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Content ArticleOn 24 March 2021, an investigation into the death of Hazel Fleur Wiltshire was opened. The conclusion of the inquest was that Mrs Wiltshire died from pneumonia caused by a fall and by COVID-19 that she acquired in hospital. The fall was caused by her trying to relieve herself without assistance in the context of long delays in answering calls bells at the time.
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News Article
Concern raised over death of five patients seen remotely by GPs
Patient Safety Learning posted a news article in News
Patients being assessed remotely in general practice, rather than face-to-face, has been raised as a risk in reports on five deaths by a single coroner since the pandemic hit. Senior coroner for Greater Manchester Alison Mutch has written five prevention of future deaths reports highlighting concerns that doctors were missing details in telephone appointments which may have been spotted, had the patient been seen in person. The reports cover a variety of conditions, including covid, a broken femur, and anxiety and depression. In March 2020, NHS England guidance instructed GPs to adopt a “total triage” approach, where face-to-face appointments should generally only follow a phone, video or digital consultation. But, in May, NHSE wrote to GPs to ask them to “ensure they are offering face to face appointments”, adding remote appointments “should be done alongside a clear offer of appointments in person”. There have been growing calls in the media for increased face-to-face appointments, while, in March 2021, a report by Healthwatch concluded: “While telephone appointments are convenient for some, others are worried that their health issues will not be accurately diagnosed.” Maureen Baker, former chair of the Royal College of GPs and Patient Safety Learning trustee told HSJ she was “not aware pre-pandemic of any major concerns with remote consulting”, adding: “It’s not that things don’t go wrong. They do, but things can and do go wrong in face-to-face consultations as well.” “Many practices have been using remote consulting very successfully for many years [but for GPs introducing remote consultations during the pandemic] the concern is that practices will have had to change and implement it very quickly.” Read full story (paywalled) Source: HSJ, 9 September 2021 You may also be interested in a recent blog from Trish Greenhalgh: 'Why remote consultation with a doctor is difficult – and how it can be improved' -
Content Article
Prevention of Future Deaths report – Ann Geraghty
Patient Safety Learning posted an article in Coroner reports
Ann Geraghty was being treated for heart failure at Good Hope Hospital and subsequently died following a cardiac arrest. In their report, the Coroner raised patient safety concerns relating to two periods of ventricular standstill (this is a rare issue when the heart stops beating and stands perfectly still), which were missed due to a combination of policy, staffing, workplace and equipment issues. -
News ArticleShortfalls in mental health services and staffing have been flagged as concerns in dozens of inquests since 2015, the Observer has revealed, with coroners issuing repeated warnings over patients facing long waiting lists or falling through gaps in service provision. The Observer has identified 56 mental health-related deaths in England and Wales from the start of 2015 to the end of 2020 where coroners identified a lack of staffing or service provision as a “matter of concern”, meaning they believed “there is a risk that future deaths could occur unless action is taken”. Coroners issue Reports to Prevent Future Deaths (PFD) when they believe action should be taken to prevent deaths occurring in future, and send them to relevant individuals or organisations, who are expected to respond. In one case, a woman referred to psychotherapy services had still not received any psychotherapy by the time she died 11 months later. In another, someone had endured a seven-month wait for a psychological assessment. Alison Cobb, senior policy and campaigns officer at the mental health charity Mind, said: “It’s shocking that so many should lose their lives because there isn’t enough capacity in mental health services to provide adequate care. These prevention of future deaths notices are meant to inform better ways of working, and it’s especially concerning that similar stories are repeating over and over again.” Read full story Source: The Guardian, 5 September 2021 Coroner's reports on the hub
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Content ArticleMyla Deviren had congenital intestinal malrotation and developed a volvulus on 26 August 2015. Her mother checked the NHS Symptom finder on line and the advice was to take her to A&E but she called 111 for advice. The Health Assistant who took the call did not appreciate the significance of key symptoms due to multiplicity of symptoms described at the outset. He passed the caller on a “ warm” transfer to the Clinical Adviser whose initial reaction on hearing that the symptoms included blue lips and breathlessness was to call an ambulance, ignored her instincts and took mum through a series of digital pathways re lesser symptoms. When directly asking about the breathlessness Myla's mum put the phone close to her daughter enabling the Clinical Adviser to hear the rapid breathing herself however they did not appreciate the significance of it and did not call an ambulance. She did however pass the call to the Out Of Hours Nurse who decided that this was a case of gastroenteritis early in the call and did not appreciate the description of a child with worsening signs. Whilst the precise point at which Myla stopped breathing is not known it was sometime between when she was last seen alive approximately 06.00 and then found unresponsive at 08.00 on the 27 August 2015. She was then taken by ambulance to Peterborough City Hospital where, despite attempts at resuscitation, she did not recover a heartbeat and she died. Post mortem revealed small bowel infarction from untreated small intestinal volvulus. It is probable that with earlier transfer to hospital by ambulance and with appropriate treatment Myla would have survived.
