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Showing results for tags 'Coroner reports'.
Found 171 results
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Content ArticleSean Mansell had a medical history of alcohol dependence syndrome. On the 5 July 2021, the West Midlands Ambulance Service received a 999 call at 19.23 hours from a neighbour of who reported that Shaun couldn't walk. The call was allocated a category 3 disposition which had a target response time frame of 120 minutes. An ambulance arrived on scene at 03.38 on the 6 July which was 8 hours and 15 minutes later and not within the response time frame. This was due to the fact that demand outstripped available resources. A welfare call was undertaken at 21.28 hours by a paramedic who had been asked to go into the control room to assist with welfare calls due to the high volume of 999 calls outstanding. The paramedic had not received prior training on how to complete these calls. The welfare call was conducted with the neighbour. No contact was made directly with Shaun during the 8 hour delay which led to a missed opportunity to identify a change in his condition. When the ambulance arrived, Shaun had passed away on the sofa in his front room. There was evidence of blood loss on the floor next to him and around his mouth. The police did not find any suspicious circumstances. A post mortem examination found the cause of death to be acute gastrointestinal haemorrhage and liver disease due to chronic alcoholism. The medical evidence was not able to determine if the delay in the arrival of the ambulance contributed to the death because there was no certainty of timeline about the bleeding.
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Content ArticleAn investigation started on 9 October 2020 into the death of Matthew Alexander Caseby. Following his admission and subsequent absconsion from the Priory Hospital in Edgbaston, Matthew stepped in front of a train on the 8 September 2020 and was fatally injured. At the time, Matthew was suffering from disorder thinking and did not have the capacity to form any intention to end his life. Matthew absconded from Beech ward over a fence in the courtyard area and at the time of his absconsion Matthew was unattended. It was inappropriate for Matthew to be left unattended in the courtyard. There were concerns regarding Matthew absconding but the recording processes on Beech ward were inadequate which resulted in the communication to staff involved in Matthew's care being lacking. As a result of risks not being fully recorded, Matthew's risk assessment was not adequate as it was not based on all of the available information. Overall, the inadequate risk assessment for Matthew, the inadequate documentation records, the lack of a risk assessment for the courtyard area and the absence of a policy regarding observations levels in the courtyard means that the courtyard was not safe for Matthew to use unattended. His death was contributed to by neglect on the part of the treating hospital.
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Content ArticleOn 3 September 2021 assistant coroner Jonathan Stevens commenced an investigation into the death of Martha Mills, aged 13 years. Martha sustained a handlebar injury whilst cycling on a family holiday in Wales. She was transferred to King’s College Hospital London and died approximately one month later. Her medical cause of death was: 1a refractory shock 1b sepsis 1c pancreatic transection (operated) 1d abdominal trauma.
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Content ArticleKaren Lesley Starling died on 7 February 2020 aged 54 and Anne Edith Martinez died on 17 December 2020 aged 65. Both deceased underwent successful lung transplant procedures at the new Royal Papworth Hospital. However, both women became infected with a hospital acquired infection, namely Mycobacteria abscessus (M. abscessus), and died. M. abscessus is an environmental non-tuberculous mycobacterium (NTM). It can sometimes be found in soil, dust and water, including municipal water supplies. It is usually harmless for healthy people but may cause opportunistic infection in vulnerable individuals. Lung transplant patients and lung defence patients such as Mrs Starling and Mrs Martinez were at particular risk of infection from mycobacteria, including M. abscessus.
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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.
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Content ArticleOn 23 April 2020 Jaqueline Lake commenced an investigation into the death of Eliot Harris aged 48. Eliot had schizophrenia and diabetes. Eliot had not been taking medication for several days and his condition deteriorated. He was admitted to Northgate under the Mental Health Act after assessment on 5 April. He was initially in seclusion then on the ward from 6 April, he spent a lot of time in his room and only ate cheese sandwiches. He only accepted medication in intramuscular form and on 9 April by depot injection. His physical observations were recorded as being normal, and a blood test on 7 April showed he did not have diabetes. His intake of food and fluid remained minimal but he was not put on a chart to monitor this. Staff last entered his room at 17:46 on 9 April. He was last seen conscious at 18:10 on 9 April. He was found unresponsive at 01:33 and declared dead at 02:00. The investigation concluded at the end of the inquest on 8 August 2022. Medical cause of death: 1a) Unascertained Conclusion: Open – the evidence does not reveal the means by which Eliot Harris came by his death.
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Content ArticleOn 24 October 2019 coroner Lydia Brown commenced an investigation into the death of Asher William Robert Sinclair, age 3. The investigation concluded at the end of the inquest on 24 January 2022. The conclusion of the inquest was: His medical cause of death was: 1a Hypoxic ischaemic brain injury 1b out of hospital cardiac arrest 1c displaced tracheal tube (trachael tube dependant) II Neonatal enterviral myocarditis and encephalitis (trachael ventilator dependant and cardiac pacemaker). Asher died on 8th October 2019 in Great Ormond Street hospital when his life support mechanisms were withdrawn.
