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Showing results for tags 'Coroner'.
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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 -
News Article
Watchdog forced to hand over NHS staff names in safety failure cases
Patient Safety Learning posted a news article in News
A national safety watchdog has been forced to release almost 100 pieces of evidence, including names of NHS staff, after being ordered to by courts. A freedom of information request, submitted by HSJ, has revealed the Healthcare Safety Investigation Branch (HSIB) has been required to release 93 interviews with staff, family members and external experts, along with their identities, over the last two years. The interviews, which relate to HSIB investigations involving hospital trusts across England, were released to coroner’s courts through eight separate orders dating from February 2019. A further four court orders compelled HSIB to release other information to coroners, including reports into trusts, findings of internal panel reviews, and evidence from external experts. The orders were made under the Coroners and Justice Act 2009. When HSJ asked whether any NHS staff or family members were named in open court, HSIB said it was “not able to comment on specific instances”, but added that all those whose evidence was shared with the coroners were notified in advance. Read full story (paywalled) Source: HSJ, 23 February 2021 -
News Article
Inquest hears evidence of mistakes in Nightingale patients’ care
Patient Safety Learning posted a news article in News
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 -
News ArticleThe health service ombudsman has warned he will ‘be in no position to investigate’ the behaviour of another watchdog under the government’s health service reforms. Rob Behrens, the Parliamentary and Health Service Ombudsman, said plans to create a “closed safe space” for the information provided by clinicians to the Healthcare Safety Investigation Branch (HSIB) will mean a reduction in his powers and he will not be able to hold HSIB to account. Mr Behrens, speaking at HSJ’s Patient Safety Congress, said that although coroners would be able to access information gathered by HSIB investigations under the reforms, the ombudsman would not be able to access this “safe space” without the permission of the High Court. The reforms would see HSIB become a new statutory independent organisation, the Health Service Safety Investigations Body, and prohibit the disclosure of “protected material” such as information or documents obtained during investigations. However, this prohibition of disclosure would not apply to information required by coroners, ordered by the High Court or necessary to investigate an offence or address a “serious and continuing” safety risk to a patient or the public. Read full story (paywalled) Source: HSJ, 22 September 2021
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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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News Article
Wrong bodies released by NHS mortuaries dozens of times
Patient-Safety-Learning posted a news article in News
New figures has revealed serious incidents have occurred in NHS trusts where the wrong bodies of patients were released to families or lost, damaged or kept the organs or bodies of babies without family permission. According to data from the Human Tissue Authority, these incidents have reduced over the years, however, the errors still affected more than 100 families in the latest year to March 2021. Incidents such as these are extremely distressing for the friends and family of the deceased patient, but also for the staff working in the mortuaries involved, who try their best to uphold the highest standards of patient care in often difficult circumstances. The fact that the mortuary profession is not a profession regulated by statute – as other professions such as laboratory staff and paramedics are – makes the maintenance of these quality standards more difficult than it needs to be." Said John Pitchers, chair of the Association of Anatomical Pathology Technology Read full story. Source: The Independent, 8 August 2021 -
News Article
NHS warned multiple times that imaging shortages may kill
Patient Safety Learning posted a news article in News
Coroners have warned the NHS nearly a dozen times in recent years that a lack of imaging capacity could lead to more deaths, HSJ can reveal. Five of these warnings followed deaths at a single site, Tameside General Hospital in Greater Manchester. The most recent case concerned a patient that died after developing covid during a prolonged wait for an MRI scan. Sir Mike Richards last year warned in a major report for NHS England about the lack of imaging equipment, and the Royal College of Radiologists has highlighted national shortages of radiology staff on numerous occasions in recent years. HSJ combed through more than 100 prevention of future death reports and responses published between 2018 and 2021 in an effort to quantify harm linked to these shortages. Of dozens of reports mentioning imaging issues, including software problems, poor note-taking and incorrect interpretation of results, HSJ identified 11 cases where coroners specifically warned either the trust or system concerned, and/or NHS England or the Department for Health and Social Care, that capacity issues could lead to future deaths. In some of the cases, coroners concluded that shortages likely contributed to a patient’s death. Read full story (paywalled) Source: HSJ, 20 May 2021 -
News Article
Baby death raises questions over maternity care
Patient Safety Learning posted a news article in News
