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Found 193 results
  1. Content Article
    Morgan-Rose Hart died after she was found unresponsive while being detained under section 3 of the Mental Health Act at the Derwent Centre at the Princess Alexandra Hospital in Essex. Morgan-Rose was last clinically observed at 14.06 on 6 July 2022 and in between the last observation and when Morgan-Rose was discovered the Coroner notes that multiple failings in her care took place, including consecutive hours observations being incorrect and falsified.
  2. Content Article
    Andrew Guillaume was admitted to Warwick Hospital on the 6 June 2023. Following a review, it was agreed that the likely diagnosis was severe aortic stenosis requiring an urgent Consultant to Consultant referral to University Hospitals Coventry and Warwickshire (UHCW) cardiology team. However, no referral was made as the Consultant was unable to get through to the switchboard at UHCW, so Mr Guillaume remained at Warwick Hospital. Subsequently his condition worsened and on the 16 June 2023 a plan was made to update the cardiothoracic surgery team at UHCW to expedite his surgery, but again they were unable to reach the team through the switchboard. Mr Guillaume was admitted to the unit on 19 June 2023, but sadly died on 20 June 2023 due to a further sudden deterioration in his condition.
  3. News Article
    Hospital neglect contributed to the death of a two month old baby after staff turned off emergency alarms, a coroner has ruled. Louella Sheridan died at Royal Bolton Hospital in on 24 April 2022 after she was admitted with bronchiolitis to the hospital’s intensive care unit before later dying from Covid and a related heart condition. Four alarms on a monitoring machine were silenced and then switched off before the baby collapsed in a high dependency unit, it has been found. On Wednesday coroner John Pollard ruled neglect by staff had contributed to Louella’s death after staff switched off the alarms on the monitors attached to her during the night. Summing up his conclusion Coroner Pollard reportedly said there was a “gross failure “ to provide basic medical care to Louell and that had care been given, had the alarms been switched on to alert staff her life may have been extended at least for a short period of time. He said turning off the alarms was a gross type of conduct. Read full story Source: The Independent, 22 December 2023
  4. Content Article
    On 11 January 2021 an investigation into the death of Susan Ann Gladstone was started. The investigation concluded at the end of the inquest on 20 November 2023. The conclusion of the inquest was Susan died as a result of a generally unknown interaction between warfarin and tramadol which caused exceptional thinning of her blood: 1a Intraparenchymal and subarachnoid haemorrhage.
  5. News Article
    NHS England has been told it must take action to raise awareness about the potentially fatal interaction between tramadol and warfarin, following the death of a patient. Graham Danbury, assistant coroner for Hertfordshire, issued a prevention of future deaths report on 1 December 2023, after Susan Gladstone, from Hertfordshire, died on 8 January 2021 from a bleed in the brain. An inquest, which ended on 20 November 2023, concluded that Gladstone “died as a result of a generally unknown interaction between warfarin and tramadol, which caused exceptional thinning of her blood”. Gladstone was prescribed tramadol twice for lower back pain: on 20 December 2020 and 4 January 2021. According to the report, she had been taking the anticoagulation medication warfarin for “a number of years”. The report continues: “There was nothing to warn the prescribing doctor of any possible interaction. I found on the balance of probabilities that an interaction between tramadol and warfarin had caused this dangerous, and in the event, fatal INR to develop. “In my opinion, actions should be taken to prevent future deaths and I believe you, NHS England, have the power to take such action.” Read full story Source: Pharmaceutical Journal, 13 December 2023
  6. Content Article
    Mr Malone was diagnosed with treatment resistant schizophrenia in 1983 and had been sectioned multiple times. In May 2023 he was diagnosed with adult autism. At a review on 31 May he was considered to be stable. On 15 June a routine clozapine review identified sub-therapeutic levels but this was not notified to his clinicians. Sub-therapeutic levels of clozapine are likely to have contributed to a worsening in his symptoms. Around 24 June he was noted to have suffered a significant deterioration – with symptoms of thought disorder, anxiety, and responding to hallucinations – and following a mental health act assessment on 28 June clinicians wanted to detain him under section 2. No inpatient psychiatric bed was available. Whilst he awaited a bed, he remained in the community with daily visits from the mental health team. Last contact was on 1 July when he accepted his medication and appeared more settled. There was no answer when he was visited on 2 July. His room at supported accommodation was entered on 3 July and he was found deceased. Recently he had expressed no suicidal ideation. Post-mortem examination confirmed the medical cause of death was:  1a Cervical spinal cord injury. 1b Laceration. The conclusion of the inquest was that death was the consequence of suicide.
