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Found 172 results
  1. Content Article
    David Wilson was admitted to Pinderfields Hospital on 27 December 2022 and subsequently underwent a CT scan which indicated an inflammation in the distal section of his colon. To identify the cause of this he underwent a flexible sigmoidoscopy, during which there was a colonic perforation which resulted in his death the following day.
  2. News Article
    A warning has been made over the possible side effects of a common NHS antibiotic by a coroner after a newly retired senior doctor died by suicide. "Respected and experienced" consultant cardiologist Robert Stevenson had no history of depression or mental health problems before he started a course of ciprofloxacin. But just over a week later, the 63-year-old went for a walk and messaged his wife to tell her he had left a note under his pillow. He was later found dead in a nearby wood. The note he had left was said to be "uncharacteristically confused and illogical" with "baseless concerns" that he might have AIDS after taking an online HIV tester kit, an inquest heard. The hearing was told Dr Stevenson hadn't been told about a "potential rare link" to suicidal behaviour in patients who took the drug, as this wasn't in line with medical guidance. Now, coroner Martin Fleming issued a warning to highlight the risk of taking the antibiotic, which is prescribed by the health service for serious conditions. Read full story Source: The Mirror, 20 June 2023
  3. Content Article
    Mr Stevenson was a 63-year-old man who was a very respected and experienced Consultant Cardiologist and General Physician at Huddersfield Royal Infirmary, who resigned from his post in May 2022 to enter full retirement.  On 6 May 2022 he was referred to the urology department for the investigation of possible prostate cancer, when a decision was also made to consult a private Consultant Urologist. In order to relieve his symptoms of prostatitis and to make him ready for an investigative biopsy, he was prescribed ciprofloxacin on the 19 May. He had no previous history of depression or mental health problems. Subsequently on the morning of 30 May 2022, Mr Stevenson left his home address on his own for his usual walk. He had not previously given any indications to his family for them to be concerned for him. At approximately 12.30pm his wife received a Facebook message from Mr Stevenson to indicate that he had left a note under the pillow of his bed.  The note was found to be uncharacteristically confused and illogical given his reference to his baseless concerns that he may have developed AIDs after taking a HIV tester kit he had previously bought on line.  Mr Stevenson was found hanging nearby. Upon the arrival of the paramedics, although resuscitative attempts were made, it was confirmed that he had passed away. During the inquest the coroner was referred by Mr Stevenson’s treating urologist to published literature relating to ciprofloxacin and quinolone antibiotics and a potential rare link to suicide behaviour in patients; although it remained unclear that he was suffering from this side effect, it remained possible for this to be the case.
  4. News Article
    An ambulance service says it has sped up clinical review of lower-priority calls, after a coroner said the new triage process — introduced in response to recent waiting time pressures — ‘will lead to further deaths’. The coroner raised concerns with West Midlands Ambulance Service after a type 1 diabetic patient died following a long delay in deciding whether to send an ambulance. Following a pilot in July 2021, all category 3 and 4 incidents at WMAS, except for a predefined list of exceptions, are sent directly to the trust’s “clinical validation team” to triage patients, with the aim of reducing the need for ambulance call-outs. It is thought a similar approach has been introduced across England since covid, as there have been huge pressures on ambulance capacity. But coroner Emma Serrano has raised concerns about the process in a prevention of future deaths report published this week. The inquest was told that Ms Finch waited 10 hours for her call to be “clinically assessed” and an ambulance call-out approved as the validation team was “under-staffed”. The PFD report also said that there was “no time limit” for assessments to take place, and no prioritisation system. Read full story (paywalled) Source: HSJ, 14 June 2023
  5. Content Article
    On the 9 October 2021 an investigation was carried out into the death of Ms Sandra Diane Finch, a 44 year old woman who had a history of Type 1 diabetes mellitus. The investigation concluded at the end of the inquest on 3 May 2023. The conclusion of the inquest was a narrative conclusion of ketoacidosis due to insulin depravation contributed to by neglect.  The cause of death was: 1a) Ketoacidosis 1b) Uncontrolled Type 1 Diabetes Mellitus 1c) Insulin depravation.