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News Article
Deaths of people with learning disabilities deserve proper scrutiny
Patient Safety Learning posted a news article in News
The critical finding at the inquest into Laura Booth’s death raises alarming concerns about the failing system of investigation into the deaths of people with learning disabilities. Initially, Laura’s death was said to be expected and was attributed to natural causes on the basis of a death certificate signed by a hospital doctor. Without the determination of Laura’s family and the intervention of the media, this inquest would never have happened, and the truth about her death from malnutrition and neglect would not have been uncovered. The concerns about how many other avoidable deaths have not been scrutinised because there is no one to speak up on behalf of those who died or because families are obstructed in their search for answers by the prevailing assumption that people will die early. The premature deaths of people with learning disabilities (on average 30 years before their non-disabled peers) demand robust scrutiny particularly as when inquests do take place, they so often reveal basic failings in healthcare. The way in which the Booth family were so nearly failed by the coronial system is a sharp reminder of how urgently reform of these processes is needed. Read full story Source: The Guardian, 2 May 2021 -
Content ArticleThese coroner reports relate to two patients, Stephen and Peter, who both died as a result of complications from use of a nasogastric tube. The coroner notes concerns that this issue may be more widespread and has therefore highlighted the report to several relevant bodies who she advises to take action.
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Content Article
Prevention of Future Deaths Report – Gary Day
PatientSafetyLearning Team posted an article in Coroner reports
Gary Day had a choroidal melanoma of the left eye. After discussing his treatment options with clinicians at Moorfields Eye Hospital, he elected to have that melanoma removed by an endoresection procedure at the hospital. Gary Day died less than 24 hours after the operation as a result of an air embolism. In the Coroner’s matters of concern, it was noted he was not advised beforehand of the potential risk of death, there was no check for an air embolism after the operation and he probably should have been kept in hospital overnight for observation. The report was sent to Moorfields Eye Hospital but has safety implications for all Trusts performing this procedure. -
News Article
Inquest finds neglect contributed to woman’s hospital death
Patient Safety Learning posted a news article in News
The death of a young disabled woman following a routine eye operation was partly caused by malnutrition as a result of neglect, a coroner has ruled. Laura Booth, 21, was admitted to the Royal Hallamshire hospital in Sheffield in September 2016 for a routine eye operation. She died the next month, on 19 October. Booth had a number of learning difficulties and life-limiting complications, having been diagnosed with partial trisomy 13, a rare genetic disorder, shortly after she was born. Her mother, Patricia Booth, told the inquest that her daughter stopped eating shortly after she was admitted to hospital, and that doctors ignored Laura’s attempts to communicate with them. She said her daughter consumed only rice milk and blackcurrant juice in hospital, and she kept telling doctors: “This isn’t right, she can’t survive on no food.” The coroner, Abigail Combes, concluded that Laura Booth became unwell while a patient at the hospital and, among other illnesses, “developed malnutrition due to inadequate management for her nutritional needs”. Combes said that Booth’s death “was contributed to by neglect”. Read full story Source: The Guardian, 26 April 2021 -
News Article
'Anger' over report into neglect death care home
Patient Safety Learning posted a news article in News
The mother of a man who died after suffering neglect said she felt "extreme distress and anger" at a critical new report into his care home. James Delaney, 37, died while he was a resident at Sapphire House in Bradwell, Norfolk, in July 2018. After an inadequate rating by the Care Quality Commission (CQC), Mr Delaney's mother said she felt lessons had not been learned from her son's death. A spokeswoman for operator Crystal Care said it had "addressed all concerns". Mr Delaney, who died of a diabetes-related illness, was required to take insulin twice a day, but, despite staff noting he had not taken insulin for three days, they failed to take action. Jacqueline Lake, senior coroner for Norfolk, said at his inquest in 2019 there had been "a gross failure" by the care home to provide "basic medical attention". The home, which houses up to five people who have a learning disability or autistic spectrum disorder, was inspected in January and February 2021 after two whistleblowers alleged that abusive practices were taking place - a claim which is being investigated by the local safeguarding team. CQC inspectors found "people were not safe and were at risk of avoidable harm", and while risk assessments for diabetes, medicines and behaviour management existed, information was often "lacking or inaccurate". After reading the report, Mr Delaney's mother, Roberta Conway, said her reaction was one of "extreme distress and anger". She said the coroner had "pointed out what needed to be done, and it hasn't been done". "It cost my son his life and I don't want to see anybody else's life being wasted," she added. Read full story Source: BBC News, 21 April 2021 -
Content ArticleThis is the coroners report into the death of Brandon-Robert, who was born on 29 May 2020, and died of E. coli sepsis a week later.