  7. Content Article
    Peter had a long history of depression, anxiety, and reported suicide attempts. He had acknowledged his reluctance to always engage fully with the treatment offered. On 3 August 2022 he was referred to the home treatment team for crisis intervention. After poor engagement he was transferred back to the community mental health team. On the 14 October he was detained by police under section 136 mental health act after expressing suicidal ideation. He told a psychiatric liaison service nurse he had no ongoing suicidal ideation and was referred to the community mental health team and his GP. He then contacted services further a number of times. On 10 November 2022 Peter was found deceased in his flat having taken a deliberate overdose of his prescribed medication. At the time of his death he was on the waiting list to be allocated a mental health care co-ordinator and there had been no multi-disciplinary meeting with all teams involved to agree how best to work with Peter. His cause of death was confirmed at post-mortem: 1a Carbamazepine toxicity. The conclusion reached was death was a consequence of suicide.
  8. News Article
    Ministers must intervene over systemic failures which are “too big for hospital or ambulance trusts to fix on their own” and have led to multiple preventable deaths, a senior coroner has warned. In a move usually considered rare for such an official, Cornwall and Isles of Scilly coroner Andrew Cox has written to the Department of Health and Social Care a second time over ongoing delays to ambulance responses and long ambulance handovers in the area. Last year he warned the NHS was “broken” after he ruled ambulance and emergency care delays contributed to the deaths of four people. Now, he has sent a similar report on the same types of failings in the deaths of John Seagrove, Pauline Humphris, and Patricia Steggles at Royal Cornwall Hospital to new health secretary Victoria Atkins. Mr Cox wrote: “I set out in my [prevention of future death report] last year my understanding of the reasons for the difficulties that are continuing in the Cornwall & Isles of Scilly coroner area. I do not believe those reasons will have changed significantly. ”The challenges are systemic in nature. They are too big for a single doctor, nurse or paramedic to fix. They are too big for either the hospital trust or the ambulance trust to fix on their own.” Read full story Source: HSJ, 1 December 2023
  9. Content Article
    Christina Ruse was admitted to the Spire Hospital on 14 December 2021 and underwent a total left hip replacement. Her condition deteriorated and observations were commenced at five minute intervals. Mrs Ruse was reviewed and on further deterioration in her condition it was decided to transfer her to the High Dependency Unit, Norfolk and Norwich University Hospital. On arrival of the ambulance Mrs Ruse was undergoing a further investigatory procedure. On this being completed Mrs Ruse was taken to the Norfolk and Norwich University Hospital, where her condition continued to deteriorate and she died on 15 December 2021.
  10. Content Article
    Barbara Hollis underwent a total left knee replacement operation on 22 February 2022. The surgery was uneventful with no complications, however after her return to the ward Mrs Hollis became restless and confused. Following a review of her deteriorating condition the decision was made to transfer her to the High Dependency Unit at the Norfolk and Norwich University Hospital. Arrangements were made for the transfer and the ambulance service was called at 19.51 and were told that immediate clinical intervention was needed, but the agreed hospital to hospital transfer pathway was not followed. There was a two hour delay in ambulance attendance, during which time Mrs Hollis continued to deteriorate. Mrs Hollis was subsequently taken to the High Dependency Unit at the Norfolk and Norwich University Hospital where her condition continued to deteriorate and she died in the early hours of the 23 February 2022.
  11. News Article
    Maternity services at Hull Royal Infirmary have recently been described in a damning report by the health watchdog as chaotic, unsafe and not fit for purpose. Three mothers, who claim staff missed signs of life-threatening conditions that could have killed them or their babies, have spoken to the BBC about their harrowing experiences at the hospital. One woman, a BBC journalist who does not want to be named, said she knew her newborn son was seriously ill within minutes of giving birth at the infirmary in 2021. "As soon as they handed him to me, I noticed something was wrong. He was panting and his breathing wasn't right," she said. Over the course of an hour, she said her concerns were dismissed by the newly-qualified midwife who said his breathing was "completely normal". "She kept reassuring me over and over that's how babies breathe. I felt like I was drowning surrounded by lifeguards," she said. But after being examined by a more experienced midwife, the baby was rushed to intensive care and diagnosed with potentially fatal sepsis. "It was like time stood still. The midwife ripped him off me and she slammed an oxygen mask on his face, called the crash team and he was taken away to the neonatal intensive care unit. "The anger I felt was overwhelming because I'd been saying for nearly an hour he was seriously ill. I was right and he had sepsis." A few months after her son's birth, she read about an inquest into the death of a four-day-old baby who had sepsis and was born at Hull Royal Infirmary. A coroner found that midwives had failed to respond to his infection quickly enough. "My blood ran cold because it was exactly the same circumstances that happened to me and that baby died. I thought they clearly haven't learned anything," she said. Read full story Source: BBC News, 6 November 2023
  12. Content Article
    While at Amberley Hall Care Home for rehabilitation, Geoffrey Whatling’s family had raised concerns that he was unwell. He was scored as a 7 on the National Early Warning Score (NEWS2) system on the 8 April 2023. Such a score requires a 999 call to be made, however instead a 111 call was made. The 111 call taker was not made aware of his NEWS2 score. Further observations were carried out on 9 April 2023 (NEWS2 score 6), and 07.00 (NEWS2 score 5) and again on 10 April 2023 at 12.13 (NEWS2 score 9/10), when emergency services were called and Mr Whatling was admitted to Queen Elizabeth Hospital. Despite treatment his condition continued to deteriorate and he died on 26 April 2023.
