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Found 196 results
  1. News Article
    A coroner has raised concerns about a mental heath trust where staff falsified records made on the night a man died. Eliot Harris, 48, died in the Northgate Hospital in Great Yarmouth, run by the Norfolk and Suffolk Foundation Trust (NSFT), in April 2020. Norfolk coroner Jacqueline Lake said that, two years on, staff were still not recording observations properly. The 48-year-old, who had schizophrenia, had been sectioned under the Mental Health Act after he became agitated at his care home and refused to take medication. He was taken to Northgate Hospital and, after a period in a seclusion room, was transferred to a private room on the ward. Mr Harris was discovered unresponsive in bed during the early hours of 10 April and pronounced dead half an hour later. In a Prevention of Future Deaths Report (PFDR), Ms Lake said: "Quality audits undertaken following Eliot Harris's death, show that observations are still not being carried out and recorded in accordance with NSFT's most recent policy - more than two years following Eliot's death." She said that on the night Mr Harris died there was no nurse in charge and instead of being allocated specific tasks, staff were told to "muck in", causing confusion about job responsibilities. These issues were not resolved at the time of the inquest, she said, with no evidence provided about whether specific tasks were allocated on the night shift. Not all staff had been trained in recording observations, there was a lack of evidence about procedures for entering a patient's room over concerns for their welfare, and there was "still some way to go to make sure care plans are completed", Ms Lake said. Read full story Source: BBC News, 6 October 2022
  2. Content Article
    On 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.
  3. Content Article
    This article tells the story of Lyndsey, who was 36 years' old and expecting her third child when she died of shock and haemorrhage, and a perforated gastric ulcer. Sadly, her baby also died as a result of Lyndsey's condition. In her narrative report, the Coroner raised concerns that Lyndsey had been prescribed methadone with no face-to-face consultation, and that she had received a prescription with no planned medical review. She also raised concerns about the reliability of the ambulance pre-alert system due the absence of systems for auditing the effectiveness and reliability of the pre-alert system and the lack of knowledge and training of staff in control.
  4. Content Article
    This article tells the story of Baby E, who died two hours after delivery following issues with the management of her labour. The maternity unit was short-staffed on the night of Baby E's birth and there were delays in getting her mother to theatre for a caesarean section. Baby E's parents felt that the hospital withheld information from them, failing to inform them of internal investigations that had taken place following Baby E's death. At the inquest, the coroner concluded that errors had been made, including the fact that Baby E's low heart rate had been missed. She also criticised the decision-making process in the management of labour, but concluded that she was unable to say whether this had made a difference to whether or not Baby E lived.
  5. Content Article
    This article tells the story of Mr K, who died following a misdiagnosis of tension pneumothorax. Mr K was 81 and had a history of chronic obstructive pulmonary disease (COPD) and bullous emphysema. He had been diagnosed with a bulla, a large air pocket, in his right lung. The medical team treating Mr K after his admission to hospital with shortness of breath failed to review his previous x-ray and medical notes, and did not involve the respiratory team in his treatment. This led to his misdiagnosis, after which he was fitted with an unnecessary chest drain. The drain collapsed the bulla and ruptured a blood vessel leading to progressive bleeding. The medical team did not recognise their error or Mr K's bleeding and he died two days following the insertion of the drain. At his inquest, the Coroner found that the unnecessary chest drain led to Mr K's death, and that there was a missed opportunity to reassess the situation at a review the next day. They ordered that a prevention of future death report be made as the evidence heard at the inquest revealed a number of matters that gave rise to concern.