  6. Content Article
    This study aimed to operationalise and use the World Health Organization's International Classification for Patient Safety (ICPS) to identify incident characteristics and contributing factors of deaths involving complications of medical or surgical care in Australia. A sample of 500 coronial findings related to patient deaths following complications of surgical or medical care in Australia were reviewed using a modified-ICPS (mICPS). This study demonstrated that the ICPS was able to be modified for practical use as a human factors taxonomy to identify sequences of incident types and contributing factors for patient deaths.
  7. Content Article
    In January 2023, the Health and Social Care Select Committee opened an inquiry into Prevention. An interdisciplinary group of six academics, clinicians, and a coroner from the University of Oxford, the University of Birmingham, and London made a submission to that inquiry. They made their submission to the Prevention inquiry after reading and analysing more than 4,000 PFDs and working with coroners and bereaved families, which has highlighted that more must be done in health and social care to learn lessons from preventable deaths. Their full submission has now been published which included a table summarising 12 of their research studies relating to preventable deaths and providing recommendations. We have extracted the table which highlights several patient safety concerns and system safety recommendations.
  8. Content Article
    Medicines cause over 1700 preventable deaths annually in England. Coroners’ Prevention of Future Death reports (PFDs) are produced in response to preventable deaths to facilitate change. The information in PFDs may help reduce medicine-related preventable deaths. Authors of this paper, published in Drug Safety, aimed to identify medicine-related deaths in coroners’ reports and to explore concerns to prevent future deaths.
  9. Content Article
    Deaths from opioids have increased in England and Wales, despite recognition of their harms. Coroners’ Prevention of Future Death reports (PFDs) provide important insights that may enable safer use and avert harms, yet these reports involving opioids have not been synthesised. Authors of this commentary, published in the Journal of the Royal Society of Medicine, therefore aimed to identify opioid-related PFDs and explore concerns expressed by coroners to prevent future deaths.
  10. Content Article
    Coroners inquire into sudden, unexpected, or unnatural deaths. We have previously established 99 cases (100 deaths) in England and Wales in which medicines or part of the medication process or both were mentioned in coroners’ ‘Regulation 28 Reports to Prevent Future Deaths’ (coroners’ reports). Authors of this paper, published in Drug Safety, aimed to see what responses were made by National Health Service (NHS) organisations and others to these 99 coroners’ reports.
  11. News Article
    A senior coroner has warned that more allergy sufferers will die due to a “lack of national leadership” following the death of a 17-year-old aspiring doctor. Heidi Connor said the “tragic” case of Alexandra Briess was “not new territory”, citing three recent cases where people had died from anaphylaxis. She has now written to the Government saying lives are at risk without better funding and research into the condition and calling for the appointment of an allergies tsar. The Berkshire coroner’s warning comes after an inquest into the death of “bright and well loved” Alexandra, who died from a reaction to a common anaesthetic. Read full story (paywalled) Source: The Times, 18 April 2023
  12. Content Article
    On 22 May 2021, 17-year-old Alexandra Briess underwent a tonsillectomy and subsequently experienced post-operative bleeding, requiring second operation carried out at Royal Berkshire Hospital on the 30 May. During anaesthesia, she experienced a sudden deterioration and cardiac arrest. Despite extensive resuscitation efforts, Alexandra died on the 31 May. Subsequent investigations have revealed that the most likely cause of her sudden deterioration was an anaphylactic reaction to Rocuronium. In this report, the Coroner highlights connections between this case and three other Prevention of Future Deaths Report’s and suggests there needs to be greater funding and a role within the NHS to coordinate a national approach to prevent/reduce future deaths.