  13. News Article
    The parents of a baby boy who died at seven weeks old after a hospital did not give him a routine injection have described the failure as “beyond cruel”. William Moris-Patto was born in July 2020 at Addenbrooke’s hospital in Cambridge, where it was recorded in error that he had received a vitamin K injection – which is needed for blood clotting. The shot is routinely given to newborns to prevent a deficiency that can lead to bleeding. His parents, Naomi and Alexander Moris-Patto, 33-year-old scientists from Chatteris, Cambridgeshire, want to raise awareness about the importance of the vitamin after a coroner concluded William would not have died had the hospital administered the injection. On Friday, the coroner Lorna Skinner KC described the omission as “a gross failure in medical care amounting to neglect”. Alexander Moris-Patto, a researcher at the University of Cambridge who recently co-founded William Oak Diagnostics to test for deficiencies in babies, said: “What’s come out of the inquest for me is that the systems they [the trust] put in place to try to prevent this happening again are not satisfactory.” He stressed the importance of the vitamin K injection, adding that about 1% of the UK population opt out of it. “We want people to know more about it, to understand how critical it can be, and for hospitals to take seriously the responsibility they have in those first precious hours of a baby’s life,” he said. Read full story Source: The Guardian, 29 October 2023
  14. News Article
    A coroner has found neglect contributed to a baby's death at the hospital where he was born. Jasper Brooks died at the Darent Valley Hospital in Kent on 15 April 2021. The coroner found gross failures by midwives and consultants at the hospital and says Jasper's death was "wholly avoidable". Jasper was a second child for Jim and Phoebe Brooks. Due to a complication during pregnancy of her first child, Phoebe was booked in to have an elective Caesarean section to deliver Jasper. But in April 2021 those plans changed overnight. A check-up found Phoebe had raised blood pressure. She was told to remain in hospital and that the C-section would happen the following morning - nine days earlier than planned - when there were more staff on duty. Jasper's parents say the midwives caring for Phoebe repeatedly failed to listen to her and Jim's concerns - that she was shaking violently, feeling sick, and thought she was bleeding internally. "We felt like an inconvenience - no-one wanted to deal with me that night," Phoebe says. "The doctor didn't want to do my C-section, the midwife that's meant to be looking after me, she just doesn't really care. "I remember saying clearly to her, 'my whole body is shaking - something's happening, and no-one's taking the time to listen to what I'm saying or listen in on my baby'." At the inquest hearing, midwife Jennifer Davis was accused by the family's barrister, Richard Baker KC, of "failing to act on signs of blood loss, failing to determine if Phoebe was in active labour, and failing to call a senior doctor when necessary". Jasper was born without a heartbeat, so a resuscitation team was called. But during the inquest, the family learned that further errors were made because the correct people failed to attend the resuscitation. There was no consultant neonatologist on site - a doctor with expertise in looking after newborn infants or those born prematurely. Intubation, the process of placing a breathing tube into the windpipe - which should only take a few minutes - did not occur for 18 minutes. There was also a delay in administering adrenaline to try to stimulate Jasper's heart. Read full story Source BBC News, 24 October 2023
  15. News Article
    A London coroner has warned the health secretary that preventable child suicides are likely to increase unless the government provides more funding for mental health services. Nadia Persaud, the east London area coroner, told Steve Barclay that the suicide of Allison Aules, 12, in July 2022 highlighted the risk of similar deaths “unless action is taken”. In a damning prevention of future deaths report addressed to Barclay, NHS England and two royal colleges, Persaud said the “under-resourcing of CAMHS [child and adolescent mental health services] contributed to delays in Allison being assessed by the mental health team”. An inquest into Allison’s death last month found that a series of failures by North East London NHS foundation trust (NELFT) contributed to her death. In her report, Persaud said delays and errors that emerged in the inquest exposed wider concerns about funding and recruitment problems in mental health services. “The failings occurred with a children and adolescent mental health service which was significantly under-resourced. Under-resourcing of CAMHS services is not confined to this local trust but is a matter of national concern,” she said. Read full story Source: The Guardian, 14 September 2023
  16. News Article