  6. News Article
    An NHS trust has “not covered itself in glory” in its dealings with the family of a vulnerable young woman who killed herself after being refused admission to hospital, a coroner has found. The three-day hearing looked at evidence withheld from the original inquest into the death of Sally Mays, who killed herself in 2014 after being turned away from a mental health unit. Mays was failed by staff “neglect” at Miranda House in Hull, a 2015 inquest ruled, after a 14-minute assessment led to her being refused a place, despite being a suicide risk. Her parents, Angela and Andy Mays, won a high court battle in December to hear details of an informal chat outside the building between Laura Elliot, a community mental health nurse who was supporting Mays, and the consultant psychiatrist Dr Kwame Fofie, which only later came to light. This was ruled to be “neither a clinical conversation nor an attempt to escalate her care” by senior coroner Prof Paul Marks on Wednesday. He said: “It was a conversation between colleagues in which the frustrations of the working day were vented.” But, he said: “The trust has not covered itself in glory with regard to its dealings with the family and the disclosing of documents.” The Mays have spent the last seven years fighting to hear details of the car park conversation, which could have changed their understanding of what happened before their daughter died. Angela Mays added: “I never considered myself to be a campaigner. I have only considered myself to be a mother who actually wants the truth about the facts relating to her daughter’s death.” Read full story Source: The Guardian, 28 September 2022
  7. Content Article
    M was a young boy who had severe asthma, resulting in regular trips to A&E. His condition was eventually well controlled with a Seretide inhaler. When M's family moved house and changed their GP, they requested a new prescription of Seretide, but when they got to the pharmacy were given the wrong type of inhaler used to treat a different form of asthma. The GP had unwittingly chosen the wrong medication from a drop-down menu. M and his family were unaware that he was taking the wrong medication, and after a few days, M became breathless and his family decided to take him to hospital. Sadly, he died on the journey to A&E. At the inquest, the Coroner found that there two main issues that contributed to M’s death: the unintentional prescription of Serevent the failure to arrange and organise follow up contributed to M’s death.
  8. Content Article
    This article tells the story of Stuart, who died as a result of medication errors while recovering from surgery at a private hospital in January 2013. Stuart had dystonia, an incurable condition that he managed by taking a careful balance of three medications. Following surgery to remove his larynx, the private neurological centre where he was staying ran out of clonazepam, a medication Stuart needed to control his dystonia. Stuart became very unwell, but instead of seeking advice from a doctor, the nurses treated his symptoms as a UTI. on 26 December he was found unresponsive in bed and rushed to ICU at a local hospital. but died a few weeks later from sever kidney and muscle damage. An inquest into Stuart's death found that the lack of clonazepam had caused an increase in Stuart’s muscle spasms, eventually leading to severe muscle and kidney damage. He then developed bronchopneumonia, which was the final factor in his death.
  9. Content Article
    This case study summarises the story of Evadney Dawkins, a 77 year-old living in East London who died on 23 August 2018 as a result of treatment errors and poor care received at Newham University Hospital. Following a fall at home, Evadney was taken to the hospital on 22nd July 2018, where she was initially treated for a chest infection and fast atrial fibrillation (an irregular and abnormally fast heart rate). As she had other co-morbidities that included chronic renal failure, a treatment plan including renal monitoring was agreed, but the hospital failed to monitor her renal function and she sustained a profound acute kidney injury. Following intensive treatment, the acute kidney injury resolved but she sustained a cardiac arrest on 23rd August 2018 and died later that day. This case study outlines how Action Against Medical Accidents (AvMA) helped Evadney's family convince the Coroner to open an inquest. The inquest found that there were ‘gross failures’ in the care provided to Evadney which led to her renal deterioration, including a failure in the frequency of blood tests, a failure in fluid monitoring and a failure to carry out renal ultrasound. The Coroner also criticised Bart's Health NHS Trust's systems of governance for not identifying for two years that Evadney’s case was a serious incident which required investigation.
  10. Content Article
    Richard von Abendorff's elderly mother died an avoidable, painful death in hospital due to being inappropriately prescribed Nalaxone. In this article, Richard outlines the steps he has taken to try and ensure lessons are learned from his mother's experience. Eventually, in 2014 NHS England published a patient safety alert relating to inappropriate doses of naloxone in patients on long-term opioid treatment. A coroner’s palliative expert report identified issues contributing to Richard's mother's poor end of life care, noting that purely advisory palliative services in an acute hospital setting are ‘not fit for purpose’ to meet the needs of more complex dying patients. Richard expresses his frustration at an ongoing lack of interest and action related to substandard end of life care.
