendations to prevent future deaths. Campaigners claim the failure to act on hundreds of coroners’ recommendations every year, and to learn from the findings of often expensive inquiries into disasters, means the same mistakes are being repeated. Gaia Pope, 19, was diagnosed with post-traumatic stress disorder after revealing that she had been drugged and raped when she was 16. She was found dead in undergrowth on a cliff 11 days after disappearing in Swanage, Dorset, in 2017. After one of the longest inquests in legal history, the coroner, Rachael Griffin, made multiple reports last year to authorities including the NHS and police to prevent future deaths, but Pope’s family says most have not been acted upon. The Inquest campaign, which works with families bereaved by state-related deaths, is calling for a “national oversight mechanism” to collate recommendations and responses in a new national database, analyse responses from public bodies, follow up on progress and share common findings. Read full story (paywalled) Source: The Times, 27 June 2023
  25. Content Article
    This report highlights the failure to learn from preventable state related deaths in the UK. It focuses on concerns around the implementation of recommendations following inquests, public inquiries, investigations and official reviews, calling for the creation of a new independent public body, a National Oversight Mechanism, to address this. The report was launched as part of the ‘No more deaths’ campaign by Inquest, an independent charity combining specialist support for bereaved people following a state related death with campaigning for justice and change. 
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