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Found 172 results
  1. Content Article
    The Preventable Deaths Tracker was set up to explore concerns raised by coroners to prevent future deaths. The tracker aims to collate data, information and analysis arising from coroners reports and other investigations and make it accessible for all. It hopes to warn against repeat hazards and highlight important lessons, to improve public safety, reduce avoidable harms and prevent premature deaths. The tracker was originally developed with funding from the National Institute for Health Research (NIHR) School for Primary Care Research.
  2. Content Article
    When a patient dies because of preventable avoidable harm it is crucial that we learn from the event and implement changes to ensure it does not reoccur. Implementing the findings and recommendations of Coroner’s Prevention of Future Deaths (PFD) reports can play a key role in this. This blog reflects on a recent discussion at a Patient Safety Management Network (PSMN) meeting about PFD reports and how their insights can be used for learning and improvement. The PSMN is an informal voluntary network for patient safety managers in England. Created by and for patient safety managers it provides a weekly drop-in session with guests to talk through issues of importance to patient safety managers, providing information, peer support and safe space for discussion. You can find out about the network here.
  3. News Article
    The death of a "vulnerable" transgender teenager who struggled to get help was preventable, a coroner has said. Daniel France, 17, was known to Cambridgeshire County Council and Cambridgeshire and Peterborough Foundation Trust (CPFT) when he took his own life on 3 April 2020. The coroner said his death showed a "dangerous gap" between services. When he died, Mr France was in the process of being transferred from children and adolescent mental health services (CAMHS) in Suffolk to adult services in Cambridgeshire. The First Response Service, which provides help for people experiencing a mental health crisis, also assessed Mr France but he had been considered not in need of urgent intervention, the coroner's report said. Cambridgeshire County Council had received two safeguarding referrals for Daniel, in October 2019 and January 2020, but had closed both. "It was accepted that the decision to close both referrals was incorrect", Mr Barlow said in his report. Mr Barlow wrote in his report, sent to both the council and CPFT: "My concern in this case is that a vulnerable young person can be known to the county council and [the] mental health trust and yet not receive the support they need pending substantive treatment." He highlighted Daniel was "repeatedly assessed as not meeting the criteria for urgent intervention" but that waiting lists for phycological therapy could mean more than a year between asking for help and being given it. "That gap between urgent and non-urgent services is potentially dangerous for a vulnerable young person, where there is a chronic risk of an impulsive act," Mr Barlow said. Read full story Source: BBC News, 25 February 2022
  4. Content Article
    On 8 April 2020 the coroner commenced an investigation into the death of Daniel France, age 17. Danny was 17 years old and was living at a YMCA hostel. He was on medication for depression and had been referred to secondary mental health services. He had made previous suicide attempts. On 3 April 2020 he took his own life. The medical cause of death was asphyxiation by hanging and the conclusion was suicide.  Danny was a vulnerable teenager: he had left home and was living in hostel accommodation; he had changed his GP practice; he was trans, had changed his name and had been referred to the Gender Identity Clinic; he had recently been discharged from secondary mental health services in Suffolk and had been referred to mental health services in Cambridge; he had previously been under CAMHS and was now being referred to adult mental health services; he had diagnoses of anxiety and depression and had been prescribed medication; he had made previous suicide attempts and had long term suicidal thoughts He had been assessed by First Response Service but had been considered as not requiring urgent intervention. Safeguarding referrals about Danny were made to Cambridgeshire County Council in October 2019 and January 2020. Both referrals were closed and it was accepted that the decision to close both referrals was incorrect. In December 2019 Danny’s new GP referred him to Cambridgeshire & Peterborough NHS Foundation Trust (CPFT). He had been seen by the Primary Care Mental Health Services but was still awaiting assessment by the Adult Locality Team at the time of his death. 
  5. Content Article
    Benjamin Lee Stroud died on the 19 March 2021 at home. He lived alone but had a partner who saw him regularly. He had a previous medical history of recreational drugs, including steroids and cannabis; he was recently diagnosed as insulin dependent diabetic and had undergone a kidney transplant. He fell and injured his back at work, and developed a dependence on pain medication, some of which were purchased on the internet. His mental health issues increased as a result of his psychical health problems. A post mortem was undertaken and the cause of death was multiple drug toxicity.