  11. News Article
    A private hospital has been rated ‘inadequate’ by a health watchdog following an inspection prompted by a young patient’s preventable death. Woodbourne Priory Hospital, in Edgbaston, has had its overall Care Quality Commission rating downgraded from “good” to “inadequate” after inspectors visited in May. The regulator’s visit was sparked by a prevention of future deaths report into the death of Birmingham University graduate Matthew Caseby, 23, who was placed at the hospital as an NHS-funded patient in September 2020. Mr Caseby had been detained under the Mental Health Act but managed to escape Woodbourne and died after being struck by a train. Earlier this year, an inquest concluded his death was contributed to by neglect on behalf of the hospital. In April, Birmingham and Solihull coroner Louise Hunt flagged urgent concerns about record keeping, risk assessments and security of courtyard fences with Priory Group and the Department of Health and Social Care. Read full story (paywalled) Source: HSJ, 22 September 2022
  12. News Article
    An ambulance trust accused of withholding key evidence from coroners was previously warned its staff needed training to ‘understand the real risk of committing criminal offences’ in relation to inquests into patient deaths. North East Ambulance Service, which has been accused by whistleblowers of withholding details from coroners in more than 90 deaths, was told by its lawyers in 2019 about serious shortcomings in its processes for disclosing information, according to internal documents obtained by a campaigner. According to the documents, the lawyers said trust staff could “pick and choose” documents to release to coroners “regardless of relevance.” The following year, an audit report said the issues had not been addressed. Whistleblowers’ concerns about the trust were first reported by The Sunday Times in the spring, with a review highlighting several cases between 2018 and 2019 where key facts were omitted in disclosures to coroners. But campaigner Minh Alexander has since obtained new details of warnings that were being made to internally, from lawyers and auditors who were advising the trust. Read full story Source: HSJ, 20 September 2022
  13. News Article
    A coroner has said she does not understand why frontline workers were not required to wear a mask during lockdown after hearing a paramedic had died with Covid. A two-day inquest into the death of Peter Hart, who died on his 52nd birthday, concluded on Tuesday (September 13) with assistant coroner Dr Karen Henderson ruling the father-of-three died of natural causes caused by Covid. She said on the balance of probabilities he caught the disease while working at East Surrey Hospital, where he died on May 12, 2020. During the onset of the pandemic only healthcare workers tending to those suspected of having Covid-19 were required to wear personal protective equipment (PPE). In accordance with national guidelines, Mr Hart, who was treating patients not suspected of having the virus, did not need to. “Retrospectively it is difficult to comprehend why the national guidance said PPE did not need to be used for all patients and healthcare workers at the earliest opportunity,” Dr Henderson said. “Although there appears a lost opportunity to ensure maximum protection I make no finding of fact whether this contributed to Mr Hart’s death. “Patients not suspected to have Covid were not expected to wear face masks. This is in effect a perfect storm and given evidence of Mrs Hart I am satisfied Mr Hart contracted Covid during his work at East Surrey Hospital,” she added. Read full story Source: Surrey Live, 13 September 2022
  14. Content Article
    On 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.
  15. Content Article
    In the first in a two-part series looking at the work of the coroner, James Sira talks to Derek Winter about the role of the coroner, medical examiner, and the coroner’s inquest.   Derek is HM Senior Coroner for the City of Sunderland and was appointed as one of the two Deputy Chief Coroners of England and Wales in 2019. He has conducted a wide range of cases in the 15 years he has spent as a coroner and has modernised the Sunderland coroner service.  Most intensive care doctors will at some point in their career be required to provide a statement for or give evidence at a coroner’s inquest, and this can be a daunting experience.
  16. News Article
    A coroner has said Britain is failing young people and more will die because of under-resourced mental health services, as she ruled that neglect led to the death of a 14-year-old girl. Penelope Schofield, the senior coroner for West Sussex, said she would write to the health secretary, Sajid Javid, to raise concerns after the case of Robyn Skilton, who killed herself after being let down by “gross failures” in NHS mental health services. Robyn, from Horsham in West Sussex, disappeared from her family home and took her own life in a park on 7 May last year, her inquest in Chichester heard. Despite serious concerns about her mental health, Robyn did not get face-to-face consultations, was not seen by a child psychiatrist or assessed for mental health issues, and was discharged from an NHS service a month before her suicide though she was on its high-risk “red list”. Her father, Alan Skilton, told the inquest he pleaded for help, and he described the lack of care his daughter received as “astonishing”. He said he believed that if Robyn had been seen earlier, her mental health would have improved and she would not have killed herself. The coroner said: “As a society we are failing young people.” She said she was shocked to hear that the number of young people seeking mental health help had increased by 95%. “Trying to manage it without more resources means we are not providing the help that young people need. Robyn’s case is a testament to that. It’s a clear risk that more lives will be lost if we don’t address it.” Read full story Source: The Guardian, 29 June 2022
  17. Content Article
    This annual publication presents statistics of deaths reported to Coroners in England and Wales in 2021. Information is provided on the number of deaths reported to coroners, post-mortem examinations and inquests held, and conclusions recorded at inquests.