  13. News Article
    According to the South West Ambulance Service Foundation Trust, 104 patient deaths reviewed under National Quality Board guidelines in quarter three of 2022-23 related to delays “which are thought to be a result of pressures within the wider health system”. The trust has stressed the deaths were not necessarily directly caused by delays, but that delays were a “common factor” in the 104 cases. Since July 2019, all ambulance trusts have been required to implement Learning from Deaths reviews following a report by the Care Quality Commission three years earlier, which found that opportunities were being missed to learn from patient deaths. A total of 876 incidents were identified as being within the scope of a review at the end of last year by SWASFT, of which 210 were reviewed. Deaths included in the review occurred while the patient is under the care of the ambulance service, from the initial 999 call being made to their care being transferred to another part of the system or to the point where a decision is made not to convey them to hospital. Read full story (paywalled) Source: HSJ, 4 April 2023
  14. News Article
    A father-of-two died of sepsis three days after being sent home from A&E with antibiotics for a suspected urinary tract infection, an inquest heard. Alex Blewitt, 48, died in July 2022 after suffering a cardiac arrest caused by a perforated bowel and sepsis. Senior coroner for Milton Keynes, Dr Sean Cummings, said Mr Blewitt's death was avoidable. The coroner recorded a narrative conclusion and said he intended to issue a prevention of future deaths report. Mr Cummings said: "The doctor, who saw and assessed Mr Blewitt in the emergency department, did not read the Urgent Care Centre communication that was provided and did not record important factual information in the clinical note. "Mr Blewitt was discharged, but returned two days later when suffering with sepsis due to a previously undiagnosed bowel perforation." Mr Blewitt's widow, Amy Blewitt, said: "Alex was in such pain and kept asking the hospital for help, but they sent him home. "My plea to the hospital is please, please don't let this type of mistake ever happen to anyone else ever again." Read full story Source: BBC News, 22 March 2023
  15. Content Article
    In this audio recording from the 2023 Chief Coroner's Conference at Central Hall Westminster, we hear Dr Georgia Richards present on the work of the Preventable Deaths Tracker. Dr Richards explains why this work was so necessary, how it can be used to reduce future avoidable deaths and why we need to ensure that the learning and data shared in coroner reports has impact on the ground.
  16. News Article
    NHS waiting times, staff shortages and service backlogs have been flagged as concerns in relation to dozens of patient deaths across England and Wales since the start of last year, the Observer can reveal, with coroners facing a succession of inquests concerning ambulance delays. Coroners issue prevention of future deaths reports (PFDs) when they believe preventive action should be taken, and send them to relevant individuals or organisations, which are expected to respond. Among 55 cases identified by the Observer are 24 patient deaths where coroners raised concerns about ambulance delays – all of them occurring before this winter’s ambulance crisis, when response times rocketed to their worst-ever levels. Wes Streeting, shadow health and social care secretary, said: “The NHS is in the biggest crisis in its history – and the crisis has a cost in lives. Patients are waiting for far longer than is safe, with terrible consequences.” But the issues highlighted by coroners in relation to patient deaths are wider than ambulance delays. They include: lengthy elective surgery backlogs; high referral thresholds and long waiting times for children’s mental health services; a national shortage of neurologists; long waiting times for psychological therapies; a lack of mental health beds and unfilled mental health staff vacancies; and a shortage of cardiologists compounded by a shortage of theatre capacity and beds. Read full story Source: The Guardian, 26 February 2023 Further reading on the hub - see a selection of Prevention of Future Deaths reports in our dedicated coroner's report section of the hub.
  17. Content Article
    On 24 May 2022, Mrs Brind went to see her GP and was taken to Queen Elizabeth Hospital arriving at 13.05 hours. The Emergency Department was busy and Mrs Brind remained on the ambulance. Physiological observations were undertaken at 12.50, 13.24 and 13.53 which showed an elevated NEWS2 score. Mrs Brind required increasing oxygen which was not escalated to the ambulance navigator at the hospital, no further physiological observations were undertaken and no ECG was undertaken. Mrs Brind was taken to the ward at 17.30 hours, when she became agitated and short of breath. Advanced life support was put into place but Mrs Brind’s condition continued to deteriorate and she died at 17.52 hours.