  6. News Article
    A man who died from a mixed medication overdose might still be alive if the help his partner was "begging" for had been provided, a coroner said. Mental health patient Benjamin Stroud, 42, had been under the care of Essex Partnership University NHS Trust (EPUT) in the weeks before his death in March. Essex coroner Michelle Brown said in a post-inquest report that, despite "escalating psychosis", his care co-ordinator did not flag the case. Following an overdose of medication in February, his partner, a nurse, called for psychiatric intervention and despite "begging" for help, Mr Stroud's care co-ordinator did not make a referral to the multi-disciplinary team (MDT). Mr Stroud died at home on 19 March and was found surrounded by empty insulin pens and pain medication. In her prevention of future deaths report, the coroner said: "It was clear from [his partner's] account that she had been begging the care co-ordinator for Mr Stroud to have an appointment with the psychiatrist, which did not occur and, from the evidence of EPUT, it was clear that Mr Stroud's care co-ordinator did not make any referral to the MDT, despite his escalating psychosis." The coroner added that the issue of care co-ordinators failing to document their reasons for not referring cases to the MDT had been raised at other inquests. "If these practices continue there is a real risk of future deaths occurring," Ms Brown warned. Paul Scott, chief executive at the trust, said: "We will continue to view all safety-related incidents as an opportunity to learn and make sure lessons are shared across the trust." Read full story Source: BBC News, 16 February 2022
  7. Content Article
    Barbara Young fell downstairs at her home at 11.30am on 15 July 2021, sustaining multiple injuries including fractures of her ribs, spine and skull. Her family immediately called the emergency services and informed the ambulance call handlers that she had fallen downstairs, was not fully conscious and had sustained an apparently severe head injury. An ambulance subsequently arrived at 2.26pm and she was taken to hospital where, due to her reduced mobility, she developed pneumonia. Mrs Young’s conditioned worsened over the coming days and she died on 24 July 2021.  In her report, the Coroner raises concerns about the ambulance waiting time in this case, and more generally about ambulance response times in cases where elderly patients experience falls.
  8. Content Article
    On the 15 May 2020, John Skinner was admitted to Watford Hospltal suffering from a tonic clonlc seizure. He had a background of cannabis usage and a subdural empyema in 2020 that had left him with epilepsy. On arrival at hospital he again had another tonic clonlc seizure and focal seizures. The Junior doctor Instructed to administer the drug sought advice from a more senior doctor as to the dose to be administered. As a result of a failure In verbal communication between the doctors, aggravated as both were masked, a dose of 15 mg/kg was heard as 50 mg/kg and an overdose was administered. He was given 3600 mg of phenytoln. He arrested within 16 minutes and died and could not be revived. 
  9. News Article
    Masks worn by doctors "aggravated" a miscommunication over the dose of an anti-epileptic drug that resulted in a man's death, a coroner has warned. John Skinner died at Watford General Hospital in May 2020. A coroner has written a Prevention of Future Deaths Report (PFDR) saying he feared the same could happen at other hospitals if action was not taken. Assistant Coroner for Hertfordshire, Graham Danbury, said in the report: "As a result of failure in verbal communication between the doctors, aggravated as both were masked, a dose of 15mg/kg was heard as 50mg/kg and an overdose was administered." Mr Danbury, writing to NHS England, said: "This is a readily foreseeable confusion which could apply in any hospital and could be avoided by use of clearer and less confusable means of communication and expression of number." A spokesperson for West Hertfordshire Hospitals NHS Trust said: "A comprehensive action plan is in place to ensure that lessons are learned from this incident." Read full story Source: 15 February 2022
  10. News Article
    Children with mental health problems are dying because of failings in NHS treatment, coroners across England have said in what psychiatrists and campaigners have called “deeply concerning” findings. In the last five years coroners have issued reports to prevent future deaths in at least 14 cases in which under-18s have died while being treated by children’s and adolescent mental health services (CAMHS). The most common issues that arise are delays in treatment and a lack of support in helping patients transition to adult services when they turn 18. Coroners issue reports to prevent future deaths in extreme cases when it is decided that if changes are not made then another person could die. Dr Elaine Lockhart, the chair of the Royal College of Psychiatrists’ faculty of child and adolescent psychiatry, said the findings were “deeply concerning” and every death was a tragedy. She said there were too often lengthy delays and services were under strain as demand rises and the NHS faces workforce shortages. “In child and adolescent mental health services in England, 15% of consultant psychiatrist posts are vacant,” Lockhart said, calling for more support, investment and planning to grow staff levels. Read full story Source: The Guardian, 3 February 2022
  11. Content Article
    Coroner regulations: Regulation 28 - Report on action to prevent other deaths. Regulation 29 - Response to a report on action to prevent other deaths.