Beth and Dan Wankiewicz want answers about why their baby son Clay died last year, shortly after his birth at Doncaster Royal Infirmary. Despite a low-risk pregnancy, the family say Clay died from multiple skull fractures. Doncaster and Bassetlaw NHS Foundation Trust said "the provision and delivery of high-quality" care is a priority. The BBC has found a 2016 review flagging concerns about the hospital's maternity care was never published. The report - one of scores of unpublished reports discovered by a Freedom of Information request by BBC's Panorama programme - highlighted significant patient safety concerns. Beth Wankiewicz was admitted to hospital last July, but after a day of labour her baby had still not been born. With no consultant doctor on site, a junior doctor made two attempts to deliver the baby with forceps, after getting advice on the phone. Father, Dan, remembers the second attempt with forceps being much more vigorous "which was a bit of a shock". The family say there was a further delay before they had a Caesarean section. Their baby had to be pushed back up the birth canal into the womb for the C-section to be performed. "I think after about 10 minutes, we both looked at the clock, and we said it's not looking good," said Dan. Around 20 minutes after their son was born, despite attempts to resuscitate him, they were told he had died. The following day they say a midwife told them she was being pressurised by other staff to say Clay had been stillborn, but she was sure he had been born alive, and she had heard a heartbeat. The family now believe this was to avoid scrutiny and the need for a coroner's inquest, which doesn't happen with still births. Read full story Source: BBC News, 19 May 2021 -
EventThis virtual conference, chaired by Mike O’Connell Legal Services Practitioner, and with an opening presentation from Andrew Harris Senior Coroner London Inner South and Professor of Coronial Law William Harvey Research Institute, Queen Mary’s University London, focuses on the role of the Coroner and preparing and attending Coroner's Inquests. Further information and book your place or email kate@hc-uk.org.uk hub members receive 10% discount. Email info@pslhub.org for code Follow the conversation on Twitter #CoronerRole
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Content ArticleThis 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.
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Content ArticleFrom 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.
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Content ArticleIn 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.
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Content ArticleAlexander James Davidson was aged 17 years and 6 months when he died at the Queens Medical Centre on 26 February 2018. Alex was previously fit and well before suddenly taking ill with abdominal pain on 17 January 2018. Between that date and his admission to the Queens Medical Centre on 8 February 2018, Alex made contact with his GP on three occasions, had four telephone triage assessments undertaken by the NHS 111 service and two admissions to his local Accident & Emergency Department at the Kingsmill Hospital. Alex’s symptoms of sudden onset acute abdominal pain, tachycardia, and vomiting and diarrhoea were attributed either to stress or to a bout of gastroenteritis. At no stage prior to 8 February 2018 was gallstones or pancreatitis considered as a differential diagnosis. When Alex was eventually admitted to the Queens Medical Centre Emergency Department on 8 February 2018, he was found to be septic as a result of an infected and necrotic pancreatic pseudocyst, which had evolved as a complication of gallstone pancreatitis, a rare condition in someone of Alex’s age. Despite medical intervention, Alex did not survive. The inquest explored the medical treatment and intervention that Alex received in the six weeks prior to his death. The medical evidence concluded that the pancreatic pseudocyst had likely formed by the time Alex began vomiting on 18 January 2018, and from that point onwards, it was unlikely he would survive even with treatment on account of the high mortality rate associated with this condition
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Content Article
Prevention of Future Deaths: Sebastian Hibberd (23 August 2019)
Sam posted an article in Coroner reports
Sebastian Hibberd, 6 years old, became ill on Saturday 10 October having developed intussusception of the bowel. He deteriorated over the weekend. His father sought medical advice on the Monday from NHS 111 and from his GP's surgery. Sebastian's condition went unrecognised as being life threatening. There were several missed opportunities for him to receive life saving treatment. Sebastian suffered a cardiac arrest and transferred to Derriford Hospital where he sadly died in the Emergency Department shortly after his arrival on the 12 October. -
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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Content ArticleSarah 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.
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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 ArticleThis 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.
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Content ArticleThis 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.
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Content ArticleM 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.
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Content ArticleRichard 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.