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Content Article
Prevention of Future Deaths report – Jamie Poole
Patient Safety Learning posted an article in Coroner reports
Jamie Lee Poole was diagnosed required the lifesaving surgery of a kidney transplant in 2011. After the transplant she was placed on a dose of immunosuppressant to prevent rejection of the transplanted kidney. One of the known side effects of the use of the medication is that it can cause low levels of magnesium within the body. Jamie was admitted to the Royal Stoke University Hospital on 27 June 2017 with low levels of magnesium and low calcium and was treated for correction of electrolyte disturbance. On the 28 June 2017 she was found on the floor having collapsed. It was discovered that she had significant swelling on her brain. This was caused by a lack of oxygen to the brain, which was either caused by a heart problem or a seizure, which on balance would have been caused by the low levels of magnesium. She was transferred to the intensive care unit at the Royal Stoke University, Stoke-on-Trent where she died. -
Content Article
Prevention of Future Deaths report – Brian Button
Patient Safety Learning posted an article in Coroner reports
Brian Button, 78 years old, was admitted to the Royal Sussex County Hospital following a fall but contracted COVID-19 pneumonitis on the Catherine James ward within the Acute Respiratory Unity. Senior coroner for Brighton and Hove, Veronica Hamilton-Deeley, in the coroner's report, said that the ward contained 13 beds and that these beds were not socially distanced. A patient review confirmed this. The Royal Sussex County Hospital has responded. -
News ArticleA 40-year-old mother of four took her own life at an NHSmental health unit after multiple opportunities were missed to keep her safe, an inquest has found, prompting her family to call for a public inquiry. Azra Parveen Hussain was allegedly the seventh in-patient in seven years to die by the same means while in the care of Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHT). Despite this, an inquest at Birmingham and Solihull Coroner’s Court last week heard that the Trust had not installed door pressure sensor alarms, which could have potentially alerted staff to the fatal danger these patients faced. While BSMHT is now taking action to install pressure sensors at Mary Seacole House, where Hussain died on 6 May, Coroner Emma Brown noted a lack of national regulation or guidance on the risks presented by internal doors in patients’ bedrooms and is issuing a Prevention of Future Deaths report calling for this to be remedied across the country. Read full story Source: The Independent, 28 March 2021
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Content Article
Prevention of Future Deaths report – Averil Hart
Patient Safety Learning posted an article in Coroner reports
Averil Hart died from anorexia nervosa at Addenbrookes Hospital, Cambridgeshire, 6 days short of her 20th birthday. In this report, Sean Horstead, Assistant Coroner, concluded that Averil's death was avoidable and that it was contributed to by neglect. -
News Article
Hospitals failing to heed warnings over patient deaths, reveals new study
Patient Safety Learning posted a news article in News
Thousands of similar errors contributing to patient deaths are being repeated by hospitals despite warnings from coroners, according to new research. An analysis of four years of official reports by coroners, issued after the conclusion of inquests into patient deaths, has revealed the impact of the NHS struggling with a lack of resources and staff. Coroners found similar mistakes across hundreds of inquests. Professor Alison Leary, chair of healthcare a workforce modelling at London South Bank University, and who led the study, told The Independent: “We are missing opportunities to prevent deaths. What we are seeing is the hard edge of underinvestment in the workforce and the under resourcing of the service. “Each of these coroner’s reports are someone’s sorrow. From talking to families, they assume when one of these reports is issued, they are acted on and the system learns from it. But the system doesn’t seem to be learning and people pay for this with their life.” Read full story Source: The Independent, 3 March 2021 -
Content ArticleThe Coroners and Justice Act allows coroners in England or Wales to issue reports after inquest, if they believe that action should be taken to prevent a future death. Coroners are under a statutory duty to issue a Prevention of Future Death (PFD) report to persons or organisations that they believe have the power to act. Cumulatively, these reports may contain useful intelligence for patient safety.