  12. Content Article
    Rule 43 reports were replaced on implementation of the Coroners and Justice Act 2009 with Reports on Action to Prevent Future Deaths (‘reports’) .For short they can be referred to as PFDs or PFD reports or Regulation 28 reports. These reports are important. Coroners have a duty not just to decide how somebody came by their death but also, where appropriate, to report about that death with a view to preventing future deaths. A bereaved family wants to be able to say: ‘His death was tragic and terrible, but at least it shouldn’t happen to somebody else.’ Broadly speaking reports should be intended to improve public health, welfare and safety. They should not be unduly general in their content; sweeping generalisations should be avoided. They should be clear, brief, focused
  13. Content Article
    Presentation from Patricia Harding, Senior Coroner, Mid Kent & Medway, North East Kent, Central & South East Kent on the role of the coroner. Includes reportable deaths, the Cor0navirus Act 2020, how to complete a MCCD, inquests, preparation of reports and giving evidence.
  14. Content Article
    Barrie Housby had a medical history that included frailty, Parkinson’s disease and macular degeneration. During a stay at Clifton Hospital he was known to be at high risk of falls and at the beginning of the nightshift on 12 July 2021, it was advised that he should be cared for on a one to one basis and not left unattended. During the shift, a member of staff allocated to monitor him left the bay to attend to other duties, and in this time Mr Housby left his bed and fell. He was transferred to a hospital emergency department but subsequently died on 13 July 2021 as a result of a traumatic subdural haemorrhage following a fall. In his report, the Coroner Alan Wilson highlights the impact of staffing shortages at the Trust and their contribution to Mr Housby’s death, stating that this poses an ongoing risk to patient safety.
  15. News Article
    The Healthcare Safety Investigation Branch (HSIB) has launched an investigation into community mental health care following the death of a 56-year-old woman. HSIB has begun examining how patients in crisis with severe mental health needs are assessed by NHS services. The investigation came after warnings from multiple coroners over the poor assessment of suicide risk in people in mental health crisis in the last year and followed the death of Frances Wellburn, who took her own life in August 2020 while under the care of Tees, Esk and Wear Valleys Foundation NHS Trust (TEWV). Wellburn had long-term mental health problems but suffered a crisis and was admitted to hospital in September 2019. Following discharge, she was not referred to a specialist NHS service for people experiencing psychosis because clinicians incorrectly believed she was too old for the service, according to a TEWV investigation report seen by The Independent. Despite being assessed as a “medium risk”, Wellburn was not contacted by mental health teams for three months. In June 2020, she was admitted to an inpatient unit for three weeks, but her health deteriorated, and she later took her own life. Separately, coroner warnings in three prevention of future deaths reports published last year found mental health staff failing to risk assess people who later took their own lives. HSIB’s investigation will look into how patients’ risk is assessed when receiving care in the community and how services interact with families and other health services. It will also examine how mental health services consider menopause when assessing women’s mental health and referrals to early intervention psychosis services. Read full story Source: The Independent, 27 January 2022
  16. Content Article
    This Prevention of Future Deaths report relates to the death of four patients who all died from endoscopic retrograde cholangio-pancreatography (ERCP) related complications, within a six-month period. All four patients had their treatment carried out by the same doctor during his training for this high-risk procedure. In her report, the Coroner Laurinder Bower raises concerns about the systems in place to gain consent and inform patients of the risks of these procedures.
  17. Content Article
    Mollie Daisy Dimmock died from perinatal asphyxia due to hypoxia 34 minutes after being delivered. This was caused by umbilical cord compression from shoulder dystocia which lasted for five minutes before Mollie was fully delivered. In his report, the Coroner Crispin Butler raises concerns about the NICE guidance in relation to intrapartum care for women with existing medical conditions or obstetric complications and their babies.
  18. News Article
    Barts Health NHS Trust has been told to take action to prevent future deaths after an elderly woman was unlawfully killed at one of its hospitals. East London acting senior coroner Graeme Irvine sent a report to the trust in which he raised concerns over the death of 78-year-old Surekha Shivalkar in 2018. The report follows an inquest into Mrs Shivalkar's death, which reached a narrative conclusion incorporating a finding of unlawful killing. A Barts spokesperson said the trust had made a number of changes after carrying out an investigation. Mrs Shivalkar underwent hip replacement revision surgery at Newham Hospital on September 28, 2018 in a procedure estimated to last between four and five hours, the coroner wrote. She had a number of serious conditions, including ischaemic heart disease, osteoporosis and chronic obstructive pulmonary disorder. But Mr Irvine said an inaccurate risk of death of less than 5% was given, as no formal risk assessment tool was used. The surgery took longer than seven and a half hours, during which time Mr Irvine said Mrs Shivalkar sustained a "prolonged and dangerous" period of hypotension, or low blood pressure. He said the anaesthetist failed to communicate this to the surgical team and agreed to prolong surgery at the six hour point. Mr Irvine said: "Poor communication between the orthopaedic surgical team and the anaesthetist during surgery led to a collective failure to identify a critically ill patient." Read full story Source: Newham Recorder, 17 January 2022
  19. Content Article
    Surekha Shivalkar was a 78-year-old woman who was scheduled for elective total hip replacement revision surgery. Following surgery she suffered a cardiac arrest and subsequently died. The conclusion of the inquest was that died from multi-organ failure and complications arising during anaesthesia and hip revision surgery, which led to hypotension and hypoperfusion in a woman with ischaemic heart and chronic obstructive pulmonary disease. In his report, the Coroner raises concerns about the lack of a use of a formal risk assessment tool prior to her surgery, communication failures between the orthopaedic surgical team and the anaesthetist and the departure of the Senior Consultant surgeon prior to the surgeries conclusion. 