  18. Content Article
    From 28 June 2022, courts and tribunals will have new powers to allow reporters and other members of the public to observe hearings remotely. The purpose of this practice guidance is to help judicial office holders understand and apply the new law.
  19. News Article
    A hospital and one of its managers are facing a criminal investigation into the death of a vulnerable man who absconded by climbing a fence. An inquest concluded failings amounting to neglect contributed to the death of Matthew Caseby in 2020, after he fled from Birmingham's Priory Hospital Woodbourne and was hit by a train. The investigation will be carried out by the Care Quality Commission (CQC). Priory said it would co-operate fully "if enquiries are raised by the CQC". Mr Caseby, 23, climbed over a 2.3m-high (7ft 6in) courtyard fence on 7 September 2020. He was found dead the following day after being hit by a train near Birmingham's University station. The inquest in April heard other patients had previously climbed the fence and, despite concerns by members of staff, no action was taken to improve security in and around the courtyard until another patient absconded two months after Mr Caseby's death. Following the inquest, coroner Louise Hunt said she was concerned the fence and courtyard area may still not be safe and urged health chiefs to consider imposing minimum standards for perimeter fences at mental health units. She also criticised record-keeping and how risk assessments were carried out. Read full story Source: BBC News, 23 June 2022
  20. News Article
    A troubled NHS trust failed for months to give vital medication to a prison inmate who had a long-standing diagnosis of HIV, an inquest has found. A jury at Essex Coroner’s Court concluded that a series of failures and neglect by Essex Partnership University Trust (EPUT) contributed to the death of Thokozani Shiri in April 2019. The 21-year-old spent two spells as a prisoner at HMP Chelmsford, where EPUT provided some services at the time. He was considered vulnerable due to a long-standing diagnosis of HIV for which he was receiving treatment before he went to prison, and the trust was aware he had HIV throughout both stays, the inquest heard. The inquest jury identified that five separate failings had “probably caused” Mr Shiri’s death. These included: a failure to provide antiretroviral medication to Mr Shiri during both periods of imprisonment; a failure to refer him to an HIV clinic; the absence of an appropriate care plan and engagement with a multidisciplinary team; and inadequate management of records. Each failing on behalf of the trust was considered by the jury to have amounted to neglect. Read full story (paywalled) Source: HSJ, 9 June 2022
  21. News Article
    The death of a retired police officer who got his head trapped in a hospital bed was an avoidable accident, an inquest has concluded. Max Dingle, 83, of Newtown, Powys, died after he became stuck between the rails and mattress at the Royal Shrewsbury Hospital on 3 May 2020. The initial post-mortem test gave the cause of death as heart disease. But a second examination, commissioned by Mr Dingle's son, found entrapment and asphyxiation to be the cause. After comparing and discussing their findings, both pathologists then agreed "entrapment did play a significant part in the cause of death", the senior coroner for Shropshire John Ellery said. The inquest was told Mr Dingle's son Phil had asked for the second post-mortem test because "did not accept" the initial findings and had sought the opinion of a pathologist in Australia, where he lives. Max Dingle, who had been admitted to the hospital with shortness of breath, died 15 minutes after he was found to be trapped, the hearing was told. Concluding the inquest, Mr Ellery said: "Based on all the evidence, the conclusions of this inquest are Mr Dingle's death was an avoidable accident." Read full story Source: BBC News, 1 June 2022
  22. News Article
    An ambulance trust has been accused of acting like a “criminal gang” and lying to dead patients’ families by an employee who repeatedly warned about paramedics’ mistakes being covered up. Paul Calvert, a coroner’s officer whose job was to produce reports on deaths, tried to raise concerns about managers at the North East Ambulance Service (NEAS) for three years before walking out last year on the verge of a breakdown. “My life was being made a misery,” said Calvert, who was previously a detective with Northumbria police. “They were basically like a criminal gang. I had tried everything I could to warn the proper authorities about how the service was destroying and concealing evidence meant for the coroner. I spoke to my managers, to human resources, to external auditors. I even made disclosures to the Care Quality Commission and Northumbria police. Nothing was done about it.” Despite their denials of a large-scale cover-up of mistakes, the NEAS this year offered Calvert £41,000 as part of a non-disclosure agreement it asked him to sign. One of the clauses meant destroying all the evidence he had collected. Another tried to stop him making any further disclosures to police. Reports and witness statements from ambulance staff were not being disclosed to the coroner “on a daily basis”, according to Calvert, amounting to key pieces of evidence relating to deaths being hidden from the public. Read full story (paywalled) Source: The Times, 29 May 2022