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Content ArticlePrevention of Future Deaths Reports (PFDs) made by coroners to address concerns arising from inquests can provide powerful leverage for change, although the reality is that health and social care organisations would generally rather avoid a PFD if possible because they also highlight - in a very public way - concerns about how their services operate which can, in turn, lead to further regulatory scrutiny, principally from the CQC. The need for more consistency in terms of thresholds for making PFDs and the form these take, plus the Chief Coroner’s strong commitment to ensuring that PFDs do what they are designed to do - i.e. harness learning from deaths - have been key drivers behind a recent re-vamping of the existing Chief Coroner’s guidance note on this. What do health and social care organisations need to know about the revised PFD guidance? This briefing looks in more detail about what’s changed (and what hasn’t).
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News Article
Coroner calls for new guidance on umbilical venous catheters after baby’s death
Patient Safety Learning posted a news article in News
A newborn baby died after doctors caring for him failed to realise that the umbilical venous catheter (UVC) through which he was being fed and medicated was wrongly positioned, a coroner has found. Anna Crawford, assistant coroner for Surrey, called for guidelines from the National Institute for Health and Care Excellence (NICE) on the use of the catheters after hearing that none currently exist. Yo Li was born extremely prematurely at St Peter’s Hospital in Chertsey on 11 January 2019 and transferred to the neonatal intensive care unit, where he was put on mechanical ventilation. A UVC was inserted but it was wrongly positioned within his liver tissue and he died four days later. Read full story (paywalled) Source: BMJ, 29 January 2021 -
News Article
Staff 'missed opportunities' to save patient
Patient Safety Learning posted a news article in News
Staff at a mental health unit missed "multiple opportunities" to realise a woman had become unwell before she died, a coroner has said. Sian Hewitt, 25, died at Milton Keynes Hospital last year after collapsing at the nearby Campbell Centre. Coroner Tom Osborne said there was "a failure to start effective CPR". A spokesman for the centre said changes have been made to how care is delivered. Ms Hewitt, who had Asperger's syndrome and bipolar disorder, was admitted to the inpatient unit on 13 March 2019. She died less than a month later on 6 April 2019 at Milton Keynes Hospital, where she was taken after collapsing on Willow Ward at the centre. An inquest concluded she died of a pulmonary embolism, caused when a blood clot travels to the lungs. In a Prevention of Future Deaths Report, Mr Osborne said the centre failed to carry out a risk assessment and there was a delay in administering a drug resulting in "her mania not being brought under control". His report said the "failure to recognise how seriously ill she had become" had "resulted in lost opportunities to treat her appropriately that may have prevented her death". He said her death suggested the NHS was "unable to provide a place of safety for those who are suffering from Asperger's syndrome" or other forms of autism "when they are also suffering additional mental health problems such as bipolar". Read full story Source: BBC News, 4 December 2020 -
News ArticleA world-leading children’s hospital has been accused of a “concerted effort” to cover up the mistakes that led to the death of a toddler. Jasmine Hughes died at London’s Great Ormond Street Hospital aged 20 months after suffering acute disseminated encephalomyelitis (ADEM), a condition in which the brain and spinal cord are inflamed following a viral infection. Doctors said that her death in February 2011 had been caused by complications of ADEM. But an analysis of detailed hospital computer records shows the toddler died after her blood pressure was mismanaged – spiking when she was treated with steroids then allowed to fall too fast. Experts say this led to catastrophic brain damage. Although the detailed computer records were supplied to the coroner who carried out Jasmine’s inquest, crucial information concerning her blood pressure was not included in official medical records that should hold the patient’s entire clinical history. Dr Malcolm Coulthard, who specialises in child blood pressure and medical records examination, carried out the analysis of the files, comprising more than 350 pages of spreadsheets. Dr Stephen Playfor, a paediatric intensive care consultant, examined the computer records and came to the same conclusion as Dr Coulthard, that mismanagement of Jasmine’s blood pressure by Great Ormond Street and Lister Hospital, in Stevenage, was responsible for her death. Dr Coulthard told The Independent: “As a specialist paediatrician, it is with great regret and disappointment that I have concluded that the doctors' records in Jasmine Hughes’ medical notes fail to reflect the truth about her diagnosis and treatment.” Read full story Source: The Independent, 20 November 2020