  18. News Article
    A woman who died shortly after giving birth to her daughter did not receive the correct medication, a coroner has ruled. Jess Hodgkinson, 26, from Chesterfield, died from a pulmonary embolism in 2021. Assistant coroner Matthew Kewley said there was a "failure" to ensure Ms Hodgkinson received blood thinners right up until the birth. Chesterfield Coroner's Court heard Ms Hodgkinson had a high risk pregnancy due to severe hypertension. On 21 April 2021, a consultant in Chesterfield prescribed a prophylactic dose of tinzaparin due to an increased risk of clotting, the inquest heard. During the inquest, the consultant said the intention was for Ms Hodgkinson to continue to receive a daily dose of anticoagulant medication up until birth. Ms Hodgkinson was transferred to a hospital in Sheffield the next day, but there was a "failure to communicate" the medication plan, Mr Kewley said. After being discharged, clinicians in Chesterfield "failed to identify" Ms Hodgkinson was no longer receiving the medication, the coroner said in his ruling. On 13 May, Ms Hodgkinson attended Chesterfield Royal Hospital and a decision was made to carry out an emergency Caesarean section. The procedure was successful and Ms Hodgkinson's baby was born. But after delivery, Ms Hodgkinson went into cardiac arrest and later died. In his concluding remarks, Mr Kewley said: "There was a failure to ensure that Jess received anticoagulant medication that a clinician had intended should be taken until birth. This failure made a more than minimal, negligible or trivial contribution to Jess' death". Read full story Source: BBC News, 31 January 2023
  19. News Article
    A highly toxic chemical compound sold illegally in diet pills is to be reclassified as a poison, a government minister has said. Pills containing DNP, or 2,4-dinitrophenol, were responsible for the deaths of 32 young vulnerable adults, said campaigner Doug Shipsey. His daughter Bethany, from Worcester, died in 2017 after taking tablets containing the chemical. The deaths were down to a "collective failure of the UK government", he said. DNP is highly toxic and not intended for human consumption. An industrial chemical, it is sold illegally in diet pills as a fat-burning substance. Experts say buying drugs online is risky as medicines may be fake, out of date or extremely harmful. Mr Shipsey said he had targeted the minister following the death of another young man who had taken the drug sold as a slimming aid. Prior to this, following the inquests of dozens of young people who had suddenly and unexpectedly died from DNP toxicity, the government had "ignored numerous coroners reports" to prevent future deaths, he said. "So, at last after 32 deaths and almost six years of campaigning, the Home Office (HO) finally accept responsibility to control DNP under the Poisons ACT 1972," he added. Read full story Source: BBC News, 28 January 2023
  20. News Article
    A coroner has urged the health secretary to take action to prevent needless deaths after a woman died of heart failure following a four-hour wait in the back of an ambulance. Lyn Brind, 61, was taken to the Queen Elizabeth Hospital (QEH) in King’s Lynn, Norfolk, with chest pains and low blood oxygen levels but could not be admitted because the hospital had “no space”. Instead she remained in a queue of ambulances outside A&E without a timely diagnosis or treatment and where warning signs about her condition were missed. It was only after four hours and 25 minutes of waiting that she was transferred to a ward, by which time she was “agitated and short of breath”. She was placed on life support but died 22 minutes later. Brind’s family believe the grandmother of four, a former dinner lady from the town, “might still be alive today” had she been admitted more swiftly. “She wasn’t given a chance,” her partner of 38 years, Richard Bunton, said. After an inquest earlier this month into Brind’s death in May 2022, the senior coroner for Norfolk, Jacqueline Lake, took the unusual step of writing to England’s health secretary, Steve Barclay, to raise concerns about the NHS and social care. She warned that others could die in similar circumstances unless action was taken. “I believe you have the power to take such action,” Lake wrote in a prevention of future deaths report. Read full story Source: The Guardian, 29 January 2023
  21. Content Article
    On 4 March 2020 an investigation into the death of Yvonne Eaves was opened. The inquest came to a narrative conclusion that "The Deceased suffered from a chronic mental disorder and serious self-neglect. After compulsory admission to hospital under the Mental Health Act there was a gross failure to provide her with basic medical care which contributed to her death and it was possible that if she had received that care and VTE prophylaxis treatment she would not have developed a pulmonary thromboembolism and died."