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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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Prevention of Future Deaths report: Karanbir Cheema
PatientSafetyLearning Team posted an article in Coroner reports
On 28 June 2017, 13 year-old Karanbir Cheemer was at school when another pupil threw a small piece of cheese at him. He was known to be allergic to cheese and he went into anaphylactic shock. Karanbir later died. In this report, senior coroner ME Hassell, highlights a number of patient safety concerns relating to his death and calls for action to prevent future deaths. -
Content ArticleShanté Turay-Thomas, a young woman who had a nut allergy, died of an acute anaphylaxis after eating hazelnuts on 18 Spetember 2018. In this report, senior coroner ME Hassell, highlights 20 'matters of concern' surrounding her death and calls for action to be taken for future deaths to be prevented.
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Content ArticleIn this article Patient Safety Learning responds to a recent news story about an Ambulance Service reviewing their defibrillators after receiving two warnings from Coroners Prevention of Future Deaths reports. It considers the specific circumstances around this and how this case highlights a broader problem of failing to harness learning from these coroners reports for patient safety.
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Content ArticleWhat can we take from the steady flow of Prevention of Future Deaths Reports (PFDs) issued by coroners in relation to patient care? How do these fit into the wider learning from deaths landscape? To help answer these questions, international law business DAC Beachcroft have taken a closer look at hospital-related PFDs to see if any common themes emerge and, if so, what is in the pipeline for tackling them.
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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 35 year-old Mr Mitica Marin. It was found that the defibrillator was set to manual mode, which meant that staff were not automatically alerted to the fact that Mitica's heart had a shockable rhythm. This caused a delay to Mr Marin receiving CPR treatment.
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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 coroners report relates to the death of 15 year-old Najeeb Katende and the delay in defibrillation due to the equipment being set to manual mode and not detecting his shockable rhythm. The coroner found that the delay in defibrillating Najeeb significantly reduced his chances of survival.
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Deaths in prison: A national scandal (INQUEST, January 2020)
Claire Cox posted an article in Prison setting
Every four days a person takes their life in prison, and rising numbers of ‘natural’ and unclassified deaths are too often found to relate to serious failures in healthcare. The lack of government action on official recommendations is leading to preventable deaths. Deaths in prison: A national scandal exposes dangerous, longstanding failures across the prison estate and historically high levels of deaths in custody, and offers unique insight and analysis into findings from 61 prison inquests in England and Wales in 2018 and 2019. The report details repeated safety failures, including mental and physical healthcare, communication systems, emergency responses, and drugs and medication. It also looks at the wider statistics and historic context, showing the repetitive and persistent nature of such failings. -
Content ArticlePatient Safety Learning's Chief Executive Helen Hughes, alongside Professor Alison Leary and Professor Sara Ryan, talk on BBC Radio 4 about coroner reports that are specifically designed to help prevent future deaths and question whether it's working in practice. Health researchers warn that lives are at risk because warnings from Coroners are not being acted upon. Analysis of more than 1000 Prevention of Future Death reports has identified five themes that come up time and time again. Patient Safety Learning has written to the Chief Coroner because of their concerns about this. Sara Ryan is a mother who believes lessons from her son's death have not been learned.
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Content ArticleAvoidable unsafe care kills and harms thousands of people in the UK each year. When a person dies as a result of a preventable error it is vital that we learn from these tragic events and take action to ensure that this does not reoccur. Coroners' Prevention of Future Deaths (PFD reports) are a crucial resource for this and should be used to make healthcare safer. Are we utilising these to their full extent to improve our safety practice and to achieve their aim, to prevent future deaths?
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Coroner's case of Maureen Brown
Claire Cox posted an article in Coroner reports
This coroner's case, by coroner Emma Serrano, describes the events that led up to Maureen Brown's death at University Hospital of Derby and Burton NHS Trust. Maureen had an inpatient fall and died from her injuries. Could this death been prevented? How can we ensure the voice of the carer/family is heard, documented and acted upon in clinical practice? -
Content ArticleSarah O'Neill, Family Liaison Manager, Solent NHS Trust, presented at the recent Bevan Brittan seminar on the role of family liaison. The presentation slides are attached.
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Content Article
Report to Prevent Future Deaths: Regulation 28 – Eileen Pollard
Claire Cox posted an article in Coroner reports
The Coroners and Justice Act 2009 allows a coroner to issue a Regulation 28 report to an individual, organisations, local authorities or government departments and their agencies where the coroner believes that action should be taken to prevent further deaths. Eileen Pollard died of a myocardial infarction. This coroners report was due to concerns raised by the patient numerous times around the call bell either not being near the patient or not working.