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News Article
Baby dies after ‘excessive force’ during forceps delivery
Patient Safety Learning posted a news article in News
A coroner has urged ministers to revisit plans to make it possible to hold inquests into babies that are stillborn after a baby died due to “excessive force” during an attempted forceps delivery. Senior coroner Caroline Beasley-Murray has written to the Ministry of Justice after she was forced to stop hearing evidence into the death of baby Frederick Terry, known as Freddie, who died under the care of the Mid and South Essex Hospitals Trust on 16 November, last year. An inquest into his death was started in September where Freddie was found to have died after suffering hypovolaemic shock as a result of losing a fifth of his blood when his skull was fractured during a traumatic birth attempt. In a report on the case the coroner said: “Baby Frederick Joseph Terry was delivered by caesarean section, after a failed forceps attempted delivery on 16 November 2019 and death was confirmed after 40 minutes of resuscitation attempts." "The evidence showed that baby Freddie's very serious scalp and brain injuries were sustained during the failed forceps attempted delivery and, but for these, baby Freddie would have survived as a perfectly formed, healthy baby." The coroner said the injuries he sustained implied “an excessive degree of force” in the application of the forceps, which are curved metal instruments that fit around a baby’s head and are designed to help deliver the baby. The inquest had to be stopped from hearing any more evidence because coroners are not able to investigate stillborn babies. As part of her report, the coroner said: “It would have been helpful for there to have been, during the course of the inquest, an exploration, in the course of evidence, of the treatment and care provided to baby Freddie and his parents at the time of delivery. "Currently there is no legislation to cover the holding of a coroner’s inquest into a stillbirth. In March 2019, the Government issued a consultation on coronial investigations of stillbirths It would be helpful for this important topic to be progressed, whatever the ultimate jurisdictional decisions.” Read full story Source: The Independent, 17 November 2020 -
Content ArticleRobbie Powell, 10, from Ystradgynlais, Powys, died at Swansea's Morriston Hospital, of Addison's disease in 1990. Four months earlier Addison's disease had been suspected by paediatricians at this hospital, when an ACTH test was ordered but was not carried out. Although Robbie's GPs were informed of the suspicion of Addison's disease, the need for the ACTH test and that Robbie should be immediately admitted back to hospital, if he became unwell, this crucial and lifesaving information was not communicated to Robbie's parents. At the time of Robbie's death, the Swansea Coroner refused the Powells' request for an inquest claiming that the child had died of natural causes. However, the Powells secured a 'Fiat' [Court Order] from the Attorney General in 2000 and an inquest took place in 2004, fourteen years after Robbie died. The verdict was 'natural causes contributed by neglect' confirming that an inquest should have taken place in 1990. Since Robbie's death, his father Will Powell, has mounted a long campaign to get a public inquiry into Robbie's case.
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Content ArticleCoroners have a statutory duty to issue a Prevention of Further Deaths report to any person or organisation where, in the opinion of the coroner, action should be taken to prevent future deaths. This is a coroner's report into the death of Susan Warby. The coroner's report concluded that the incorrect intravenous fluid was given and remained in place for approximately 36 hours before it was changed. As a direct result, blood tests on samples drawn from the arterial line gave incorrect results. The incorrect results were exacerbated by the poor technique being used by staff to draw blood from the arterial line transducer set when they failed to fully account for the 'dead space', which needed to be fully removed to obtain an accurate result. These erroneous blood results led to Sue being given doses of insulin medication over a two-day period that she did not need. The incorrect insulin doses caused Sue to suffer from bouts of extremely low blood sugar (hypoglycaemia) which caused her to develop a brain injury of uncertain severity.
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Content ArticleHarry Richford was born at the Queen Elizabeth the Queen Mother Hospital (QEQM), Margate, Kent on 2/11/17. He died on 9/11/17 at the William Harvey Hospital, Ashford to where he had been transferred. The cause of death was 1a Hypoxic Ischaemic Brain Encephalopathy. There was a narrative conclusion setting out some seven failures in the care of Harry Richford together with a conclusion that his death was contributed to by neglect.