  22. Content Article
    On the 5 February 2020 an inquest was opened into the death of Hayley Smith. The jury concluded on 9 March 2022 with a narrative conclusion “The deceased died from complications of anorexia nervosa.” Hayley had developed severe and enduring anorexia nervosa at around the age of nine or ten and was resistant to treatment including several hospital admissions both voluntary, and at times compulsory treatment under the Mental Health Act. She was repeatedly admitted to hospital. On the 23 December 2019 Hayley had not eaten, became confused and unwell, and an ambulance was called. The correct emergency treatment was provided but Hayley responded quickly and regained consciousness and refused further treatment or admission to hospital. On 24 December she became unwell again and this time was taken to Queen Elizabeth the Queen Mother hospital where she again refused treatment and discharged herself against medical advice. The responsible medical officer from the Kent Eating disorder team gave evidence that had the team known of either of these episodes they would have taken steps to admit her and treat her.] On Christmas Day 2019 she collapsed for a final time and this time, had an out of hospital cardiac arrest, and was admitted to Queen Elizabeth the Queen Mother hospital and transferred to Intensive care where she was diagnosed as suffering from hypoxic brain damage as a result of her cardiac arrest due to severe hypoglycaemia as a consequence of her Anorexia Nervosa. She died on 29 December 2019 at the age of 27.
  23. Content Article
    This prevention of future deaths report looks at the death of Ben King, who died of acute respiratory failure, obesity hypoventilation syndrome and use of sedative medication. Ben had Down's Syndrome and obstructive sleep apnoea and had been detained under the Mental Health Act at Jeesal Cawston Park (JCP) from 2018. Ben’s weight as at June 2019 was recorded at 85.2 kg which had risen to 106 kg by June 2020. He was given the sedative Promethazine after becoming agitated and found unresponsive on 29 July 2020. He died later that day at  Norfolk and Norwich University Hospital.
  24. Content Article
    This report from Simon Milburn, Area Coroner for the area of Cambridgeshire and Peterborough, looks at the death of Jonathan Kingsman, who died of pulmonary thromboembolism and deep vein thrombosis on 1 February 2021. Mr Kingsman had been admitted to Fulbourn Hospital, Cambridge under section 2 of the Mental Health Act 1983 on 26 January. It was noted that on admission, Mr Kingsman had not consumed any fluids for several hours. The doctor on call carried out an initial risk assessment for venous thromboembolism (VTE), but as Mr Kingsman's mobility was deemed to 'not have significantly reduced ability', the assessor was directed by the guidance to stop the assessment. It was agreed at the Inquest that Mr Kingsman fell into this category and likewise agreed that throughout his time in hospital that there were no changes to his mobility which would have prompted a renewed risk assessment. However, Mr Kingsman did have other risk factors for VTE, and the coroner raised matters of concern about the risk assessment process as follows: That the risk assessment requires no consideration of risk factors other than mobility unless ‘Step 1’ is passed regardless of the number of other risk factors which may be present and their severity – Mr Kingsman was not obviously at risk of ‘significantly increased immobility compared to his normal state’ but died as a result of a DVT/VTE nonetheless. It is reasonable to expect that others may be in the same position in the future. The risk assessment form contains no guidance on its completion and no definition of certain terms. A copy of the report was sent to The Secretary of State for the Department of Health.
  25. News Article
    Asystemic failure to provide basic physical care on NHS mental health wards is killing patients across the country, despite scores of warnings from coroners over the past decade, The Independent can reveal. An investigation has uncovered at least 50 “prevention of future death” reports – used by coroners to warn health services of widespread failures – since 2012, involving 26 NHS trusts and private healthcare providers. Cases include deaths caused by malnutrition, lack of exercise, and starvation in patients detained in mental health facilities. Experts warn that poor training and a lack of funding are factors in the neglect of vulnerable patients. The Independent investigation uncovered: Staff failing to carrying out basic health checks, such as assessment for risk of blood clots. Cases of nurses and care assistants without adequate CPR training. Doctors unable to carry out emergency response procedures. Patients not treated for side effects of antipsychotic medication. Rapidly deteriorating health going unnoticed and untreated. Coroners have exposed multiple cases of mental health patients receiving inadequate treatment in general hospitals, with their illness being mistaken for a psychiatric problem. Read full story Source: The Independent, 18 December 2022
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