  20. Content Article
    Jane Bruce was discharged from hospital on 24 March 2020 and was receiving wound care from the community nursing team twice a week, after surgery on a fracture following a fall in November 2019. She initially appeared to be recovering until 29 April when her pain increased significantly, rendering her bed-bound, with the exudate from the wound significantly increased. She continued to deteriorate and presented to Leicester Royal Infirmary on 1 May with features consistent with sepsis, and subsequently died the following day. In her report, the Coroner highlights concerns about an absence of continuity in Ms Bruce’s wound care. She notes that she had been seen by several different nurses but due to lack of photographic evidence/accessible electronic records they did not have the relevant information to recognise the change in her condition.
  21. News Article
    Coroners in England are demanding changes in a series of reports highlighting how the struggling healthcare system’s responses to the pressures of the COVID-19 pandemic contributed to patients’ deaths. Coroners are obliged to write a report recommending action in any cases where they believe that this is necessary to prevent future deaths. Reports now emerging suggest that factors in deaths during the pandemic include the move by GPs to telephone consultations, the requirement for vulnerable patients to attend hospital appointments alone, and the lack of safeguards for patients in care homes. The replacement of in-person appointments by telephone consultations reduced GPs’ ability to pinpoint patients’ needs, the coroners said, and the absence of family members from consultations with vulnerable patients meant that clinicians were often unable to get a full picture of their needs. An example is in the Yorkshire and Humber region which saw an increased incidence of children with severe nutritional anaemia in 2020, resulting in two deaths. Maya Zab, who died aged 11 months, was one of the two. Language barriers had caused missed opportunities for primary carers to see Maya, but this was compounded by the pandemic, said Ian Pears, coroner. The “stay at home” message resulted in fewer one-to-one consultations and meant that healthcare professionals were unable to spot signs of her condition, while the limitation of social contact meant that other professionals and friends were unable to report concerns. Read full story Source: BMJ, 8 December 2021
  22. Content Article
    The Royal College of Anaesthetists recently received a coroners report where an oesophageal intubation took place and was not recognised in time to save the life of the patient. Unrecognised oesophageal intubation is preventable through adherence to published recommendations on the monitoring of exhaled carbon dioxide (capnography) and its correct interpretation. All clinicians involved in airway management should watch the College and DAS video on capnography. Always remember 'No Trace = Wrong Place' and actively seek to exclude oesophageal intubation when a flat capnograph trace is encountered.
  23. Content Article
    Christopher Collinson was admitted to the Medical Assessment Unit at Birmingham Heartlands Hospital with suspected deep vein thrombosis and pulmonary embolism. He was admitted at 1.28pm on 14 June 2021, but was not seen by a Doctor until 9.33pm. He was later prescribed a prophylactic dose of Enoxaparin, rather than the therapeutic dose which the doctor had intended to prescribe. He collapsed at 11.00pm suffering a cardiac arrest and could not be revived. He died at 2.14am on 15 June 2021.
  24. Content Article
    On 11 June 2019 an investigation into the death of Brooke Martin aged 19 started. Brooke was a patient at Isla House, Chadwick Lodge, Milton Keynes and was detained under the Mental Health Act. She had been diagnosed with Emotionally Unstable Personality Disorder and Autism Spectrum Disorder. Brooke was found hanging in her room and was taken to Milton Keynes University Hospital where she died on 11 June 2019.
  25. News Article
    An inquest into the death of a London bus driver at London’s Nightingale Hospital during the first wave of coronavirus has heard evidence about equipment mistakes which may have harmed patients. Kishorkumar Patel, aged 58, was one of the first patients to be admitted to the field hospital at London’s Excel Conference Centre in April last year. An inquest at East London Coroner’s Court was told doctors and nurses were forced to work “leanly” because of limited staff and ventilators to help patients breathe. Mr Patel is one of 10 patients who had the wrong filter used on the ventilator machines which it is thought triggered a cardiac arrest in Mr Patel, a father of six. A serious incident report identified 10 patients were affected by the use of the wrong filter, with three said to have been harmed as a result. Read coroner's report Read full story Source: The Independent, 6 October 2021
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