    The family of a young trans woman who is believed to have taken her own life have said she was “failed by those tasked with her care”, as the coroner investigating her death described services for transgender people as “underfunded and insufficiently resourced”. Alice Litman had been waiting to receive gender-affirming healthcare for more than three years when she died in Brighton at the age of 20 in May 2022. Ahead of an inquest which began in Hove on Monday, her mother, Dr Caroline Litman, described Alice’s death as “preventable with access to the right support”. Adjourning the inquest on Wednesday to give a narrative conclusion in two weeks’ time, the coroner Sarah Clarke told the court: “It seems to me that all of these services are underfunded and insufficiently resourced for the level of need that the society we live in now presents". Describing the trans healthcare system as “not fit for purpose”, Alice's family, who are being supported by the Good Law Project, added: “We are grateful that the coroner has agreed that the conditions of Alice’s death warrant a report to prevent future deaths.” Read full story Source: The Guardian, 20 September 2023
  17. Content Article
    Harold Pedley, known as Derek, attended his GP surgery during the late afternoon on 21.12.22 and after spending most of that day feeling unwell with symptoms including abdominal pain and vomiting. He was appropriately referred to the hospital and travelled there with his friend after his GP had discussed his case with doctors. Due to a lack of available beds in the assessment unit, Derek needed to remain in the emergency department. Following his arrival at 20.07 hours, doctors were not notified of his attendance. He remained in the emergency department waiting area for almost two hours during which time due to significant pressures faced by the department he was not assessed or spoken to by a medical professional. At 21.59 hours a triage nurse called for him. By then, Derek had been unresponsive for some time and had died, his death confirmed at 22.26 hours. A subsequent post mortem examination revealed he died from the effects of non-survivable extensive small bowel ischaemia caused by a significantly narrowed mesenteric artery. His death was contributed to by heart disease.
  18. News Article
    A coroner has warned that a private hospital is relying on NHS ambulances to transport patients despite “being fully aware” of the pressures on the ambulance service and resulting delays. The warning came at the end of an inquest into a patient who died after a 14-hour wait for an ambulance to transfer him from the private Spire hospital in Norwich to the NHS-run Norfolk and Norwich university hospital a few minutes’ drive away. The last two years have seen a succession of inquests relating to ambulance delays. But in the latest case Jacqueline Lake, senior coroner for Norfolk, expressed concerns over Spire hospital’s use of NHS ambulances when complications and emergencies mean its patients need NHS care. “Spire Norwich hospital does not deal with multi-disciplinary and emergency treatment at its hospital and transfers patients requiring such treatment to local acute trusts, usually the Norfolk and Norwich university hospital,” Lake wrote in a prevention of future deaths (PFD) report. “Spire Norwich hospital continues to rely on EEAST [East of England Ambulance Service NHS Trust] to transport such patients to the acute hospital, being fully aware of the demands placed on the EEAST generally and the delays which occur as a result.” Research suggests that nearly 600 patients were urgently transferred from private healthcare to NHS emergency care in the year to June 2021 across the UK – around one in a thousand private healthcare patients. But previous analysis by the Centre for Health and the Public Interest (CHPI) thinktank found that some private hospitals were transferring more than one in every 250 of their inpatients to NHS hospitals. ‘“Transferring unwell patients from a private hospital to an NHS hospital is a known patient safety risk which all patients treated in the private sector face – including the increased numbers of NHS patients who are now being treated in private hospitals because of government policy,” said David Rowland, director of the CHPI. “And despite numerous tragedies and despite the fact that politicians and regulators are fully aware of this risk, nothing has been done to address it.” Read full story Source: The Guardian, 23 September 2023
  19. Content Article
     On 3 August 2022, Geoffrey Hoad underwent a total hip replacement at The Spire Hospital. On 5 August 2022, Mr Hoad was diagnosed with a paralytic ileus and some respiratory compromise with gradually deteriorating renal function. On 6 August 2022, Mr Hoad’s transfer to Norfolk and Norwich University Hospital was agreed due to possible bowel obstruction, possible pulmonary infection and deteriorating renal function.   Ambulance service was called at 18:16 hours and again at 23.45. On 7 August 2022, the ambulance service was called again at 07.38 hours. The ambulance was on scene at 08:26 hours.         The medical cause of death was: 1a) Sub Acute Myocardial Infarction 1b)  Coronary Artery Atherosclerosis 2) Hospital Admission for Post Operative lieus.