  23. News Article
    Doctors are receiving "inadequate" training about the risk of sepsis after a mother-of-five died following an abortion, a coroner has warned. Sarah Dunn, 31, died of "natural causes contributed to by neglect" in hospital on 11 April 2020, an inquest found. Assistant coroner for Blackpool and Fylde, Louise Rae, said Ms Dunn had been treated as a Covid patient even though the "signs of sepsis were apparent". Her cause of death was recorded as "streptococcus sepsis following medical termination of pregnancy". In her record of inquest, the coroner noted Ms Dunn was admitted to Blackpool Victoria Hospital in Lancashire on 10 April 2020. She was suffering from a streptococcus infection caused by an early medical abortion on 23 March, which had produced sepsis and toxic shock by the time she was admitted to hospital. The coroner said "signs of sepsis were apparent" before and at the time of Ms Dunn's hospital admission but she was instead treated as a Covid-19 patient. "Sepsis was not recognised or treated by the GP surgery, emergency department or acute medical unit and upon Sarah's arrival at hospital, the sepsis pathway was not followed," she added. Read full story Source: BBC News, 19 May 2022
  24. Content Article
    Sarah Louise Dunn was admitted to the Blackpool Victoria Hospital on 10 April 2020. She was suffering from a Group A Streptococus infection following an early medical abortion on 23 March 2020 which by the time of her admission at hospital had produced sepsis and had progressed to toxic shock. Signs of sepsis were apparent before and on her admission given Sarah’s history and symptoms but Sarah was treated upon admission to hospital as a Covid-19 patient. Prior to admission, Sarah had not been seen by a doctor on either 9 or 10 April despite contacting both her GP surgery and the Out of Hours Service. The surgery pharmacist had not read Sarah’s notes properly and was not aware on 9 April that she had recently had undergone an early medical abortion. Her GP on 1 April had not recorded his face to face consultation with her nor noted the possibility of infection. Sepsis was not recognised or treated by the GP surgery, emergency department or Acute Medical Unit and upon Sarah’s arrival at hospital, the sepsis pathway was not followed. Antibiotics were not given to Sarah until 7.5 hours after her arrival at hospital. Sarah suffered a seizure at 6.30pm on the Acute Medical Unit and was transferred to the Intensive Care Unit. These matters in aggregate impacted on her care and Sarah would not have died had she been admitted to hospital sooner. Sarah died on 11 April 2020 on the Intensive Care Unit at Blackpool Victoria Hospital at 2.15am.
  25. News Article
    Heart surgery patients in London have died “unnecessarily” and faced increased risk of death as botched NHS investigations into dozens of deaths reduced a hospital’s ability to treat people, a coroner has warned. “Unnecessary” patient deaths have occurred as a result of heart surgery at St George’s University Hospital Trust being restricted and emergencies diverted to other “over stretched” hospitals, following investigations by national NHS bodies. The warning that deaths have occurred and may occur in the future, comes following the conclusion of a series of inquest hearings in March, during which it was found the NHS’ wrongly blamed a team of cardiac surgeons for the deaths of dozens of patients. Coroner Fiona Wilcox, in a report published on Wednesday, has now said the “inadequate” NHS led investigations, which criticised the care of 67 patients, led to people being put increased risk of death. The NHS’ investigations into the deaths of 67 patients ruled there were “shortcomings” in care. It led to complex operations being diverted elsewhere and doctors being referred to the General Medical Council. Two doctors have sinced been exonerated following GMC hearings. According to the coroner’s findings, capacity within cardiac surgery at the unit is down by 60% and staff are becoming “deskilled.” Read full story Source: The Independent, 11 May 2022
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