  20. Content Article
    Harry's Story is a website set up by Derek Richford, the grandfather of Harry Richford, who died in November 2017 at just a week old following failures in care during and after his birth. The site outlines how Harry's family worked tirelessly to uncover what happened to Harry and the poor standard of care at the maternity unit at East Kent University Hospitals Foundation Trust (EKUHFT). It covers the following aspects of the family's experience: Our Investigation The Inquest Cover Up? - You Decide HSIB Involvement What Happened Next The Kirkup Inquiry Accountability Harry's Legacy The site also contains a section offering advice for parents whose babies die or suffer harm in hospital during the perinatal period.
  21. Content Article
    On 3 August 2022 an investigation was carried out into the death of Allison Vivian Jacome Aules. Allison was 12 years old when she passed away on the 19 July 2022. The investigation concluded at the end of the inquest on the 17 August 2023. The conclusion was that Allison died as a result of suicide, contributed to by neglect.
  22. News Article
    A coroner has strongly criticised a mental health trust for failing to investigate serious incidents promptly. Tees Esk and Wear Valleys Foundation Trust has been told that delays in probing serious incidents may “compromise the quality” of these investigations and hence “their value in preventing deaths”. The warnings, from Jeremy Chipperfield, senior coroner for County Durham and Darlington, come amid an ongoing inquest into the death of TEWV patient Ian Darwin. Mr Darwin died aged 42 in March, and the serious incident review into his death is still ongoing. A recently published prevention of future deaths report relating to Mr Darwin’s death said TEWV’s serious incident death investigations, “at all levels of seriousness, are routinely (if not invariably) significantly delayed and I understand there is no expectation of immediate, or any timetable for eventual rectification”. “In permitting delay of ‘serious incident’ investigations, TEWV may permit lethal hazard to persist for longer than necessary, and compromise the quality of such investigations and hence their value in preventing avoidable deaths.”
  23. Content Article
    On 7 March 2023 the coroner commenced an investigation into the death of Ian Darwin, aged 42. The investigation has not yet concluded and the inquest has not yet been heard. However, during the course of the investigation the inquiries revealed matters giving rise to concern. The coroner concluded that in his opinion there is a risk that future deaths could occur unless action is taken.
  24. News Article
    The family of a student who died after hospital staff missed that she had developed sepsis despite a string of warning signs have claimed she was the victim of a “lack of care”, as a coroner ruled there were “gross” failures in her treatment. Staff at Southmead hospital in Bristol failed to carry out the sepsis screening and observations needed to keep 20-year-old Maddy Lawrence safe after she was taken to hospital with a dislocated hip sustained in a rugby tackle. Outside court, the student’s mother, Karen Lawrence, said: “It has been a constant struggle to understand how a healthy, strong and fit 20-year-old could lose her life to sepsis which was allowed to develop under the care of professionals. “Her screams of pain and our pleas for help were merely managed, temporarily quietened with painkillers while the infection progressed unnoticed by hospital staff. “Our daughter was failed by a number of nurses and medical staff; symptoms were ignored, observations were not taken, on one occasion for 16 hours. There was no curiosity, basic tests were not completed even when hospital policy required them. “Maddy herself expressed concern on multiple occasions but her pain was not being taken seriously. As well as failing to fulfil their duty, those nurses and medical staff offered no sympathy, no compassion and little attention. “This failure meant Maddy was not given the chance to beat sepsis. Significant delays in its discovery meant the crucial window for treatment was missed. Maddy did not die due to under-staffing or a lack of money. Her death was the result of a lack of care.” Read full story Source: The Independent, 8 September 2023
  25. News Article
    Dozens of young autistic people have died after serious failings in their care despite repeated warnings from coroners, BBC News has found. Their investigation found issues that were flagged a decade ago are still being warned about now. Two bereaved mothers said lessons had not been learned by their local health authority after the deaths of their teenage sons, two years apart. The coroner who oversaw both cases, noted a repeated failure in care. After the first death, the coroner criticised NHS Kent and Medway for "inadequate support" and said a similar incident may happen if this continued. Two years later, the second autistic teenager died under the care of the same authority. The same coroner found that had the victim received the recommended level of care, he might have got the therapy he needed. In the first piece of research of its kind, the BBC combed through more than 4,000 Prevention of Future Death (PFD) notices delivered in England and Wales over the past 10 years. Read full story Source: BBC News, 7 September 2023
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